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Latacz P, Popiela T, Brzegowy P, Lasocha B, Kwiecień K, Simka M. Safety and Efficacy of Low-Dose Eptifibatide for Tandem Occlusions in Acute Ischemic Stroke. Neurol Int 2024; 16:253-262. [PMID: 38392958 PMCID: PMC10892545 DOI: 10.3390/neurolint16010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVES The optimal treatment strategy for ischemic stroke in patients presenting with tandem occlusions of the internal carotid artery remains controversial. Several studies have demonstrated better clinical outcomes after eptifibatide, which is a short half-life antiplatelet agent. This retrospective analysis focused on the safety and efficacy of low-dose eptifibatide administration in stroke patients with tandem lesions. METHODS We evaluated the results of endovascular treatment in 148 stroke patients with tandem lesions. Patients in whom balloon angioplasty alone resulted in satisfactory cerebral flow did not receive eptifibatide (33 patients); others received this drug together with stent implantation (115 patients). Eptifibatide was given as an intravenous bolus of 180 μg/kg and then in a modified low dose of 1 μg/kg/min for 24 hours. RESULTS There were no statistically significant differences between both groups regarding 30-day mortality, frequency of thrombotic events, or hemorrhagic complications. An analysis of clinical status at 30-day follow-up revealed that the administration of eptifibatide was associated with a statistically significant better outcome: a higher rate of either no neurological symptoms or only mild symptoms (4 NIHSS points maximally). CONCLUSIONS The administration of eptifibatide in stroke patients presenting with tandem lesions is relatively safe. Moreover, treatment with this drug can improve clinical outcomes in these challenging patients.
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Affiliation(s)
- Paweł Latacz
- Department of Vascular Surgery and Angiology, Brothers of Mercy St. John of God Hospital, 31-061 Krakow, Poland; (P.L.); (K.K.)
| | - Tadeusz Popiela
- Chair of Radiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (T.P.); (P.B.)
| | - Paweł Brzegowy
- Chair of Radiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (T.P.); (P.B.)
| | | | - Krzysztof Kwiecień
- Department of Vascular Surgery and Angiology, Brothers of Mercy St. John of God Hospital, 31-061 Krakow, Poland; (P.L.); (K.K.)
| | - Marian Simka
- Institute of Medical Sciences, University of Opole, 45-040 Opole, Poland
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Ospel JM, Mirza M, Clarençon F, Siddiqui A, Doyle K, Consoli A, Mokin M, Ullberg T, Zaidat O, Bourcier R, Kulcsar Z, Gounis MJ, Liebeskind DS, Fiehler J, Narata AP, Ribo M, Jovin T, Sakai N, Rai A, McCarthy R, Dorn F, Andersson T, Majoie CBLM, Hanel R, Jadhav A, Riedel C, Chamorro A, Brinjikji W, Costalat V, DeMeyer SF, Nogueira RG, Cognard C, Montaner J, Leung TW, Molina C, van Beusekom H, Davalos A, Weisel J, Chapot R, Möhlenbruch M, Brouwer P. What is a Challenging Clot? : A DELPHI Consensus Statement from the CLOTS 7.0 Summit. Clin Neuroradiol 2023; 33:1007-1016. [PMID: 37284876 DOI: 10.1007/s00062-023-01301-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/27/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Predicting a challenging clot when performing mechanical thrombectomy in acute stroke can be difficult. One reason for this difficulty is a lack of agreement on how to precisely define these clots. We explored the opinions of stroke thrombectomy and clot research experts regarding challenging clots, defined as difficult to recanalize clots by endovascular approaches, and clot/patient features that may be indicative of such clots. METHODS A modified DELPHI technique was used before and during the CLOTS 7.0 Summit, which included experts in thrombectomy and clot research from different specialties. The first round included open-ended questions and the second and final rounds each consisted of 30 closed-ended questions, 29 on various clinical and clot features, and 1 on number of passes before switching techniques. Consensus was defined as agreement ≥ 50%. Features with consensus and rated ≥ 3 out of 4 on the certainty scale were included in the definition of a challenging clot. RESULTS Three DELPHI rounds were performed. Panelists achieved consensus on 16/30 questions, of which 8 were rated 3 or 4 on the certainty scale, namely white-colored clots (mean certainty score 3.1), calcified clots under histology (3.7) and imaging (3.7), stiff clots (3.0), sticky/adherent clots (3.1), hard clots (3.1), difficult to pass clots (3.1) and clots that are resistant to pulling (3.0). Most panelists considered switching endovascular treatment (EVT) techniques after 2-3 unsuccessful attempts. CONCLUSION This DELPHI consensus identified 8 distinct features of a challenging clot. The varying degree of certainty amongst the panelists emphasizes the need for more pragmatic studies to enable accurate a priori identification of such occlusions prior to EVT.
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Affiliation(s)
- Johanna M Ospel
- Departments of Diagnostic Imaging and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, T2N2T9, Calgary, AB, Canada.
| | | | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Adnan Siddiqui
- Department of Neurosurgery, University of New York at Buffalo, Buffalo, NY, USA
| | - Karen Doyle
- Department of Physiology and CURAM-SFI Research Centre for Medical Devices, University of Galway, Galway, Ireland
| | - Arturo Consoli
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, France
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Teresa Ullberg
- Departments of Neurology and Diagnostic Imaging, Skåne University Hospital, and Department of clinical sciences, Neurology, Lund University, Lund, Sweden
| | - Osama Zaidat
- Neuroscience and Stroke Center, Mercy Health Bon Secours St Vincent Hospital, Toledo, OH, USA
| | - Romain Bourcier
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, L'institut du thorax, Nantes, Pays de la Loire, France
| | - Zsolt Kulcsar
- Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, USA
| | - David S Liebeskind
- UCLA Stroke Center and Department of Neurology, University of California, Los Angeles, USA
| | - Jens Fiehler
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ana Paula Narata
- Department of Interventional Neuroradiology, University Hospital of Southampton, Southampton, UK
| | - Marc Ribo
- Unitat d'Ictus, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Tudor Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ansaar Rai
- Neuroradiology Department, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, USA
| | - Ray McCarthy
- Research and Development, Cerenovus, Galway, Ireland
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital of Bonn, Bonn, Germany
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital and Clinical Neuroscience, Karolinska Intitutet, Stockholm, Sweden
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Ricardo Hanel
- Baptist neurological institute, Baptist Health, Jacksonville, FL, USA
| | - Ashutosh Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Christian Riedel
- Department of Neuroradiology, University Hospital Göttingen, Georg-August-University, Göttingen, Germany
| | - Angel Chamorro
- Hospital Clinic of Barcelona and Institut d'Investigaçions Biomèdicas August Pi Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Waleed Brinjikji
- Department of Radiology and Neurosurgery, Mayo Clinic Rochester, Rochester, MN, USA
| | - Vincent Costalat
- Neuroradiology department, University Hospital Güi-de-Chauliac, CHU de Montpellier, Montpellier, France
| | - Simon F DeMeyer
- Laboratory For Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Centre, Pittsburgh, USA
| | - Christophe Cognard
- Department of diagnostic and therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR) Barcelona, Barcelona, Spain
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Carlos Molina
- Stroke Center Vall d'Hebron Hospital, Barcelona, Spain
| | - Heleen van Beusekom
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Antoni Davalos
- Department of Neuroscience, University Autònoma de Barcelona, Barcelona, Spain
| | - John Weisel
- Department of Cell and Developmental Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Rene Chapot
- Department of Neuroradiology, Alfried Krupp Krankenhaus Ruttenscheid, Essen, Germany
| | - Markus Möhlenbruch
- Department of Interventional Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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Holden D, May CC, Robbins BT, Cook AM, Jung S, Smetana KS, Roels C, Harlan SS, Keegan S, Brophy G, Al Mohaish S, Sandler M, Spetz S, Wohlfarth K, Owusu-Guha J, Buschur P, Hetrick E, Dombrowski K, Glover J, Levesque M, Dingman S, Hussain M. Multicenter comparison of antiplatelet treatment strategies for urgent/emergent neuroendovascular stenting. Interv Neuroradiol 2023:15910199231180003. [PMID: 37402388 DOI: 10.1177/15910199231180003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Emergent neuroendovascular stenting presents challenges for the utilization of antiplatelet agents. METHODS This was a multicenter, retrospective cohort of patients who underwent emergent neuroendovascular stenting. The primary endpoints were thrombotic and bleeding events in relation to the timing of antiplatelet administration, route of administration, and choice of intravenous (IV) agent and the study investigated practice variability in antiplatelet utilization. RESULTS Five-hundred and seventy patients were screened across 12 sites. Of those, 167 were included for data analysis. For patients who presented with ischemic stroke, artery dissection and emergent internal carotid artery (ICA) stenting who received an antiplatelet agent prior to or during the procedure, 57% were given an IV antiplatelet agent; for patients who were given an antiplatelet agent after the procedure, 96% were given an oral agent. For patients who presented for aneurysm repair and received an antiplatelet agent prior to or during the procedure, 74% were given an IV agent; patients who were given an antiplatelet agent after the completion of the procedure were given an oral antiplatelet agent 90% of the time. In patients who presented with ischemic stroke, artery dissection and emergent ICA stenting who received oral antiplatelet agents post-procedure were more likely to have thrombotic events compared to those who received oral antiplatelet agents prior to or during the procedure (29% vs 9%; p = 0.04). There were no differences in the primary outcomes observed when comparing other antiplatelet treatment strategies. CONCLUSION The optimal timing of antiplatelet administration in relation to stent placement and route of administration of antiplatelet agents is unclear. Timing and route of administration of antiplatelet agents may have an effect on thrombosis in emergent neuroendovascular stenting. Significant practice variation exists in antiplatelet agent utilization in emergent neuroendovascular stenting.
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Affiliation(s)
- Devin Holden
- Department of Pharmacy, Albany Medical Center, Albany, NY, USA
| | - Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Blake T Robbins
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, KY, USA
| | - Aaron M Cook
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, KY, USA
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Comparison of Safety and Efficacy after Emergency Stenting in Patients Exhibiting Intracranial Atherosclerotic Stenosis Associated with Large-vessel Occlusion with and without Intravenous Infusion of Tirofiban. Cardiovasc Intervent Radiol 2023; 46:377-384. [PMID: 36797426 PMCID: PMC10014670 DOI: 10.1007/s00270-023-03372-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/23/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE Intracranial rescue stent angioplasty is a bailout strategy for acute stroke patients in cases of unsuccessful endovascular thrombectomy due to underlying atherosclerotic stenosis. However, there is no consensus on a preprocedural and intraprocedural antiplatelet regimen. The aim of this single-centre study was to compare the safety and efficacy of emergency stenting in patients exhibiting intracranial atherosclerotic stenosis-related acute large-vessel occlusion with or without peri-interventional intravenous infusion of tirofiban. MATERIALS AND METHODS We performed a retrospective analysis of 78 patients who were treated with rescuestent angioplasty between 2010 and 2019 due to acute ischaemic stroke. The patients were divided into 2 groups: those who received peri-interventional intravenous tirofiban and those who did not receive tirofiban. We compared clinical safety and functional outcomes in both treatment groups with symptomatic haemorrhage as the primary endpoint. Bivariate and multivariable logistic regression was performed to investigate the association between tirofiban and outcome measures. RESULTS Thirty-seven patients were treated with intravenous tirofiban (47.4%), and 41 patients did not receive intravenous tirofiban (52.6%). Statistical analysis revealed no significant difference between the two groups in the rate of symptomatic haemorrhage (16.2% in the tirofiban group versus 14.6% in the control group, p = 0.847). The 3-month mortality (21.6% in the tirofiban group versus 17.1% in the control group, p = 0.611) and good functional outcomes according to the modified Rankin scale (45.9% versus 34.1%, p = 0.289) were comparable. CONCLUSION The results of our study suggest that the application of tirofiban for rescue stenting after failed mechanical thrombectomy is safe.
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Ni H, Yang T, Jia Z, Shi H, Liu S, Zhao L. Outcomes in acute ischemic stroke patients undergoing endovascular thrombectomy: Cervical internal carotid artery pseudo-occlusion vs. true occlusion. Front Neurol 2023; 13:1106358. [PMID: 36698876 PMCID: PMC9868848 DOI: 10.3389/fneur.2022.1106358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 12/19/2022] [Indexed: 01/12/2023] Open
Abstract
Background and purpose Pseudo-occlusion of the cervical internal carotid artery (cICA) refers to an absence of intraluminal contrast on computed tomography angiography (CTA), while the artery is patent on digital subtraction angiography during endovascular thrombectomy. We aimed to compare the outcomes between the cICA pseudo-occlusion and true occlusion after thrombectomy. Methods We retrospectively analyzed patients with apparent cICA occlusion on CTA who underwent thrombectomy between January 2016 and August 2021, and divided them into the pseudo-occlusion and true occlusion groups based on angiographic exploration. Recanalization failure was defined as a modified Thrombolysis in Cerebral Infarction score of 0-2a. Poor outcome was defined as a 90-day modified Rankin Scale score of 3-6. Propensity score matching was performed to compare the outcomes. Sensitivity analysis using multivariate-adjusted regression in the original cohort was conducted to test the robustness of the findings. Results Of the 146 patients included, 79 patients (54.1%) had cICA pseudo-occlusion and 67 patients (45.9%) had true occlusion. Following 1:1 propensity score-matched analysis, patients with pseudo-occlusion had an increased likelihood of recanalization failure (OR, 3.18; 95% CI, 1.06-9.59; P = 0.040) and poor outcome (OR, 2.80; 95% CI, 1.07-7.30; P = 0.035) compared with patients with true occlusion. Sensitivity analysis showed that cICA pseudo-occlusion remained independently associated with recanalization failure (OR, 2.55; 95% CI, 1.07-6.09; P = 0.036) and poor outcome (OR, 2.48; 95% CI, 1.08-5.67; P = 0.032). Conclusions Patients with cICA pseudo-occlusion on CTA treated with thrombectomy had an increased risk of reperfusion failure and poor outcome compared with true occlusion patients.
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Affiliation(s)
- Heng Ni
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tao Yang
- Department of Neurology, Changzhou Second People's Hospital, Changzhou, China
| | - Zhenyu Jia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Haibin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China,Sheng Liu ✉
| | - Linbo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China,*Correspondence: Linbo Zhao ✉
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6
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Baek JH, Kim BM, Ihm EH, Kim CH, Kim DJ, Heo JH, Nam HS, Kim YD, Suh S, Kim B, Won Y, Baek BH, Yoon W, Kwon HJ, Chang Y, Jung C, Jeong HW. Clinical outcomes of rescue stenting for failed endovascular thrombectomy: a multicenter prospective registry. J Neurointerv Surg 2022; 14:1166-1172. [PMID: 35022298 DOI: 10.1136/neurintsurg-2021-018308] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/01/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is a primary endovascular modality for acute intracranial large vessel occlusion. However, further treatment, such as rescue stenting, is occasionally necessary for refractory cases. We aimed to investigate the efficacy and safety of rescue stenting in first-line MT failure and to identify the clinical factors affecting its clinical outcome. METHODS A multicenter prospective registry was designed for this study. We enrolled consecutive patients who underwent rescue stenting for first-line MT failure. Endovascular details and outcomes, follow-up patency of the stented artery, and clinical outcomes were summarized and compared between the favorable and unfavorable outcome groups. RESULTS A total of 78 patients were included. Intracranial atherosclerotic stenosis was the most common etiology for rescue stenting (97.4%). Seventy-seven patients (98.7%) were successfully recanalized by rescue stenting. A favorable outcome was observed in 66.7% of patients. Symptomatic intracranial hemorrhage and mortality were observed in 5.1% and 4.0% of patients, respectively. The stented artery was patent in 82.1% of patients on follow-up angiography. In a multivariable analysis, a patent stent on follow-up angiography was an independent factor for a favorable outcome (OR 87.6; 95% CI 4.77 to 1608.9; p=0.003). Postprocedural intravenous maintenance of glycoprotein IIb/IIIa inhibitor was significantly associated with the follow-up patency of the stented artery (OR 5.72; 95% CI 1.45 to 22.6; p=0.013). CONCLUSIONS In this multicenter prospective registry, rescue stenting for first-line MT failure was effective and safe. For a favorable outcome, follow-up patency of the stented artery was important, which was significantly associated with postprocedural maintenance of glycoprotein IIb/IIIa inhibitors.
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Affiliation(s)
- Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of).,Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Byung Moon Kim
- Interventional Neuroradiology, Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Eun Hyun Ihm
- Department of Neurosurgery, Andong Hospital, Andong, Korea (the Republic of)
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University Dongsan Medical Center, Daegu, Korea (the Republic of)
| | - Dong Joon Kim
- Interventional Neuroradiology, Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Ji Hoe Heo
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Hyo Suk Nam
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Young Dae Kim
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Sangil Suh
- Department of Radiology, Korea University Guro Hospital, Seoul, Korea (the Republic of)
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea (the Republic of)
| | - Yoodong Won
- Department of Radiology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea (the Republic of)
| | - Byung Hyun Baek
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea (the Republic of)
| | - Woong Yoon
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea (the Republic of)
| | - Hyon-Jo Kwon
- Department of Neurosurgery, Regional Cerebrovascular Center, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea (the Republic of)
| | - Yoonkyung Chang
- Department of Neurology, Ewha Womans University College of Medicine, Mokdong Hospital, Seoul, Korea (the Republic of)
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea (the Republic of)
| | - Hae Woong Jeong
- Diagnostic Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea (the Republic of)
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Yeo LLL, Jing M, Bhogal P, Tu T, Gopinathan A, Yang C, Tan BYQ, Arnberg F, Sia CH, Holmin S, Andersson T. Evidence-Based Updates to Thrombectomy: Targets, New Techniques, and Devices. Front Neurol 2021; 12:712527. [PMID: 34566856 PMCID: PMC8459011 DOI: 10.3389/fneur.2021.712527] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/30/2021] [Indexed: 01/23/2023] Open
Abstract
Endovascular thrombectomy (EVT) has been validated in several randomized controlled trials in recent years for its efficacy in the treatment of acute ischemic strokes (AIS) and is now the standard of care according to international guidelines. However, in about 20% of EVT procedures, recanalization is not achieved, and over 50% of patients who undergo EVT still do not have good functional outcome. In this article, we provide an extensive review of the latest evidence and developments in the field of EVT, with particular focus on the factors that improve patient outcomes. These factors include new and adjunctive techniques such as combination of direct aspiration and stent retriever, intra-arterial urokinase or 2b/3a inhibitors, rescue stenting, as well as novel devices including balloon guide catheters and the newer generations of aspiration catheters and stent retrievers. We also examined the latest notion of using first-pass effect (FPE) as the target to achieve during EVT, which has been associated with an improved functional outcome. While the field of EVT has been rapidly evolving, further research is required in specific AIS patient populations such as those with large ischemic core, late presentation beyond 24 h, posterior circulation strokes, and with distal medium vessel occlusion or tandem lesions to better assess its efficacy and safety.
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Affiliation(s)
- Leonard L L Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Mingxue Jing
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Pervinder Bhogal
- Department of Neuroradiology, St. Bartholomew's and the Royal London Hospital, London, United Kingdom
| | - Tianming Tu
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Anil Gopinathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Cunli Yang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Benjamin Y Q Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tommy Andersson
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
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8
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Holden DN, Entezami P, Bush MC, Field NC, Paul AR, Boulos AS, Yamamoto J, Dalfino JC. Characterization of antiplatelet response to low-dose cangrelor utilizing platelet function testing in neuroendovascular patients. Pharmacotherapy 2021; 41:811-819. [PMID: 34496076 DOI: 10.1002/phar.2619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/18/2021] [Accepted: 08/18/2021] [Indexed: 11/09/2022]
Abstract
STUDY OBJECTIVES The optimal antiplatelet therapy for emergent neuroendovascular stenting is uncertain. Cangrelor is an intravenous P2Y12 inhibitor that is an attractive option due its favorable pharmacokinetic profile and ease of measurability but optimal dosing remains unclear. The primary objective of this study is to characterize the dose response of low dose cangrelor (<2 mcg/kg/min) with the utilization of platelet function testing (PFT). DESIGN A retrospective review of all patients treated with cangrelor for either procedural stenting or bridging was conducted between January 1st, 2019 and October 31st, 2020. Seventy-two patients met inclusion criteria. An in-depth analysis of dose response to low dose cangrelor based on PFT was performed. PATIENTS Neuroendovascular patients treated with cangrelor. SETTING Albany Medical Center Hospital. INTERVENTION AND MAIN RESULTS Patients who underwent procedural stenting were given a bolus of 5 mcg/kg and an initial infusion rate of either 0.75 mcg/kg/min or 1 mcg/kg/min. Patients who were bridged with cangrelor were administered an initial infusion rate of 0.75 mcg/kg/min or 1 mcg/kg/min. Twelve patient's doses were titrated to achieve a platelet reactivity unit (PRU) between 50-150; three patient's doses were titrated multiple times. Based on initial PFT results, utilizing the 1 mcg/kg/min maintenance dose resulted in more patients being in the acceptable (10-180) and desired (50-150) PRU range than the 0.75 mcg/kg/min dose (47% vs 56% and 70% vs 80%, respectively). Final recorded PRU results showed that 64% of patients had PRUs in the optimal range (50-150) and 88% of patients had PRUs in the desire range (10-180). CONCLUSIONS Utilizing low doses of cangrelor with platelet function testing is an option during emergent neuroendovascular stenting and bridging. Cangrelor demonstrates significant variability in response at low doses and exhibits a dose response relationship when PFT is utilized.
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Affiliation(s)
- Devin N Holden
- Department of Pharmacy, Albany Medical Center, Albany, New York, USA
| | - Pouya Entezami
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Maximilian C Bush
- Department of Pharmacy, Albany Medical Center, Albany, New York, USA
| | - Nicholas C Field
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Alexandra R Paul
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Alan S Boulos
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Junichi Yamamoto
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - John C Dalfino
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
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Ma G, Sun X, Tong X, Jia B, Huo X, Luo G, Wang B, Deng Y, Gao F, Song L, Ma N, Miao Z, Mo D. Safety and Efficacy of Direct Angioplasty in Acute Basilar Artery Occlusion Due to Atherosclerosis. Front Neurol 2021; 12:651653. [PMID: 34349717 PMCID: PMC8326335 DOI: 10.3389/fneur.2021.651653] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/16/2021] [Indexed: 11/15/2022] Open
Abstract
Background and Purpose: Endovascular treatment (EVT) is one of the promising treatment options in patients with intracranial atherosclerotic disease (ICAD)-related basilar artery occlusion (BAO). In this study, we compared the safety and efficacy of direct angioplasty (DA) with stent-retriever thrombectomy (SRT) with or without rescue treatment in ICAD-related BAO. Methods: We retrospectively evaluated 187 patients who underwent EVT for BAO from January 2012 to July 2018. We identified patients who underwent EVT due to ICAD-related BAO. Patients who accepted SRT with or without rescue treatment were classified into the SRT group. Patients treated with DA with or without stent placement were classified into DA group. Clinical and laboratory findings and outcomes were compared between groups. Results: A total of 108 patients were enrolled, among them 77 underwent SRT and 31 underwent DA; 61 (79.2%) SRT group patients underwent angioplasty with or without stent placement. Compared with patients in the SRT group, those in the DA group experienced a significantly shorter procedure time [60 min (60–120 min) vs. 120 min (60–120 min); p = 0.038] and a lower number of device passes [2 passes (1–2 passes) vs. 3 passes (2–4 passes); p < 0.001]. No significant differences in balloon angioplasty (35.5 vs. 22.1%; p = 0.150), emergent stent placement (64.5 vs. 57.1%; p = 0.481), successful recanalization (93.5 vs. 85.7%; p = 0.340), embolization in distal or new territory (3.2 vs. 9.1%, p = 0.314), and reocclusion (22.6 vs. 9.1%; p = 0.109) among DA and SRT groups were found. Additionally, no differences in symptomatic intracranial hemorrhage incidence [adjusted odds ratio (OR), 0.74; 95% CI, 0.06–9.44; p = 0.815], functional independence (adjusted OR, 1.44; 95% CI, 0.50–4.16; p = 0.497), and mortality rate (adjusted OR, 0.36; 95% CI, 0.06–2.04; p = 0.247) were noted among groups. Conclusions: In certain patients with ICAD-related BAO, DA may shorten procedure time and reduce required device passes compared to SRT. In this study, DA was retrospectively found to be of similar safety and efficacy as SRT.
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Affiliation(s)
- Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gang Luo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bo Wang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yiming Deng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ligang Song
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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10
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The use of cangrelor in neurovascular interventions: a multicenter experience. Neuroradiology 2020; 63:925-934. [PMID: 33174182 DOI: 10.1007/s00234-020-02599-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/03/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE Thromboembolic events represent the most common procedure-related complication associated with neurointerventions. Cangrelor is a potent, intravenous (IV), P2Y12-receptor antagonist with a rapid onset and offset presented as an alternative antiplatelet agent. We aim to evaluate the safety and effectiveness of IV cangrelor in neurovascular intervention. METHODS This is a retrospective analysis of data from four cerebrovascular interventional centers. We identified patients who underwent acute neurovascular intervention and received cangrelor as part of their optimum care. Patients were divided into 2 groups: ischemic and aneurysm. Periprocedural thromboembolic events, hemorrhagic complications, and outcomes were analyzed. RESULTS Sixty-six patients were included, 42 allocated into the ischemic group (IG), and 24 into aneurysm group (AG). The IG periprocedural symptomatic complication rate was 9.5%, represented by 3 postoperative intracranial hemorrhages and 1 retroperitoneal hematoma. At discharge, 47.6% had a favorable outcome and the mortality rate was 2.4%, related to clinical deterioration of a large infarct. In the AG, 4.2% had a periprocedural complication during or after cangrelor infusion, represented by an intracranial hemorrhage in an initially ruptured aneurysm. Favorable clinical outcome was seen in 56.2% and 87.7% of ruptured and unruptured aneurysms, respectively, upon discharge. CONCLUSIONS Cangrelor may be a feasible alternative for patients requiring immediate intervention with the use of endoluminal devices. It allows the possibility for a secure transition to long-term ticagrelor and progression to surgery in the setting of unexpected complications.
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