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Zhou M, Wu Z, Maalim AA, Zeng Y, Guo X, Zhang Z, Yuan X, Enos ZM, Shu K, Lei T, Zhu M. Overlapping Stent Treatment for Ruptured Dissecting Aneurysms in Posterior Circulation. Brain Sci 2023; 13:1507. [PMID: 38002469 PMCID: PMC10669846 DOI: 10.3390/brainsci13111507] [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: 07/23/2023] [Revised: 10/04/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
Ruptured dissecting aneurysms in posterior intracranial circulation present significant clinical challenges and often cause poor prognoses. Our cohort used overlapping stents as the primary treatment. We analyzed the medical records of 27 patients (18 men/nine women) with ruptured posterior circulation dissecting aneurysms (PCDAs). Their average age was 52 years. We selected 11 patients who used Enterprise (EP) and LVIS stents overlappingly and matched them 1:1 with counterparts who received either EP or LVIS stents individually. Overlapping stents was a feasible treatment in all 27 cases. We successfully followed up 26 patients for ≥6 months. Regrettably, one patient died from intracranial hypertension on Day 7 post-procedure. Immediate post-procedure angiographies indicated Raymond grade I, II, and III occlusions of PCDAs in 16 (59.3%), 7 (25.9%), and 4 (14.8%) cases, respectively. At an average follow-up duration of 16.2 months, 25 patients (96.2%) had modified Rankin Scale scores of 0-2, signifying positive outcomes. One patient (3.8%) had a score of 3-4. Recurrence rates for the EP and LVIS stent groups were higher than those of the overlapping stent group (45.45% vs. 9.09%, p = 0.15 and 27.27% vs. 9.09%, p = 0.59, respectively). No significant difference in recurrence rates existed between the overlapping and single-stent groups. Similarly, follow-up outcomes were consistent between the two groups. Overlapping stents could be an efficient method for treating ruptured PCDAs.
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Affiliation(s)
- Minghui Zhou
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zengbao Wu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ali Abdi Maalim
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ying Zeng
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Xiao Guo
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zhenhua Zhang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Xiaohong Yuan
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Zacharia Majaliwa Enos
- Department of Neurosurgery, Tongji Tianyou Hospital Affiliated to Wuhan University of Science and Technology, Wuhan 430030, China;
| | - Kai Shu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Ting Lei
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
| | - Mingxin Zhu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (M.Z.); (Z.W.); (A.A.M.); (Y.Z.); (X.G.); (Z.Z.); (X.Y.); (K.S.); (T.L.)
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Li W, Wang A, Ma C, Wang Y, Zhao Y, Zhang Y, Wang K, Zhang Y, Wang Y, Yang X, Liu J, Liu X. Antiplatelet therapy adjustment improved the radiomic characteristics of acute silent cerebral infarction after stent-assisted coiling in patients with high on-treatment platelet reactivity: A prospective study. Front Neurosci 2023; 17:1068047. [PMID: 36845416 PMCID: PMC9948085 DOI: 10.3389/fnins.2023.1068047] [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: 10/21/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
Background We aimed to investigate the effects of high on-treatment platelet reactivity (HPR) and antiplatelet therapy adjustment on high-risk radiomic features in patients with antiplatelet therapy adjustment on acute silent cerebral infarction (ASCI) who had unruptured intracranial aneurysms (UIA) after stent placement. Methods This single-institution study prospectively included 230 UIA patients who had ACSI after stent placement in our hospital between January 2015 and July 2020. All patients underwent magnetic resonance imaging with diffusion-weighted imaging (MRI-DWI) after stent placement and 1,485 radiomic features were extracted from each patient. The least absolute shrinkage and selection operator regression methods were used for selection of high-risk radiomic features associated with clinical symptoms. In addition, 199 patients with ASCI were classified into three groups: controls without HPR (n = 113), HPR patients with standard antiplatelet therapy (n = 63) and HPR patients with antiplatelet therapy adjustment (n = 23). We compared high-risk radiomic features between three groups. Results Of the patients who had acute infarction after MRI-DWI, 31 (13.5%) exhibited clinical symptoms. Eight risk radiomic features associated with clinical symptoms were selected, and the radiomics signature exhibited good performance. In ASCI patients, compared with controls, the radiomic characteristics of ischemic lesion in HPR patients were consistent with the following high-risk radiomic features associated with clinical symptoms: higher gray-level values, greater variance in intensity values, and greater homogeneity. However, the adjustment of antiplatelet therapy in HPR patients modified the high-risk radiomic features, which showed lower gray-level values, less variance in intensity values, and more heterogeneous texture. The radiomic shape feature of elongation showed no notable difference between three groups. Conclusion Adjustment of antiplatelet therapy might reduce the high-risk radiomic features of UIA patients with HPR after stent placement.
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Affiliation(s)
- Wenqiang Li
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chao Ma
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanmin Wang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yapeng Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yisen Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kun Wang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yang Wang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China,*Correspondence: Xinjian Yang,
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China,Jian Liu,
| | - Xianzhi Liu
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Xianzhi Liu,
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Sirakova K, Penkov M, Matanov S, Minkin K, Ninov K, Hadzhiyanev A, Karakostov V, Ivanova I, Sirakov S. Progressive volume reduction and long-term aneurysmal collapse following flow diversion treatment of giant and symptomatic cerebral aneurysms. Front Neurol 2022; 13:972599. [PMID: 36034286 PMCID: PMC9403733 DOI: 10.3389/fneur.2022.972599] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe primary goal of conventional endovascular and microvascular approaches is the clinical and radiological resolution of the symptomatic aneurysm-induced mass effect. This study assessed the volume changes and mass effect reduction due to sac shrinkage after treatment with flow diverter stents (FD) for unruptured cerebral aneurysms.MethodsWe analyzed retrospectively 36 symptomatic aneurysms that were larger or equal to 25 mm in diameter in patients treated at our center from January 2016 to April 2022. Radiological and clinical outcomes were analyzed, including aneurysmal volume changes and resolution of aneurysm-related symptoms.ResultsAt 6 months, 25 aneurysms decreased in size, 2 remained unchanged, and 9 aneurysms demonstrated a post-treatment dimensional increase. At 12 months, 30 aneurysms showed a progressive radiological volume reduction. Either no change or negligible shrinkage was observed in the remaining six aneurysms. At 24 months, 32 aneurysms showed aneurysmal shrinkage by a mean 47% volume loss with respect to baseline. At the last follow-up, all 13 patients who had presented with third cranial nerve palsy showed improvements. Complete reversal of the pretreatment edematous changes was confirmed in all cases. The overall post-treatment complication rate was 8.3%, as 3 patients experienced non-fatal delayed rupture of their aneurysm. There was no mortality in this study.ConclusionFlow diversion could effectively induce progressive aneurysmal shrinkage and resolution of the mass effect associated with giant symptomatic cerebral aneurysms.
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Affiliation(s)
| | - Marin Penkov
- Radiology Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Svetozar Matanov
- Radiology Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Krasimir Minkin
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Kristian Ninov
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Asen Hadzhiyanev
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Vasil Karakostov
- Neurosurgery Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Irena Ivanova
- Clinical Laboratory Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Stanimir Sirakov
- Radiology Department, University Hospital St Ivan Rilski, Sofia, Bulgaria
- *Correspondence: Stanimir Sirakov
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Hendrix P, Griessenauer CJ, Schirmer CM. Not quite time to stop testing aspirin response yet? J Neurointerv Surg 2021; 14:640-641. [PMID: 34750108 DOI: 10.1136/neurintsurg-2021-018233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Philipp Hendrix
- Department of Neurosurgery, Geisinger, Danville and Wilkes-Barre, Pennsylvania, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger, Danville and Wilkes-Barre, Pennsylvania, USA
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Li W, Zhu W, Wang A, Zhang G, Zhang Y, Wang K, Zhang Y, Wang C, Zhang L, Zhao H, Wang P, Chen K, Liu J, Yang X. Effect of Adjusted Antiplatelet Therapy on Preventing Ischemic Events After Stenting for Intracranial Aneurysms. Stroke 2021; 52:3815-3825. [PMID: 34538087 DOI: 10.1161/strokeaha.120.032989] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE This study tests whether patients with unruptured intracranial aneurysm who underwent stent placement benefitted from platelet function monitoring-guided adjustment of antiplatelet therapy. METHODS We conducted a randomized, open-label, parallel group, assessor-blinded trial. Patients with unruptured intracranial aneurysm who underwent stent placement were assigned in a 1:1 ratio to receive either drug adjustment (patients who had high on-treatment platelet reactivity to antiplatelet therapy on the basis of platelet function monitoring [monitoring group]) or conventional therapy (without monitoring and drug adjustment [conventional group]). The second monitoring was performed 14 days after randomization in patients with drug adjustment. The primary outcome was the composite frequency of ischemic stroke, transient ischemic attack, stent thrombosis, urgent revascularization, and cerebrovascular death within 7 days after stent implantation. The safety outcome was the composite frequency of major, minor, or minimal bleeding within 1 month after stent implantation. RESULTS In total, 314 patients were included (n=157 per group). The primary combined outcome occurred in 19 patients (12.1%) in the conventional group and 8 patients (5.1%) in the monitoring group (hazard ratio, 0.39 [95% CI, 0.17-0.92]; P=0.03). Ischemic stroke occurred at a lower frequency in the monitoring group compared with that in the conventional group (4.5% versus 12.1%; hazard ratio, 0.34 [95% CI, 0.14-0.83]; P=0.01), which drove the overall primary combined outcome. The safety outcome occurred in the monitoring group (7.0%) and in the conventional group (1.9%; hazard ratio, 3.87 [95% CI, 1.06-14.14]; P=0.03). A significant difference was observed in the frequency of minor or minimal bleeding events between the two groups (monitoring group versus conventional group, 6.4% versus 1.3%; P=0.02) but not in the frequency of major bleeding events between the two groups. CONCLUSIONS Platelet function monitoring-guided antiplatelet therapy reduces thromboembolic events in patients with unruptured intracranial aneurysm after stent placement, significantly enhancing minor or minimal bleeding events but not major bleeding events. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03989557.
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Affiliation(s)
- Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China. (W.L., W.Z., Yisen Zhang, K.W., Ying Zhang, C.W., J.L., X.Y.)
| | - Wei Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China. (W.L., W.Z., Yisen Zhang, K.W., Ying Zhang, C.W., J.L., X.Y.)
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W.)
| | - Guojun Zhang
- Laboratory Diagnosis Center, Beijing Tiantan Hospital, Capital Medical University, China. (G.Z., L.Z., H.Z., P.W., K.C.)
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China. (W.L., W.Z., Yisen Zhang, K.W., Ying Zhang, C.W., J.L., X.Y.)
| | - Kun Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China. (W.L., W.Z., Yisen Zhang, K.W., Ying Zhang, C.W., J.L., X.Y.)
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China. (W.L., W.Z., Yisen Zhang, K.W., Ying Zhang, C.W., J.L., X.Y.)
| | - Chao Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China. (W.L., W.Z., Yisen Zhang, K.W., Ying Zhang, C.W., J.L., X.Y.)
| | - Limin Zhang
- Laboratory Diagnosis Center, Beijing Tiantan Hospital, Capital Medical University, China. (G.Z., L.Z., H.Z., P.W., K.C.)
| | - Hui Zhao
- Laboratory Diagnosis Center, Beijing Tiantan Hospital, Capital Medical University, China. (G.Z., L.Z., H.Z., P.W., K.C.)
| | - Ping Wang
- Laboratory Diagnosis Center, Beijing Tiantan Hospital, Capital Medical University, China. (G.Z., L.Z., H.Z., P.W., K.C.)
| | - Kelin Chen
- Laboratory Diagnosis Center, Beijing Tiantan Hospital, Capital Medical University, China. (G.Z., L.Z., H.Z., P.W., K.C.)
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China. (W.L., W.Z., Yisen Zhang, K.W., Ying Zhang, C.W., J.L., X.Y.)
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, China. (W.L., W.Z., Yisen Zhang, K.W., Ying Zhang, C.W., J.L., X.Y.)
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Takeuchi M, Uyama A, Matsumoto T, Tsuto K, Konishi Y, Iwabuchi S. Experimental Safety Evaluation of Inflated Assisting Balloons for Endovascular Surgery. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:707-711. [PMID: 37502270 PMCID: PMC10371007 DOI: 10.5797/jnet.oa.2020-0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/01/2021] [Indexed: 07/29/2023]
Abstract
Objective The balloon-assisted technique is one of the methods used for cerebral aneurysm embolization. There are several applications of assisting balloons such as remodeling the neck of cerebral aneurysms, protecting blood vessel branches, and stabilizing the microcatheter. In this study, we measured the pressure inside inflated assisting balloons to assess safety or procedure. Methods A T-junction silicone model was used. The pressure inside the balloon inflated to the set herniation levels in the T-junction model was measured using a fiber pressure sensor. We compared the pressure and difference between each assisting balloon. Results The pressure required for inflating the balloon to the set herniation level in the T-junction model varied depending on the type of assisting balloon. The results suggest that differences in pressure among inflated balloons are likely attributable to differences in the materials used in the lumens of the balloons. Conclusion The pressure inside various inflated assisting balloons was measured for comparison and differences were found. This experiment contributes to the safety of the balloon-assisted technique.
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Affiliation(s)
- Masataka Takeuchi
- Department of Neurosurgery, Seishou Hospital, Odawara, Kanagawa, Japan
- Department of Neurosurgery, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Atsushi Uyama
- Department of Neurosurgery, Seishou Hospital, Odawara, Kanagawa, Japan
| | - Takashi Matsumoto
- Department of Neurosurgery, Seishou Hospital, Odawara, Kanagawa, Japan
| | - Kazuma Tsuto
- Department of Neurosurgery, Seishou Hospital, Odawara, Kanagawa, Japan
| | - Yoshifumi Konishi
- Department of Neurosurgery, Seishou Hospital, Odawara, Kanagawa, Japan
| | - Satoshi Iwabuchi
- Department of Neurosurgery (Ohashi), School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
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Nakagawa I, Park HS, Kotsugi M, Yokoyama S, Nakase K, Furuta T, Myouchin K, Yamada S, Nakase H. Active management of the target P2Y12 reaction unit range in patients undergoing stent-assisted coil embolization for unruptured cerebral aneurysms. J Neurointerv Surg 2021; 13:1017-1021. [PMID: 33674394 DOI: 10.1136/neurintsurg-2020-017249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Platelet function tests have been increasingly adopted to measure patient responses to antiplatelet drugs, and to predict complications. However, no established optimal antiplatelet management for stent-assisted coil embolization (SAC) have been established. The purpose of the present study was to investigate the efficacy and feasibility of clopidogrel dose adjustment for active target P2Y12 reaction unit (PRU). METHODS A total of 202 consecutive patients undergoing SAC to treat unruptured intracranial aneurysms were prospectively recruited. All patients were given two antiplatelet agents starting 7 days prior to the procedure, and platelet function was measured with the VerifyNow test. Clopidogrel hyper-responsive patients received reduced dosing according to the values of follow-up PRUs before and 7, 14, 30, and 90 days after the procedure. Patients were divided into three groups according to clopidogrel responsiveness before treatment, and clinical outcomes and time in target PRU ranges (TTR) were analyzed. RESULTS No delayed ischemic or hemorrhagic events occurred that were associated with out-of-range PRU. PRU values in the hypo-responsive and hyper-responsive groups significantly improved 7 days after treatment with active target PRU management (p=0.05,<0.001, respectively). PRU values were controlled within the target PRU range with drug adjustment (p=0.034), and the time in TTR for all patients was 97% (4.8%-100%), which showed the feasibility of optimal control of PRU values with the protocol. CONCLUSION Active target PRU management can achieve control of optimal PRU values and may decrease perioperative ischemic and hemorrhagic events among patients undergoing SAC.
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Affiliation(s)
- Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University School of Medicine Graduate School of Medicine, Kashihara, Nara, Japan
| | - Hun Soo Park
- Department of Neurosurgery, Nara Medical University School of Medicine Graduate School of Medicine, Kashihara, Nara, Japan
| | - Masashi Kotsugi
- Department of Neurosurgery, Nara Medical University School of Medicine Graduate School of Medicine, Kashihara, Nara, Japan
| | - Shohei Yokoyama
- Department of Neurosurgery, Nara Medical University School of Medicine Graduate School of Medicine, Kashihara, Nara, Japan
| | - Kenta Nakase
- Department of Neurosurgery, Nara Medical University School of Medicine Graduate School of Medicine, Kashihara, Nara, Japan
| | - Takanori Furuta
- Department of Neurosurgery, Nara Medical University School of Medicine Graduate School of Medicine, Kashihara, Nara, Japan
| | - Kaoru Myouchin
- Department of Radiology, Nara Medical University School of Medicine Graduate School of Medicine, Kashihara, Nara, Japan
| | - Shuichi Yamada
- Department of Neurosurgery, Nara Medical University School of Medicine Graduate School of Medicine, Kashihara, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University School of Medicine Graduate School of Medicine, Kashihara, Nara, Japan
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Rosengart A, Collins MK, Hendrix P, Uber R, Sartori M, Jain A, Mao J, Goren O, Schirmer CM, Griessenauer CJ. P 2Y 12 inhibitors in neuroendovascular surgery: An opportunity for precision medicine. Interv Neuroradiol 2021; 27:682-694. [PMID: 33541183 DOI: 10.1177/1591019921991394] [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: 11/16/2022] Open
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT), primarily the combination of aspirin with a P2Y12 inhibitor, in patients undergoing intravascular stent or flow diverter placement remains the primary strategy to reduce device-related thromboembolic complications. However, selection, timing, and dosing of DAPT is critical and can be challenging given the existing significant inter- and intraindividual response variations to P2Y12 inhibitors. METHODS Assessment of indexed, peer-reviewed literature from 2000 to 2020 in interventional cardiology and neuroendovascular therapeutics with critical, peer-reviewed appraisal and extraction of evidence and strategies to utilize DAPT in cardio- and neurovascular patients with endoluminal devices. RESULTS Both geno- and phenotyping for DAPT are rapidly and conveniently available as point-of-care testing at a favorable cost-benefit ratio. Furthermore, systematic inclusion of a quantifying clinical risk score combined with an operator-linked, technical risk assessment for potential adverse events allows a more precise and individualized approach to new P2Y12 inhibitor therapy. CONCLUSIONS The latest evidence, primarily obtained from cardiovascular intervention trials, supports that combining patient pharmacogenetics with drug response monitoring, as part of an individually tailored, precision medicine approach, is both predictive and cost-effective in achieving and maintaining individual target platelet inhibition levels. Indirect evidence supports that this gain in optimizing drug responses translates to reducing main adverse events and overall treatment costs in patients undergoing DAPT after intracranial stent or flow diverting treatment.
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Affiliation(s)
- Axel Rosengart
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
| | - Malie K Collins
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Philipp Hendrix
- Department of Neurosurgery, Saarland University Medical Center and Saarland University, Faculty of Medicine, Homburg/Saar, Germany
| | | | | | - Abhi Jain
- Department of Radiology, Einstein Medical Center, Philadelphia, PA, USA
| | - Jennifer Mao
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Oded Goren
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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Sirakov A, Bhogal P, Möhlenbruch M, Sirakov S. Endovascular treatment of patients with intracranial aneurysms: feasibility and successful employment of a new low profile visible intraluminal support (LVIS) EVO stent. Neuroradiol J 2020; 33:377-385. [PMID: 32692304 PMCID: PMC7482042 DOI: 10.1177/1971400920941402] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND AND PURPOSE Low-profile self-expandable stents have increased the number of intracranial aneurysms treated by endovascular means. The new low-profile visible intraluminal support device LVIS EVO (Microvention), the successor of LVIS Jr, is a self-expandable and retrievable microstent system, designed for implantation into intracranial arteries with a diameter up to 2.0 mm. In this retrospective study we aimed to elucidate the technical feasibility and clinical safety of the novel LVIS EVO stent for stent-assisted coil embolisation of intracranial aneurysms. MATERIALS AND METHODS A single centre technical report of the first six consecutive cases of stent-assisted coil embolisation with the novel LVIS EVO stent for the treatment of unruptured or recanalised intracranial aneurysms. Records were made of basic demographics, aneurysmal characteristics, device properties and related technical details, adverse events, clinical outcomes and occlusion rates on available radiological follow-up. RESULTS Six LVIS EVO devices were successfully implanted in all subjects to treat a total number of six intracranial aneurysms. No device-related intraprocedural complications were seen. At early clinical follow-up six out of six (100%) patients had a modified Ranking score of 0-1. Early angiographic and cross-sectional radiological follow-up, available in five out of six (83.3%) of the patients confirmed unchanged aneurysmal occlusion rates. A minor, transitory neurological deficit was recorded in one of the six (16.6%) patients. Mortality was 0%. CONCLUSIONS Preliminary experience in this subset of our patients confirms a notably improved technical behaviour of the novel LVIS EVO stent system when compared to its ancestor LVIS Jr. The enhanced visibility of the stent and the refined delivery/retrieval capabilities of the stent further increase the safety margins of the devices profile, especially in cases of tortuous anatomy.
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Affiliation(s)
- Alexander Sirakov
- Radiology Department, University Hospital Saint Ivan Rilski, Bulgaria
| | - Pervinder Bhogal
- Interventional Neuroradiology Department, The Royal London Hospital, UK
| | | | - Stanimir Sirakov
- Radiology Department, University Hospital Saint Ivan Rilski, Bulgaria
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10
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Utility of P2Y 12 Reactive Unit Assessment on Ticagrelor in Cerebral Aneurysms Treated with Intracranial Stenting and Flow Diversion: Cohort Study and Case Report From Two Neurovascular Centers. World Neurosurg 2020; 142:e445-e452. [PMID: 32688033 DOI: 10.1016/j.wneu.2020.07.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Dual antiplatelet therapy consisting of aspirin and clopidogrel is the standard of care for neurointerventional stenting and flow diversion. Platelet function testing has been increasingly performed to identify patients with a hypo- or hyper-response to clopidogrel. Ticagrelor has been a popular alternative antiplatelet agent for such patients. We assessed the role of platelet function testing in patients receiving ticagrelor and undergoing stenting or flow diversion. METHODS The data from patients who had undergone stent-assisted coiling or Pipeline flow diversion of a cerebral aneurysm with ticagrelor therapy at any point during their treatment course from May 2017 to August 2019 at a single academic institution in the United States were retrospectively reviewed. Platelet function testing was used to determine the P2Y12 reactive units (PRUs), and the results were correlated with the procedural complications. RESULTS A total of 28 patients with 29 aneurysms were treated while receiving ticagrelor. Of the 29 aneurysms, 16 (55.2%) were treated with flow diversion and 13 (44.8%) with stent-assisted coiling. Four thromboembolic complications (13.8%) and no hemorrhagic complications developed. Of the 8 patients with ≥1 PRU value >100, 4 (50%) had experienced a thromboembolic complication. The patients without a PRU value >100 did not experience any complications. CONCLUSION A risk of thromboembolic complications exists for patients receiving ticagrelor, which correlated with the PRUs in the present preliminary study. The findings from the present study suggest that the safe PRU range for patients receiving ticagrelor should be shifted to 0-100, which is lower than that of clopidogrel, thought to be 60-210. Further validation of the optimal PRU range for patients receiving ticagrelor is necessary.
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11
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Wirtz MM, Schirmer CM, Goren O, Bohan CO, Dalal S, Weiner G, Foreman PM, Griessenauer CJ. Utility of platelet function testing in stent-assisted coiling of cerebral aneurysms. Interv Neuroradiol 2020; 26:275-282. [PMID: 31856647 PMCID: PMC7254623 DOI: 10.1177/1591019919894140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/18/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Thromboembolic complications are the primary risks of stent-coiling of cerebral aneurysms. The utility of platelet function testing in stent-assisted aneurysm coiling remains controversial. This study aimed to assess a pharmacy-mediated antiplatelet management protocol for stent-assisted coiling. METHODS Stent-coiled aneurysms at an academic institution in the United States between 2015 and 2018 were retrospectively reviewed. All patients were managed using a pharmacy-mediated antiplatelet protocol, which required repeated platelet function testing and subsequent dose adjustments. Medication dosage, number of adjustments, aspirin reaction units (ARU) and P2Y12 reaction units (PRU), as well as complication rates, angiographic and functional outcome were analyzed. RESULTS A total of 56 aneurysms (median size 5 mm, range 2.6-14.0 mm) in 54 patients (median age 58.5 years) were treated with stent-assisted coil embolization. Most aneurysms were located at the basilar tip (28.6%). Median pre-procedure ARU and PRU were 442.5 (range 363-594) and 123.5 (range 1-252), respectively. Approximately two-thirds of all procedures required at least one aspirin dose adjustment and 88.5% of procedures required at least one clopidogrel dose adjustment. There were two (3.6%) thromboembolic complications. One of the thromboembolic complications occurred in a patient where the pharmacy-mediated protocol was violated. There were no hemorrhagic complications. Last imaging follow-up demonstrated complete aneurysm occlusion in 83.9%. CONCLUSION In patients where the pharmacy-mediated antiplatelet protocol was followed, the thromboembolic complication rate was 1.8%. This complication rate compares favorably to those reported in large contemporary series. Nevertheless, the pharmacy-mediated protocol places a significant burden on both the patient and healthcare system.
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Affiliation(s)
- Mirja M Wirtz
- Department of Neurosurgery, Geisinger, Danville, PA, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger, Danville, PA, USA
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Oded Goren
- Department of Neurosurgery, Geisinger, Danville, PA, USA
| | | | - Shamsher Dalal
- Department of Neurosurgery, Geisinger, Danville, PA, USA
- Department of Radiology, Geisinger, Danville, PA, USA
| | - Gregory Weiner
- Department of Neurosurgery, Geisinger, Danville, PA, USA
| | - Paul M Foreman
- Department of Neurosurgery, Geisinger, Danville, PA, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger, Danville, PA, USA
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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12
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Maragkos GA, Ascanio LC, Salem MM, Gopakumar S, Gomez-Paz S, Enriquez-Marulanda A, Jain A, Schirmer CM, Foreman PM, Griessenauer CJ, Kan P, Ogilvy CS, Thomas AJ. Predictive factors of incomplete aneurysm occlusion after endovascular treatment with the Pipeline embolization device. J Neurosurg 2020; 132:1598-1605. [PMID: 31026827 DOI: 10.3171/2019.1.jns183226] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Pipeline embolization device (PED) is a routine choice for the endovascular treatment of select intracranial aneurysms. Its success is based on the high rates of aneurysm occlusion, followed by near-zero recanalization probability once occlusion has occurred. Therefore, identification of patient factors predictive of incomplete occlusion on the last angiographic follow-up is critical to its success. METHODS A multicenter retrospective cohort analysis was conducted on consecutive patients treated with a PED for unruptured aneurysms in 3 academic institutions in the US. Patients with angiographic follow-up were selected to identify the factors associated with incomplete occlusion. RESULTS Among all 3 participating institutions a total of 523 PED placement procedures were identified. There were 284 procedures for 316 aneurysms, which had radiographic follow-up and were included in this analysis (median age 58 years; female-to-male ratio 4.2:1). Complete occlusion (100% occlusion) was noted in 76.6% of aneurysms, whereas incomplete occlusion (≤ 99% occlusion) at last follow-up was identified in 23.4%. After accounting for factor collinearity and confounding, multivariable analysis identified older age (> 70 years; OR 4.46, 95% CI 2.30-8.65, p < 0.001); higher maximal diameter (≥ 15 mm; OR 3.29, 95% CI 1.43-7.55, p = 0.005); and fusiform morphology (OR 2.89, 95% CI 1.06-7.85, p = 0.038) to be independently associated with higher rates of incomplete occlusion at last follow-up. Thromboembolic complications were noted in 1.4% and hemorrhagic complications were found in 0.7% of procedures. CONCLUSIONS Incomplete aneurysm occlusion following placement of a PED was independently associated with age > 70 years, aneurysm diameter ≥ 15 mm, and fusiform morphology. Such predictive factors can be used to guide individualized treatment selection and counseling in patients undergoing cerebrovascular neurosurgery.
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Affiliation(s)
- Georgios A Maragkos
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Luis C Ascanio
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mohamed M Salem
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Santiago Gomez-Paz
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Abhi Jain
- 3Department of Neurosurgery, Geisinger, Danville, Pennsylvania
- 5Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | | | - Paul M Foreman
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christoph J Griessenauer
- 3Department of Neurosurgery, Geisinger, Danville, Pennsylvania
- 4Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; and
| | - Peter Kan
- 2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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13
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Wipplinger C, Griessenauer CJ. Commentary: Antiplatelet Therapy in Flow Diversion. Neurosurgery 2020; 86:E231-E233. [PMID: 31844900 DOI: 10.1093/neuros/nyz462] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 08/23/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Christoph J Griessenauer
- Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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14
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Tonetti DA, Jankowitz BT, Gross BA. Antiplatelet Therapy in Flow Diversion. Neurosurgery 2019; 86:S47-S52. [DOI: 10.1093/neuros/nyz391] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 07/25/2019] [Indexed: 01/03/2023] Open
Abstract
Abstract
Dual antiplatelet therapy is typically employed as a means to mitigate thromboembolic complications after deployment of flow diverters, most commonly consisting of aspirin with either clopidogrel, prasugrel, or ticagrelor. Recent studies have demonstrated at least similar efficacy for ticagrelor as compared to clopidogrel in the form of periprocedural complications and angiographic results. Though controversial, systematic reviews of platelet function assay usage have demonstrated greater rates of thrombotic complications in antiplatelet hyporesponders and greater rates of hemorrhagic complications in hyperresponders. Though in its infancy, the management of antiplatelet therapy for acutely ruptured aneurysms treated with flow diversion is not yet standardized, with approaches including intravenous glycoprotein IIb-IIIa inhibitors and subsequent antiplatelet loading vs antiplatelet loading, response assessment, and subsequent treatment.
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Affiliation(s)
- Daniel A Tonetti
- UPMC Stroke Institute and Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian T Jankowitz
- UPMC Stroke Institute and Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bradley A Gross
- UPMC Stroke Institute and Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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15
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Ajadi E, Kabir S, Cook A, Grupke S, Alhajeri A, Fraser JF. Predictive value of platelet reactivity unit (PRU) value for thrombotic and hemorrhagic events during flow diversion procedures: a meta-analysis. J Neurointerv Surg 2019; 11:1123-1128. [PMID: 31005859 DOI: 10.1136/neurintsurg-2019-014765] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/26/2019] [Accepted: 03/28/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Platelet function testing prior to flow diversion procedures, although initially heavily debated, has seen a substantial increase in its adoption to assess the risk of operative and perioperative thrombotic and hemorrhagic events. This meta-analysis was conducted to assess platelet function testing, particularly the VerifyNow Platelet Reactivity Unit (PRU) assay, for a relationship between the reported assay PRU value and thrombotic and hemorrhagic events. MATERIALS AND METHODS The currently available literature (2013-2018) was surveyed with PubMed and Google Scholar searches. Included studies were those for which there were at least 30 cases during the study period, for which VerifyNow platelet reactivity unit values were obtained prior to the procedures and for which intraoperative and perioperative adverse events were noted. PRU value cut-offs ranging from >200 to >240 comprised the hyporesponse group while values ranging from <60 to <70 comprised the hyper-response group. The data were subject to statistical analysis to assess the relationship between PRU values and thrombotic and hemorrhagic events. The collected data were subsequently statistically analyzed to assess for publication bias. RESULTS The searches yielded 27 studies, of which 12 met the inclusion criteria for the meta-analysis. The meta-analysis included data from 1464 reported Pipeline cases. The study included 273 men and 1177 women with a mean age across the analyzed procedures of 58 years (range 25-85). After loading with antiplatelet medications, preprocedural platelet hyper-responsiveness was associated with a greater incidence of hemorrhagic events with an increased absolute risk of 12%, but showed no relationship with thrombotic events. Preprocedural platelet hyporesponsiveness was associated with a greater incidence of thrombotic events with an absolute risk of 15%, but showed no relationship with hemorrhagic events. CONCLUSIONS VerifyNow PRU values that correspond to platelet hyporesponse or hyper-response to dual antiplatelet therapy are associated with a higher risk of thrombotic and hemorrhagic events, respectively. Thus, the PRU value may offer some predictive value for these events.
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Affiliation(s)
- Ebunoluwa Ajadi
- University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Shaowli Kabir
- Department of Statistics, College of Arts and Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Aaron Cook
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Stephen Grupke
- Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Abdulnasser Alhajeri
- Department of Neurology, University of Kentucky, Lexington, KY, USA.,Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Justin F Fraser
- Department of Neurology, University of Kentucky, Lexington, KY, USA.,Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA.,Department of Radiology, University of Kentucky, Lexington, KY, USA.,Department of Neuroscience, University of Kentucky, Lexington, KY, USA
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16
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Barra ME, Berger K, Tesoro EP, Brophy GM. Periprocedural Neuroendovascular Antiplatelet Strategies for Thrombosis Prevention in Clopidogrel-Hyporesponsive Patients. Pharmacotherapy 2019; 39:317-334. [PMID: 30723937 DOI: 10.1002/phar.2228] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patients undergoing neuroendovascular procedures such as cerebral aneurysm coiling and intracranial stent deployment are frequently treated with antiplatelet agents to prevent thrombotic complications. The combination of aspirin and a P2Y12 inhibitor such as clopidogrel is often initiated days before elective procedures or as loading doses for emergent procedures; however, some patients may still experience thrombotic complications. Patients identified as clopidogrel hyporesponders are more likely to experience poor outcomes and may require changes to their regimens. Historically, high-dose clopidogrel regimens were used in response to subtherapeutic results of platelet function assays and point-of-care testing despite limited supporting data. Recently, more data have emerged using alternative P2Y12 inhibitors such as prasugrel and ticagrelor. Dosing for neuroendovascular conditions is often extrapolated from the cardiac literature, although outcomes in cardiac patients may not be relevant to neurologic patients, making prophylactic treatment recommendations challenging for these patients. This review summarizes the literature for antiplatelet prophylaxis in patients undergoing neuroendovascular device placement, focusing on alternative regimens for clopidogrel hyporesponders.
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Affiliation(s)
- Megan E Barra
- Massachusetts General Hospital, Boston, Massachusetts
| | - Karen Berger
- NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
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17
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Griessenauer CJ, Goren O, Dalal SS, Schirmer CM. Pipeline Embolization Device with Shield Technology for Intracranial Aneurysms: An Initial U.S. Experience. World Neurosurg 2018; 119:10-14. [PMID: 30075266 DOI: 10.1016/j.wneu.2018.07.203] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Thromboembolic complications remain a major reason for morbidity and mortality after flow diversion, in addition to hemorrhagic complications not limited to the brain predicated on the prolonged need for dual antiplatelet therapy. Surface modification to decrease thrombogenicity and accelerate aneurysm occlusion is a promising alteration to mitigate those risks. The Pipeline embolization device with Shield Technology possesses such characteristics; however, it has not yet been approved in the United States. CASE DESCRIPTION We present the case of a 38-year-old woman with a Spetzler-Martin grade 4 left parietal arteriovenous malformation with a total of 8 feeding vessel aneurysms and recent rupture of 1 of those aneurysms that was treated with balloon-assisted coil embolization. Four M1-segment middle cerebral artery aneurysms and 1 supraclinoid internal carotid artery aneurysm were treated with 2 Pipeline embolization Shield devices after a compassionate use request was approved. At 3 weeks after the procedure, the patient experienced a minor ischemic stroke after having missed the prescribed dual antiplatelet therapy. At the 3-month follow-up examination, the patient was neurologically intact and all the aneurysms were occluded. Dual antiplatelet therapy was discontinued. CONCLUSIONS Flow diverters with surface modification to decrease thrombogenicity and accelerate aneurysm occlusion are promising endovascular tools for patients at high risk of complications with dual antiplatelet therapy. The present case represents one of the first cases performed in the United States using such a device. Despite the favorable outcome in the present case, the question of whether such technology obviates the need for dual antiplatelet therapy remains to be determined.
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Affiliation(s)
- Christoph J Griessenauer
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA; Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.
| | - Oded Goren
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA
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