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Young M, Enriquez-Marulanda A, Salih M, Shutran M, Budohoski K, Grandhi R, Taussky P, Ogilvy CS. Management of Intracranial Aneurysms that Do Not Occlude on Initial Follow-up After Treatment With the Pipeline Embolization Device. Neurosurgery 2024; 94:271-277. [PMID: 37655903 DOI: 10.1227/neu.0000000000002655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The pipeline embolization device (PED) has become widely accepted as a safe and efficacious treatment for intracranial aneurysms with high rates of complete occlusion at initial follow-up. For aneurysms that are not completely occluded at initial follow-up, further treatment decision-making is varied. Furthermore, the risk of aneurysmal rupture in these incompletely occluded aneurysms after PED is not known. The objective of this study was to determine treatment decision-making that results in increased occlusion status at final follow-up and to evaluate risk of rupture in those aneurysms that do not go onto occlusion. METHODS This study is a retrospective review of prospective data for intracranial aneurysms treated with PED at two institutions from 2013 to 2019. Aneurysms with near-complete or incomplete occlusion at initial follow-up were included in the statistical analysis. RESULTS There were 606 total aneurysms treated at two academic institutions with PED with incomplete occlusion at initial follow-up in 134 aneurysms (22.1%). Of the 134 aneurysms that were nonoccluded at initial follow-up, 76 aneurysms (56.7%) went on to complete or near complete occlusion with final complete or near complete occlusion in 90.4% of all aneurysms treated. The time to final imaging follow-up was 28.2 months (13.8-44.3) Retreatment with a second flow diverter was used in 28 aneurysms (20.9%). No aneurysms that were incompletely occluded at initial follow-up had delayed rupture. Furthermore, older patient age was statistically significant for incomplete occlusion at initial follow-up ( P = .05). CONCLUSION Intracranial aneurysms treated with the PED that do not occlude at initial follow-up may go on to complete occlusion with continuous observation, alteration in antiplatelet regimens, or repeat treatment. Delayed aneurysmal rupture was not seen in patients with incomplete occlusion.
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Affiliation(s)
- Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Alejandro Enriquez-Marulanda
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Karol Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
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Mitchell DL, McGuire LS, Khalid SI, Alaraj A. Assessing the efficacy of VerifyNow platelet-function testing in predicting postoperative thromboembolic complications of neuroendovascular surgery: A systematic review and meta-analysis (part 1). Interv Neuroradiol 2024:15910199231224008. [PMID: 38186294 DOI: 10.1177/15910199231224008] [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: 01/09/2024] Open
Abstract
BACKGROUND Despite the heavily debated use of routine platelet-function testing, the VerifyNow Platelet Reactivity Unit (PRU) assay has been increasingly adopted as standard of care for assessing risk of postoperative thromboembolic complications of neuroendovascular surgery. OBJECTIVE We conducted a systematic review and meta-analysis to examine the relationship between platelet response and risk of ischemic events from neuroendovascular surgery, assess the efficacy of point-of-care platelet-function testing in predicting thromboembolic outcomes, and assess whether a clinically useful threshold for platelet response can be defined in order to standardize guidelines. METHODS PubMed, Embase, and Scopus were searched. Following deduplication, articles were first screened for relevance by title and abstract, followed by full text. RESULTS Of 735 resultant articles, 22 studies consisting of 3266 patients undergoing neuroendovascular intervention were included. Diagnoses included both intracranial and extracranial pathologies, of which 45.8% were treated with flow diversion, 16.4% with stent-assisted coil embolization, 15.8% with intracranial stenting, 12.0% with simple coil embolization, 3.4% with balloon-assisted coil embolization, 3.6% with extracranial stenting, and 3.0% with an alternate method. 54.5% (12/22) of studies determined platelet hyporesponse to be an independent predictor of postoperative thromboembolic complications, with 27.3% (6/22) of studies reporting a similar, but non-statistically significant trend. 18.2% (4/22) of studies found no relationship between platelet response and postoperative thromboembolic complications. The estimated clinical threshold for PRU to prevent thromboembolic complications varied greatly across studies (Range: > 144-295 PRU). Meta-analysis found platelet hyporesponse to have a 2.23-fold increased risk of thromboembolic complications compared to normoresponders (RR = 2.23, P = 0.03). CONCLUSION While PRU demonstrates a significant predictive value for postoperative thromboembolic complications of neuroendovascular surgery, the target therapeutic threshold for minimizing ischemic events remains unclear. Further studies, such as large multicenter cohorts of the existing data, are needed to standardize guidelines.
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Affiliation(s)
- Devon L Mitchell
- Chicago Medical School, Rosalind Franklin University, Chicago, IL, USA
| | | | - Syed I Khalid
- Department of Neurosurgery, University of Illinois, Chicago, IL, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois, Chicago, IL, USA
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3
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Mitchell DL, McGuire LS, Khalid SI, Alaraj A. Assessing the efficacy of VerifyNow platelet-function testing in predicting postoperative hemorrhagic complications of neuroendovascular surgery: A systematic review and meta-analysis (part 2). Interv Neuroradiol 2024:15910199231225716. [PMID: 38192126 DOI: 10.1177/15910199231225716] [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: 01/10/2024] Open
Abstract
BACKGROUND Dual antiplatelet therapy is used to reduce the risk of thromboembolic complications in neuroendovascular surgery. However, the predictive utility of preoperative platelet-sensitivity testing for decreasing bleed risk in patients undergoing endovascular neurointervention remains unclear. OBJECTIVE We conducted a systematic review and meta-analysis to illustrate the association between platelet response and risk of hemorrhagic complications from neuroendovascular surgery, examine the efficacy of the VerifyNow platelet reactivity unit (PRU) assay in predicting hemorrhagic outcomes, and assess whether a clinically useful threshold for platelet response can be defined to standardize guidelines. METHODS PubMed, Embase, and Scopus were searched. Articles were screened for relevance by title and abstract, followed by full text. RESULTS Of 735 resultant articles, 17 studies of 2084 patients undergoing neuroendovascular intervention were included. Diagnoses included both intracranial and extracranial pathologies, of which 37.8% were treated with flow diversion, 22.4% with stent-assisted coil embolization, 14.3% with intracranial stenting, 12.8% with simple coil embolization, 5.8% with balloon-assisted coil embolization, 2.0% with extracranial stenting, and 4.8% with an alternate method. Precisely, 52.9% (9 out of 17) of studies determined platelet hyperresponse to be an independent predictor of postoperative hemorrhagic complications, with 11.8% (2 out of 17) of studies reporting a similar but non-statistically significant trend. 35.3% (6 out of 17) of studies found no relationship between platelet response and postoperative hemorrhagic complications. The estimated clinical threshold for PRU to prevent hemorrhagic complications varied considerably across studies (range: <46-118 PRU). Meta-analysis found platelet hyperresponse to have more than a 3-fold increased risk of hemorrhagic complications compared to normoresponders (relative risk = 3.2, p = 0.001). CONCLUSION Although this meta-analysis shows the predictive utility of the P2Y12 assay for postoperative hemorrhagic complications in neuroendovascular surgery, the optimal therapeutic threshold for minimizing bleeding risk is still uncertain. To better understand the utility of the P2Y12 assay in the perioperative period, further prospective research is needed.
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Affiliation(s)
- Devon L Mitchell
- Chicago Medical School, Rosalind Franklin University, North Chicago, IL, USA
| | | | - Syed I Khalid
- Department of Neurosurgery, University of Illinois, Chicago, IL, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois, Chicago, IL, USA
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4
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Flynn LM, Mohamed E, Dobbs N, Nania A, Du Plessis J, Keston PM, Downer JJ. Safety of dual antiplatelet therapy using aspirin and low-dose Prasugrel with platelet reactivity testing in flow diverter treatment of intracranial aneurysms. Interv Neuroradiol 2023:15910199231217142. [PMID: 38031444 DOI: 10.1177/15910199231217142] [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: 12/01/2023] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is standard care for intracranial stenting to prevent thrombotic complications. Clopidogrel resistance has resulted in patients receiving newer P2Y12 inhibitors like Prasugrel, which may reduce thrombotic complications but could increase haemorrhagic complications. This study, utilising platelet reactivity testing, compared thrombotic and haemorrhagic complications associated with Clopidogrel or 20 mg Prasugrel loading in patients treated with flow diverters (FD) for intracranial aneurysms. METHODS We retrospectively analysed prospectively collected data from 225 consecutive FD procedures. All patients received aspirin. 147 cases received Clopidogrel and 82 received Prasugrel. All patients had VerifyNow testing before the procedure. RESULTS P2Y12 non-responders were significantly more likely to have thrombotic complications than responders and hyper-responders (7% vs. 2%, p = 0.01). Low-dose Prasugrel resulted in a significantly lower rate of non-responders when compared with Clopidogrel (7% vs. 25%, p < 0.01). We found no statistically significant difference in rates of haemorrhage between the Clopidogrel and Prasugrel groups (2.4% vs. 3.9%, p = 0.47). There were 12 complications (≤7 days) in the Clopidogrel group versus 6 in the Prasugrel group (9% vs. 7.8%, respectively, p = 0.91) and a non-significant reduction in thrombotic complications in the Prasugrel group (5.2% vs. 3.9%, p = 0.88). No significant difference was shown in long-term complications between the groups (p = 0.33). CONCLUSION These results support the use of platelet reactivity testing and the safety of low-dose Prasugrel for FD treatment of intracranial aneurysms.
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Affiliation(s)
- Liam M Flynn
- Department of Clinical Neurosciences, Edinburgh, UK
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Bouchal SM, Patra DP, Qazi Z, Bendok BR. Commentary: Common Carotid Artery to Middle Cerebral Artery Bypass With Radial Interposition Graft for Internal Carotid Artery (ICA) Occlusion After Stent-Coil Embolization of Giant ICA Terminus Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e113-e114. [PMID: 37195048 DOI: 10.1227/ons.0000000000000768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 05/18/2023] Open
Affiliation(s)
| | - Devi P Patra
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Zeeshan Qazi
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
- Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
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Wang X, Luo L, Wang Y, An Z. Effect of Platelet Function Testing Guidance on Clinical Outcomes for Patients with Intracranial Aneurysms Undergoing Endovascular Treatment. AJNR Am J Neuroradiol 2023; 44:928-933. [PMID: 37414457 PMCID: PMC10411848 DOI: 10.3174/ajnr.a7923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/01/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Platelet function testing has been proposed to better adjust individualized antiplatelet treatment for patients undergoing endovascular treatment for intracranial aneurysms. Its clinical significance needs to be comprehensively evaluated. PURPOSE Our aim was to evaluate the impact of platelet function testing-guided versus standard antiplatelet treatment in patients receiving endovascular treatment for intracranial aneurysms. DATA SOURCES PubMed, EMBASE, and the Cochrane Library of clinical trials were searched from inception until March 2023. STUDY SELECTION Eleven studies comprising 6199 patients were included. DATA ANALYSIS ORs with 95% CIs were calculated using random effects models. DATA SYNTHESIS The platelet function testing-guided group was associated with a decreased rate of symptomatic thromboembolic events (OR = 0.57; 95% CI, 0.42-0.76; I2 = 26%). No significant difference was found in asymptomatic thromboembolic events (OR = 1.07; 95% CI, 0.39-2.94; I2 = 48%), hemorrhagic events (OR = 0.71; 95% CI, 0.42-1.19; I2 = 34%), intracranial hemorrhagic events (OR = 0.61; 95% CI, 0.03-10.79; I2 = 62%), morbidity (OR = 0.53; 95% CI, 0.05-5.72; I2 = 86%), and mortality (OR = 1.96; 95% CI, 0.64-5.97; I2 = 0%) between the 2 groups. Subgroup analysis suggested that platelet function testing-guided therapy may contribute to fewer symptomatic thromboembolic events in patients who received stent-assisted coiling (OR = 0.43; 95% CI, 0.18-1.02; I2 = 43%) or a combination of stent-assisted and flow-diverter stent placement (OR = 0.61; 95% CI, 0.36-1.02; I2 = 0%) or who changed from clopidogrel to other thienopyridines (OR = 0.64; 95% CI, 0.40-1.02; I2 = 18%), though the difference did not reach statistical significance. LIMITATIONS Heterogeneous endovascular treatment methods and adjusted antiplatelet regimens were limitations. CONCLUSIONS Platelet function testing-guided antiplatelet strategy significantly reduced the incidence of symptomatic thromboembolic events without any increase in the hemorrhagic events for patients undergoing endovascular treatment for intracranial aneurysms.
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Affiliation(s)
- X Wang
- From the Departments of Pharmacy (X.W., Z.A.)
| | - L Luo
- Department of Pharmacy (L.L.), Beijing Huairou Hospital, Beijing, China
| | - Y Wang
- Neurosurgery (Y.W.), Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Z An
- From the Departments of Pharmacy (X.W., Z.A.)
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Liu L, Xu L, Guo N, Yang Y, Liu X, Qi T, Liang F. Ticagrelor is related to nuisance bleeding after flow diversion of unruptured intracranial aneurysms. Neurosurg Rev 2023; 46:134. [PMID: 37269331 DOI: 10.1007/s10143-023-02043-y] [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: 04/12/2023] [Revised: 05/12/2023] [Accepted: 05/27/2023] [Indexed: 06/05/2023]
Abstract
Nuisance bleeding (NB) without urgent medical attention is rarely characterized despite its frequent occurrence in patients with cerebral aneurysms undergoing flow diversion (FD) who are maintained on dual antiplatelet therapy (DAPT). This study explored the risk factors for NB. Patients with unruptured cerebral aneurysms who underwent intervention using FD (July 2018 to May 2022) and had follow-up data were enrolled. Patient demographics, clinical characteristics, aneurysm features and follow-up data were analysed. Bleeding complications were classified as NB, internal bleeding and alarming bleeding. NB was characterized by easy bruising, bleeding from small cuts and nonfatal petechiae and ecchymosis. Univariate and multivariate logistic regression analyses were performed to determine risk factors for NB. This study assessed 121 patients. Of these, 52 (43.0%) patients had NB. Compared with the non-bleeding group, the NB group had more females (82.7% vs. 56.5%; p = 0.003), lower smoking rate (7.7% vs. 23.2%; p = 0.027) and smaller aneurysms (6.65 mm [4.60-9.60 mm] vs. 8.82 mm [5.65-15.65 mm]; p = 0.007) and had more patients maintained on ticagrelor-containing DAPT regimen (90.4% vs. 66.7%; p = 0.002). Multivariate logistic regression revealed that ticagrelor-containing DAPT regimen (odds ratio, 3.91; 95% confidence interval, 1.29-11.87; p = 0.016) was associated with NB. These results suggest that NB is a common bleeding complaint in patients on DAPT. In patients undergoing FD, DAPT with ticagrelor was the only independent risk factor for NB.
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Affiliation(s)
- Linfeng Liu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Lin Xu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Ning Guo
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Yibing Yang
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Xinman Liu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Tiewei Qi
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Feng Liang
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China.
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Ma Y, Madjidyar J, Schubert T, Thurner P, Barnaure I, Kulcsar Z. Single antiplatelet regimen in flow diverter treatment of cerebral aneurysms: The drug matters. A systematic review and meta-analysis. Interv Neuroradiol 2023:15910199231177745. [PMID: 37221854 DOI: 10.1177/15910199231177745] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Hemorrhagic and thromboembolic complications (TECs) are the main concerns in the endovascular treatment of intracranial aneurysms using flow diverter devices (FDs). The clinical demand for single antiplatelet therapy (SAPT) is increasing especially with the development of devices with lower thrombogenicity profile. However, the safety of SAPT is not well established. OBJECTIVE To analyze the safety and efficacy of SAPT in terms of ischemic and hemorrhagic complications in patients undergoing FDs treatment for cerebral aneurysms. METHODS A systematic literature search and meta-analysis were conducted in PubMed, Ovid MEDLINE, Ovid Embase, and Web of Science from January 2010 until October 2022. Twelve articles which reported SAPT and data on hemorrhagic, TECs, and mortality following FDs treatment were included. RESULTS Overall, the 12 studies involved 237 patients with 295 aneurysms. Five investigated the safety and efficacy of SAPT in 202 unruptured aneurysms. Six studies focused on 57 ruptured aneurysms. One study included both ruptured and unruptured aneurysms. Among the 237 patients, prasugrel was most often used as SAPT in 168 cases (70.9%), followed by aspirin in 42 (17.7%) patients, and by ticagrelor in 27 (11.4%). Overall, the hemorrhagic complication rate was 0.1% (95% CI 0% to 1.8%). The TEC rate was 7.6% (95% CI 1.7% to 16.1%). In the subgroup analysis, the TEC rates of prasugrel monotherapy of 2.4% (95% CI 0% to 9.3%) and ticagrelor monotherapy of 4.2% (95% CI 0.1% to 21.1%) were lower than of aspirin monotherapy 20.2% (95% CI 5.9% to 38.6%). The overall mortality rate was 1.3% (95% CI 0% to 6.1%). CONCLUSION According to the available data, SAPT regimen in patients undergoing FDs treatment for cerebral aneurysms has an acceptable safety profile, especially with the use of ADP-receptor antagonists.
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Affiliation(s)
- Yihui Ma
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jawid Madjidyar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Tilman Schubert
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Patrick Thurner
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Isabelle Barnaure
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Vollherbst DF, Lücking H, DuPlessis J, Sonnberger M, Maurer C, Kocer N, Killer-Oberpfalzer M, Rautio R, Valvassori L, Berlis A, Gasser S, Gatt S, Dörfler A, Bendszus M, Möhlenbruch MA. The FRESH Study: Treatment of Intracranial Aneurysms with the New FRED X Flow Diverter with Antithrombotic Surface Treatment Technology-First Multicenter Experience in 161 Patients. AJNR Am J Neuroradiol 2023; 44:474-480. [PMID: 36997283 PMCID: PMC10084892 DOI: 10.3174/ajnr.a7834] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/23/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND AND PURPOSE Flow diverters with antithrombotic coatings are increasingly used to improve the safety of flow diverter treatments of intracranial aneurysms. This study aimed to investigate the safety and short-term efficacy of the new FRED X flow diverter. MATERIALS AND METHODS Medical charts and procedural and imaging data of a consecutive series of patients with intracranial aneurysms who were treated with the FRED X at 9 international neurovascular centers were retrospectively analyzed. RESULTS One hundred sixty-one patients (77.6% women; mean age, 55 years) with 184 aneurysms (11.2% acutely ruptured) were included in this study. Most aneurysms were located in the anterior circulation (77.0%), most frequently at the ICA (72.7%). The FRED X was successfully implanted in all procedures. Additional coiling was performed in 29.8%. In-stent balloon angioplasty was necessary in 2.5%. The rate of major adverse events was 3.1%. Thrombotic events occurred in 7 patients (4.3%) with 4 intra- and 4 postprocedural in-stent thromboses, respectively (1 patient had both peri- and postprocedural thrombosis). Of these thrombotic events, only 2 (1.2%) led to major adverse events (ischemic strokes). Postinterventional neurologic morbidity and mortality were observed in 1.9% and 1.2%, respectively. The rate of complete aneurysm occlusion after a mean follow-up of 7.0 months was 66.0%. CONCLUSIONS The new FRED X is a safe and feasible device for aneurysm treatment. In this retrospective multicenter study, the rate of thrombotic complications was low, and the short-term occlusion rates are satisfactory.
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Affiliation(s)
- D F Vollherbst
- From the Department of Neuroradiology (D.F.V., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - H Lücking
- Department of Neuroradiology (H.L., A.D.), University of Erlangen-Nuremberg, Erlangen, Germany
| | - J DuPlessis
- Department of Clinical Neurosciences (J.D., S. Gatt), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M Sonnberger
- Department of Neuroradiology (M.S., S. Gasser), Johannes Kepler University Linz, Linz, Austria
| | - C Maurer
- Department of Diagnostic and Interventional Neuroradiology (C.M., A.B.), University Hospital Augsburg, Augsburg, Germany
| | - N Kocer
- Department of Radiology (N.K.), Division of Neuroradiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - M Killer-Oberpfalzer
- Department of Neurology (M.K.-O.), Institute of Neurointervention, Paracelsus Medizinische Privatuniversität, Salzburg, Austria
| | - R Rautio
- Department of Interventional Radiology (R.R.), Turku University Hospital, Turku, Finland
| | - L Valvassori
- Department of Neuroradiology (L.V.), San Carlo Borromeo Hospital, Milano, Lombardia, Italy
| | - A Berlis
- Department of Diagnostic and Interventional Neuroradiology (C.M., A.B.), University Hospital Augsburg, Augsburg, Germany
| | - S Gasser
- Department of Neuroradiology (M.S., S. Gasser), Johannes Kepler University Linz, Linz, Austria
| | - S Gatt
- Department of Clinical Neurosciences (J.D., S. Gatt), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - A Dörfler
- Department of Neuroradiology (H.L., A.D.), University of Erlangen-Nuremberg, Erlangen, Germany
| | - M Bendszus
- From the Department of Neuroradiology (D.F.V., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - M A Möhlenbruch
- From the Department of Neuroradiology (D.F.V., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
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Gonzalez SM, Iordanou J, Adams W, Tsiang J, Frazzetta J, Kim M, Rezaii E, Pecoraro N, Zsigray B, Simon JE, Zakaria J, Jusue-Torres I, Li D, Heiferman DM, Serrone JC. Effect of Stent Porosity, Platelet Function Test Usage, and Dual Antiplatelet Therapy Duration on Clinical and Radiographic Outcomes After Stenting for Cerebral Aneurysms: A Meta-Analysis. World Neurosurg 2023; 171:159-166.e13. [PMID: 36529432 DOI: 10.1016/j.wneu.2022.12.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The use of stents with various porosities for treating cerebral aneurysms requires dual antiplatelet therapy (DAPT) without clear guidelines on the utility of platelet function tests (PFTs) and the duration of DAPT. We sought to determine the effects of stent porosity, PFT usage, and DAPT duration on the radiographic and clinical outcomes after stenting of cerebral aneurysms. METHODS PubMed was searched on March 29, 2021 for studies of cerebral aneurysm stenting that had specified the stent type and DAPT duration. A random effects meta-analysis was used to measure the prevalence of nonprocedural thrombotic and hemorrhagic events, clinical outcomes, aneurysm occlusion, and in-stent stenosis stratified by stent porosity, PFT usage, and DAPT duration. RESULTS The review yielded 105 studies (89 retrospective and 16 prospective) with 117 stenting cohorts (50 high porosity, 17 intermediate porosity, and 50 low porosity). In the high-, intermediate-, and low-porosity stenting cohorts, PFT usage was 26.0%, 47.1%, and 62.0% and the mean DAPT duration was 3.51 ± 2.33, 3.97 ± 1.92, and 5.18 ± 2.27 months, respectively. The intermediate-porosity stents showed a reduced incidence of hemorrhagic events (π = 0.32%) compared with low-porosity stents (π = 1.36%; P = 0.01) and improved aneurysm occlusion (π = 6.18%) compared with high-porosity stents (π = 14.42%; P = 0.001) and low-porosity stents (π = 11.71%; P = 0.04). The prevalence of in-stent stenosis was lower for the intermediate-porosity (π = 0.57%) and high-porosity (π = 1.51%) stents than for the low-porosity stents (π = 3.30%; P < 0.05). PFT use had resulted in fewer poor clinical outcomes (π = 3.54%) compared with those without PFT use (π = 5.94%; P = 0.04). The DAPT duration had no effect on the outcomes. CONCLUSIONS In the present meta-analysis, which had selected for studies of cerebral aneurysm stenting that had reported the DAPT duration, intermediate-porosity stents and PFT use had resulted significantly improved outcomes. No effect of DAPT duration could be detected.
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Affiliation(s)
| | - Jordan Iordanou
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - William Adams
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Illinois, USA
| | - John Tsiang
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Joseph Frazzetta
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Miri Kim
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Elhaum Rezaii
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Nathan Pecoraro
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Brandon Zsigray
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Joshua E Simon
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Jehad Zakaria
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | | | - Daphne Li
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Daniel M Heiferman
- Department of Neurological Surgery, Edward-Elmhurst Health, Naperville, Illinois, USA
| | - Joseph C Serrone
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA; Department of Neurological Surgery, Edward Hines Jr Veterans Affairs Hospital, Hines, Illinois, USA.
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11
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Ji Z, Yang W, Ma Y, Bian L, Li G, Fu Y, Piao Y, Zhang H. Case report: Late in-stent thrombosis in a patient with vertebrobasilar dolichoectasia after stent-assisted coil embolization due to the discontinuation of antiplatelet therapy. Front Neurol 2023; 14:1129816. [PMID: 37122309 PMCID: PMC10130566 DOI: 10.3389/fneur.2023.1129816] [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: 12/22/2022] [Accepted: 03/20/2023] [Indexed: 05/02/2023] Open
Abstract
Vertebrobasilar dolichoectasia (VBD) is a rare type of cerebrovascular disorder with high rates of morbidity and mortality. Due to the distinct pathological characteristics that fragmented internal elastic lamina and multiple dissections, VBD is difficult to treat and cured. Stent-assisted coil embolization is one of the main treatment modalities for such lesions. However, the duration of healing remained questionable, and there were no effective measures for evaluating endothelial coverage. Before complete endothelial coverage, the discontinuation of antiplatelet therapy may lead to fatal in-stent thrombosis; however, continued antiplatelet therapy could also result in bleeding complications. Thus, we present an autopsy case of late in-stent thrombosis due to the discontinuation of antiplatelet therapy and systematically review the literature to provide a reference for endovascular treatment and antiplatelet regimen of VBD.
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Affiliation(s)
- Zhe Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wanxin Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Peking University, Haidian, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongjuan Fu
- Department of Pathology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yueshan Piao
- Department of Pathology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Hongqi Zhang
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12
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Han J, Liang F, Zhang Y, Zhang Y, Liang S, Zhu H, Chang Y, Ma C, Liu L, Jia Z, Jiang C. Pipeline embolization devices for the treatment of nonsaccular aneurysms in pediatric patients. Front Neurol 2023; 14:1115618. [PMID: 36925937 PMCID: PMC10011091 DOI: 10.3389/fneur.2023.1115618] [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: 12/04/2022] [Accepted: 02/07/2023] [Indexed: 03/08/2023] Open
Abstract
Objective Pediatric nonsaccular aneurysms are rare but challenging lesions; pipeline embolization devices (PEDs) are their potential treatment option. In this study, we aimed to evaluate the safety and efficacy of PEDs for treatment of these aneurysms. Methods We retrospectively selected pediatric patients with nonsaccular aneurysms treated using PEDs between June 2015 and July 2021 from our prospectively maintained database. For each patient, demographics, aneurysm characteristics, procedure details, and clinical and angiographic follow-up data were collected and summarized. Results This study included 16 pediatric patients with 16 nonsaccular aneurysms treated with PEDs. A median clinical follow-up time of 1,376 days was achieved in 93.75% of the patients. The complication rate of the included patients was 25%, with two patients developing mass effect, one patient undergoing major ischemic stroke, and one patient experiencing stent foreshortening after the procedure. The complete occlusion rate of aneurysms without any neurologic sequelae was 93.33%, with a median angiographic follow-up period of 246 days. The mortality rate was 6.25%. Conclusions The use of PEDs to treat pediatric nonsaccular aneurysms is feasible, with a high rate of complete occlusion of the aneurysm and favorable follow-up outcomes.
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Affiliation(s)
- Jintao Han
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Fei Liang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Yuxiang Zhang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Yupeng Zhang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Haoyu Zhu
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuzhou Chang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chao Ma
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Lian Liu
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zichang Jia
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Chuhan Jiang
- Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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13
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Gozal YM, Abou-Al-Shaar H, Alzhrani G, Taussky P, Couldwell WT. Complications of Endovascular and Open Aneurysm Surgery in the Era of Flow Diversion. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:85-94. [PMID: 37548727 DOI: 10.1007/978-3-030-12887-6_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
The techniques used for treatment of intracranial aneurysms have progressed dramatically over the decades. The introduction of modern endovascular techniques and the continued refinement of progressively less invasive neurosurgical approaches have contributed to steadily improving clinical outcomes. Moreover, innovations such as flow-diverting stents have achieved dramatic success and have gained rapid widespread adoption. Particularly in lesions for which the application of conventional treatment techniques is difficult, flow diversion technology has revolutionized aneurysm management. This review provides a discussion on the morbidity and mortality encountered in the treatment of intracranial aneurysms in the modern era. Common adverse events faced in the management of these lesions with open surgery and various endovascular techniques are highlighted.
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Affiliation(s)
- Yair M Gozal
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
- Mayfield Clinic, Cincinnati, OH, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gmaan Alzhrani
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
- Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA.
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14
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Young CC, Bass DI, Cruz MJ, Carroll K, Vanent KN, Lee C, Sen RD, Feroze AH, Williams JR, Levy S, McCray D, Kelly CM, Barber J, Kim LJ, Levitt MR. Clopidogrel hyper-response increases peripheral hemorrhagic complications without increasing intracranial complications in endovascular aneurysm treatments requiring dual antiplatelet therapy. J Clin Neurosci 2022; 105:66-72. [PMID: 36113244 DOI: 10.1016/j.jocn.2022.09.005] [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: 04/19/2022] [Revised: 08/09/2022] [Accepted: 09/03/2022] [Indexed: 10/31/2022]
Abstract
Clinical significance of increased clopidogrel response measured by VerifyNow P2Y12 assay is unclear; management guidelines are lacking in the context of neuroendovascular intervention. Our objective was to assess whether increased clopidogrel response predicts complications from endovascular aneurysm treatment requiring dual antiplatelet therapy. A single-institution, 9-year retrospective study of patients undergoing endovascular treatments for ruptured and unruptured aneurysms requiring aspirin and clopidogrel was conducted. Patients were grouped according to preoperative platelet inhibition in response to clopidogrel measured by the VerifyNow P2Y12 assay (VNP; P2Y12 reactivity units, PRU). Demographic and clinical features were compared across groups. Hemorrhagic complication rates (intracranial, major extracranial, minor extracranial) and thromboembolic complications (in-stent stenosis, stroke/transient ischemic attack) were compared, controlling for potential confounders and multiple comparisons. Data were collected from 284 patients across 317 procedures. Pre-operative VNP assays identified 9 % Extreme Responders (PRU ≤ 15), 13 % Hyper-Responders (PRU 16-60), 62 % Therapeutic Responders (PRU 61-214), 16 % Hypo-Responders (PRU ≥ 215). Increased response to clopidogrel was associated with increased risk of any hemorrhagic complication (≤60 PRU vs > 60 PRU; 39 % vs 24 %, P = 0.050); all intracranial hemorrhages occurred in patients with PRU > 60. Thromboembolic complications were similar between therapeutic and subtherapeutic patients (<215 PRU vs ≥ 215 PRU; 15 % vs 16 %, P = 0.835). Increased preoperative clopidogrel response is associated with increased rate of extracranial hemorrhagic complications in endovascular aneurysm treatments. Hyper-responders (16-60 PRU) and Extreme Responders (≤15 PRU) were not associated with intracranial hemorrhagic or thrombotic complications. Hypo-responders who underwent adjustment of antiplatelet therapy and neurointerventions did not experience higher rates of complications.
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Affiliation(s)
- Christopher C Young
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - David I Bass
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Michael J Cruz
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Kate Carroll
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Kevin N Vanent
- School of Medicine, University of Washington, Seattle, WA 98104, USA
| | - Chungeun Lee
- School of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Rajeev D Sen
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Abdullah H Feroze
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - John R Williams
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Samuel Levy
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA
| | - Denzel McCray
- Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA
| | - Cory M Kelly
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA; Department of Radiology, University of Washington, Seattle, WA 98104, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, WA 98104, USA; Stroke & Applied Neurosciences Center, University of Washington, Seattle, WA 98104, USA; Department of Radiology, University of Washington, Seattle, WA 98104, USA; Department of Mechanical Engineering, University of Washington, Seattle, WA 98104, USA.
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15
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Hohenstatt S, Ulfert C, Herweh C, Schönenberger S, Purrucker JC, Bendszus M, Möhlenbruch MA, Vollherbst DF. Acute Intraprocedural Thrombosis After Flow Diverter Stent Implantation: Risk Factors and Relevance of Standard Observation Time for Early Detection and Management. Clin Neuroradiol 2022; 33:343-351. [PMID: 36068407 DOI: 10.1007/s00062-022-01214-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Acute intraprocedural thrombosis (AIT) is a severe complication of flow diverter stent (FDS) implantation for the treatment of intracranial aneurysms. Even though device-related thromboembolic complications are well known, there are no acknowledged risk factors nor defined surveillance protocols for their early detection. This study aimed to demonstrate that an angiographic active surveillance is effective to detect and treat AIT. Furthermore, we investigated risk factors for the occurrence of AIT. METHODS A prospective institutional protocol consisting of a defined observation period of 30 min following FDS deployment was established to detect AIT. Overall incidence, as well as the efficacy and safety of AIT treatment were assessed. Moreover, radiological and clinical outcomes of patients with AIT were analyzed. The influence of various patient- and procedure-related factors on the occurrence of AIT was investigated using multivariable forward logistic regression. RESULTS During active surveillance twelve cases of AIT were observed among a total of 161 procedures (incidence: 7.5%). The median time of first observation was 15.5 min (IQR 9.5) after FDS implantation. The early recognition of AIT ensured a prompt treatment with intravenous application of a glycoprotein IIb/IIIa inhibitor, which led to complete thrombus resolution in all cases without hemorrhagic complications. Patients with pre-existing arterial hypertension and side branches originating from the aneurysmal sac had a higher risk of AIT (respectively OR, 9.844; OR, 3.553). There were two cases of re-thrombosis in the short-term postoperative period, of whom one died. The remaining patients with AIT had a good clinical outcome. CONCLUSION Active surveillance for 30 min after FDS implantation is an effective strategy for early detection and ensuing treatment of AIT and can thus prevent secondary sequalae. Hypertension and side branches originating from the aneurysmal sac may increase the risk of AIT.
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Affiliation(s)
- Sophia Hohenstatt
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Christian Ulfert
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany.
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16
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Alkhars H, Haq W, Al-Tayeb A, Sigounas D. Feasibility and Safety of Transradial Aneurysm Embolization: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 165:e110-e127. [PMID: 35654332 DOI: 10.1016/j.wneu.2022.05.112] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Use of the transradial access (TRA) approach for neuroendovascular procedures has been increasing in recent years. Our aim is to assess the feasibility, success rate, and complications associated with TRA for intracranial aneurysm embolization. METHODS PubMed, Scopus, and Embase were systematically searched for studies using TRA for intracranial aneurysm embolization. Random-effects models were used to obtain pooled rates of procedural success and complications. RESULTS Twenty-four studies comprising 1283 (85.9%) TRA and 122 (8.2%) distal TRA aneurysm embolization procedures were included. The pooled success rate of the 18 studies in the meta-analysis was 93.5% (95% confidence interval [CI], 91.1%-95.8%). The pooled thromboembolic complication rate was 0.5% (95% CI, 0.1%-0.9%), the hemorrhagic complication rate was 0.5% (95% CI, 0.1%-0.9%), and the access site complication rate was 0.8% (95% CI, 0.3%-1.3%). One study (4.3%) used exclusively a 7-French guide catheter, and most used a 6-French guide catheter (22 of 23 studies, 95.7%), which was further incorporated as part of a triaxial configuration through a sheathless 8-French system in 4 studies (17.4%), 7-French guide catheter in 2 studies (8.7%), and 8-French sheath in 1 study (4.3%). The embolization techniques used were flow diverter placement in 451 cases (39.1%), coiling in 376 (32.6%), stent-assisted coiling in 127 (11.0%), balloon-assisted coiling in 104 (9.0%), Woven EndoBridge system in 50 (4.3%), and flow diverter placement plus coiling in 42 (3.6%). CONCLUSIONS Treating intracranial aneurysms using various embolization techniques through TRA is feasible and associated with low access site and intraoperative complications.
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Affiliation(s)
- Hussain Alkhars
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Waqas Haq
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ahmed Al-Tayeb
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Dimitri Sigounas
- Department of Neurosurgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.
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Use of a p64 MW Flow Diverter with Hydrophilic Polymer Coating (HPC) and Prasugrel Single Antiplatelet Therapy for the Treatment of Unruptured Anterior Circulation Aneurysms: Safety Data and Short-term Occlusion Rates. Cardiovasc Intervent Radiol 2022; 45:1364-1374. [PMID: 35562486 PMCID: PMC9458553 DOI: 10.1007/s00270-022-03153-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/08/2022] [Indexed: 01/18/2023]
Abstract
Purpose To assess the safety and short-term occlusion rates in procedures using the p64 MW hydrophilic polymer-coated (HPC) flow diverter (FD) with prasugrel single antiplatelet therapy (SAPT) for the treatment of anterior circulation saccular aneurysms. Methods We retrospectively identified patients who underwent treatment of one or more intracranial anterior circulation saccular aneurysms between March 2020 and December 2021 with a p64 MW HPC FD and prasugrel SAPT with verified P2Y12 platelet receptor inhibition. Patients diagnosed with fusiform, dissecting, or recently ruptured aneurysms were excluded. Periprocedural and postprocedural complications, clinical outcomes, and angiographic follow-up results were evaluated. Results One hundred and two patients with 132 intracranial aneurysms met the inclusion criteria. Previous or concomitant treatments (e.g., coil occlusion) had been performed on 18 of these aneurysms. The technical success rate (i.e., implantation of the intended FD) was 100% with an average of 1.1 devices implanted per patient. Periprocedural and postprocedural complications occurred in 13.6% and 6.8% of these patients, respectively. No mortality or permanent clinical deterioration (i.e., modified Rankin scale score ≥ 3) were reported. Early follow-up digital subtraction angiography revealed aneurysmal occlusion rates of 72.6% and 83.8% at four and nine months, respectively. Conclusions The implantation of a p64 MW HPC FD with prasugrel SAPT is safe and results in rapid, reliable and effective aneurysmal occlusion. Supplementary Information The online version contains supplementary material available at 10.1007/s00270-022-03153-8.
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18
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Choi JH, Sim SY, Shin YS, Chung J. A Single Flow Re-direction Endoluminal Device for the Treatment of Large and Giant Anterior Circulation Intracranial Aneurysms. Yonsei Med J 2022; 63:349-356. [PMID: 35352886 PMCID: PMC8965426 DOI: 10.3349/ymj.2022.63.4.349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/08/2021] [Accepted: 12/16/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The purpose of this study was to report the author's experiences in treating large (10-25 mm) and giant (>25 mm) intracranial aneurysms (IAs) using a single Flow Re-direction Endoluminal Device (FRED) without assistant coiling, with a focus on procedure-related complications. MATERIALS AND METHODS A total of 33 patients who were treated with FRED between January 2018 and July 2020 were retrospectively reviewed. The timing of procedure-related complications was chronologically categorized as acute (within 7 days), subacute (8 to 21 days), and delayed (after 21 days) periods. Follow-up angiography was performed at 2 to 27 months (mean 9.7 months), and clinical follow-up was performed at 1 to 31 months (mean 14.1 months) in all patients. RESULTS Six (18.2%) patients experienced procedure-related complications, including 2 (6.1%) in acute period, 1 (3.0%) in subacute period, and 3 (9.1%) in delayed period. Thromboembolic complications occurred in 5 (15.2%) patients and hemorrhagic complications in 1 (3.0%). Permanent morbidity and mortality rates were 3.0% each. Non-internal carotid artery (ICA) location of IAs (odds ratio 6.532; 95% confidence interval, 1.335-17.816; p=0.034) was the only independent risk factor for procedure-related complications on multivariate logistic regression analysis. CONCLUSION The procedure-related complication rate was 18.2% in this study. Procedure-related complications might increase when treating large and giant IAs located on a non-ICA, especially on the middle cerebral artery. Therefore, it may be suggested that neurointerventionists and endovascular neurosurgeons should pay attention to the location of IAs when treating large and giant IAs with a single FRED.
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Affiliation(s)
- Jai Ho Choi
- Department of Neurosurgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sook Young Sim
- Department of Neurosurgery, Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Li S, Lu Z, Tang H, Shang C, Zhao R, Dai D, Li Q, Hong B, Huang Q, Zhou Y, Liu J. Flow diversion for aneurysms beyond the circle of Willis: A preliminary experience. J Clin Neurosci 2021; 95:63-69. [PMID: 34929653 DOI: 10.1016/j.jocn.2021.11.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/12/2021] [Accepted: 11/26/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of flow diversion (FDs) for the aneurysms beyond the circle of Willis. METHODS AND MATERIALS We retrospectively reviewed the prospectively maintained database in our center and enrolled patients with aneurysms beyond the circle of Willis (defined as at or distal to the M1, A2, and P2 segments) that were treated with FDs. RESULTS Between July 2017 to December 2020, 28 patients with 28 aneurysms met the inclusion criteria and were included in this study, with a median age of 50 years old (IQR, 36-63 years). Thirty FDs, including 5 Pipelines and 25 Tubridge FDs, were deployed. Perioperative complications were noticed in 2 patients (7.1%), while asymptomatic adverse events occurred in another three patients (10.7%). Delayed complications occurred in 3.6% of patients (1/28). All patients received clinical follow-up, with the mortality and long-term morbidity of 0 and 3.6% (1/28), respectively. Angiographic follow-up data were available for 26 patients (92.9%) with an interval of 10 ± 7 months (ranged 2-26 months). Sixteen patients (61.5%) showed complete or nearly complete occlusion of aneurysms (OKM grading scale D and C); 6 cases (23.1%) were revealed incomplete occlusion (OKM grading scale B), and 4 cases (15.4%) remained unchanged (OKM grading scale A). The existence of the perforators derived from aneurysms was associated with a lower occlusion rate (p = 0.032). CONCLUSION Flow diversion is reliable in the treatment of distal aneurysms with a high technical success rate and low permanent disability rate. The presence of side branches derived from aneurysms was associated with a lower aneurysm occlusion rate.
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Affiliation(s)
- Sisi Li
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Zhiwen Lu
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Haishuang Tang
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Naval Medical Center of PLA, Navy Medical University, Shanghai 200050, China
| | - Chenghao Shang
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Rui Zhao
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Dongwei Dai
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Qiang Li
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Bo Hong
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Qinghai Huang
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Yu Zhou
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China.
| | - Jianmin Liu
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China.
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20
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Ma Y, Jia C, Zhang T, Feng Y, Chen X, Zhao W. Safety and efficacy of intravenous tirofiban for stent-assisted coiling in acutely ruptured intracranial aneurysms: A single center experience. Interv Neuroradiol 2021; 28:476-481. [PMID: 34515564 PMCID: PMC9326857 DOI: 10.1177/15910199211042463] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There have been few reports on the use of tirofiban in ruptured intracranial aneurysms and the results were conflicting. However, the safety and efficacy of optimal dosage and the reasonable treatment course of tirofiban have not been determined. OBJECTIVE To determine the safety and efficacy of a new protocol for its prophylactic tirofiban application during the endovascular treatment of ruptured intracranial aneurysms with no oral antiplatelet medications. METHODS This retrospective study was based on 105 patients with ruptured aneurysms who underwent stent-assisted coiling at our institution between August 2017 and July 2020. Intravenous tirofiban was administered to patients after stent deployment. Tirofiban was administered as an intravenous bolus (5 µg/kg) over a 3 min period immediately after stent deployment, followed by a 0.06-0.08 µg/kg/min maintenance infusion for 12-24 h. Dual oral antiplatelet therapy was overlapped with half the tirofiban dose 2 h before the cessation of the tirofiban infusion. Cases of intracranial hemorrhage or thromboembolism were recorded. RESULTS This study included a total of 105 patients with ruptured intracranial aneurysms, who underwent stent-assisted coiling. In terms of clinical severity, a presenting Hunt-Hess clinical-grade I was observed in 47 (44.8%) cases, grade II in 19 (18.1%) cases, grade III in 30 (28.6%) cases, grade IV in 6 (5.6%) cases, and grade V in 3 (2.9%) cases. None of the patients showed a newly developed tirofiban-related intracerebral hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, or ventriculostomy-related hemorrhage. There were 3 (2.8%) patients who had thromboembolic complications. CONCLUSIONS We have determined a new protocol for prophylactic intraoperative tirofiban during the endovascular treatment of ruptured intracranial aneurysms with no oral antiplatelet medications. In our study, tirofiban showed a low risk of hemorrhagic or thromboembolic complications. Tirofiban appears to be a safe and alternative during the stent-assisted coiling of ruptured intracranial aneurysms.
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Affiliation(s)
- Yihui Ma
- Department of Neurosurgery, 89674Zhongnan Hospital of Wuhan University, China
| | - Chenguang Jia
- Department of Neurosurgery, 89674Zhongnan Hospital of Wuhan University, China
| | - Tingbao Zhang
- Department of Neurosurgery, 89674Zhongnan Hospital of Wuhan University, China
| | - Yu Feng
- Department of Neurosurgery, 89674Zhongnan Hospital of Wuhan University, China
| | - Xinjun Chen
- Department of Neurosurgery, 89674Zhongnan Hospital of Wuhan University, China
| | - Wenyuan Zhao
- Department of Neurosurgery, 89674Zhongnan Hospital of Wuhan University, China
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21
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Park KY, Ozaki T, Kostynskyy A, Kortman H, Hilario A, Nicholson P, Agid R, Krings T, Pereira VM. Ticagrelor versus Clopidogrel in the Dual Antiplatelet Regimen for Intracranial Stenting or Flow-Diverter Treatment for Unruptured Cerebral Aneurysms: A Single-Center Cohort Study. AJNR Am J Neuroradiol 2021; 42:1638-1644. [PMID: 34244132 DOI: 10.3174/ajnr.a7216] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/25/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE Ticagrelor is a novel P2Y12 antagonist, and little is known about its efficacy and safety in the endovascular treatment of aneurysms. This study evaluated the efficacy and safety of ticagrelor versus clopidogrel for stent-assisted coiling or flow-diversion treatment in patients with unruptured cerebral aneurysms. MATERIALS AND METHODS From November 2003 to February 2019, two hundred one patients (mean age, 57.5 years; 156 women) with 233 unruptured aneurysms underwent stent-assisted coiling or flow-diversion treatment. All patients received antiplatelet therapy of aspirin plus clopidogrel (clopidogrel group, 121 patients with 140 aneurysms) or aspirin plus ticagrelor (ticagrelor group, 80 patients with 93 aneurysms). The clinical and radiologic data in each group were retrospectively reviewed and compared. RESULTS Two hundred thirty-six procedures were performed, including stent-assisted coiling (n = 101) and flow diversion (n = 135). At 90 days, the primary outcome-a composite of any stroke and death-occurred in 9.9% of the clopidogrel group and 8.6% of the ticagrelor group (P = .822). Ischemic stroke occurred in 10 (7.0%) of the clopidogrel group and 7 (7.5%) of the ticagrelor group (P > .999). Disabling stroke occurred in 4 (2.8%) in the clopidogrel group and in 4 (4.3%) in the ticagrelor group (P = .716). Ninety-day death occurred in 3 (2.1%) in the clopidogrel group and 1 (1.1%) in the ticagrelor group (P > .999). Any bleeding at 90 days occurred in 13 (9.2%) in the clopidogrel group and 6 (6.5%) in the ticagrelor group (P = .479). CONCLUSIONS Ticagrelor appears to be as effective and safe as clopidogrel in stent-assisted coiling or flow-diversion treatment for unruptured cerebral aneurysms.
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Affiliation(s)
- K Y Park
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Neurosurgery (K.Y.P.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - T Ozaki
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - A Kostynskyy
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - H Kortman
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Radiology (H.K.), Elisabeth-TweeSteden Ziekenhuis St. Elisabeth Hospital, Tilburg, the Netherlands
| | - A Hilario
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - P Nicholson
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - R Agid
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - T Krings
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - V M Pereira
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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22
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Catapano JS, Srinivasan VM, Wakim AA, Lundberg JN, Rutledge C, Cole TS, Baranoski JF, Fredrickson VL, Rahmani R, Albuquerque FC, Ducruet AF. Omeprazole-clopidogrel interaction and neurovascular complications after flow-diverter device placement. J Neurointerv Surg 2021; 14:380-383. [PMID: 34083398 DOI: 10.1136/neurintsurg-2021-017397] [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: 02/03/2021] [Accepted: 05/10/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Omeprazole is a common proton pump inhibitor that interferes with the hepatic activation of clopidogrel and potentially reduces its platelet-inhibitory effect. Omeprazole has been shown to increase P2Y12 levels and adverse cardiovascular outcomes in patients treated with drug-eluting stents. However, omeprazole use among patients treated with flow-diverting stents for intracranial aneurysms has not been evaluated. METHODS All patients with placement of a flow-diverting device for treatment of an intracranial aneurysm at a tertiary institution from January 1, 2014, to December 31, 2018, were retrospectively analyzed. Inclusion criteria included documented clopidogrel administration, available P2Y12 levels, and thorough documentation of administration of other medications, including omeprazole. RESULTS A total of 138 patients met the inclusion criteria. Sixteen patients (12%) were receiving omeprazole and clopidogrel at treatment. P2Y12 reactivity was significantly greater in the omeprazole cohort (mean P2Y12 level, 250 P2Y12 reaction units (PRU)) than in the control cohort (mean P2Y12 level, 112PRU) (P<0.001). Furthermore, a greater proportion of patients had a P2Y12 level >180 PRU in the omeprazole cohort (14 of 16 [88%] vs 24 of 122 [20%]; P<0.001; OR [95% CI], 29 [6-134]). CONCLUSION Omeprazole was associated with a significant increase in the mean P2Y12 reactivity level among patients with intracranial aneurysms treated with flow-diverting devices who received clopidogrel. However, receipt of omeprazole was not associated with an increased risk of ischemic events or stent stenosis. For neuroendovascular patients who are treated with a flow diverter while receiving clopidogrel, alternative gastrointestinal medication regimens should be considered.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andre A Wakim
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jaclyn N Lundberg
- Department of General Medicine, Creighton University School of Medicine, Phoenix Health Sciences Campus, Phoenix, Arizona, USA
| | - Caleb Rutledge
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Vance L Fredrickson
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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23
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Batur H, Topcuoglu MA, Balci S, Arsava EM, Arat A. Dual Testing to Achieve Low On-treatment Platelet Reactivity for Aneurysm Embolization. Clin Neuroradiol 2021; 31:1159-1165. [PMID: 33844028 DOI: 10.1007/s00062-021-01011-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Although point-of-care tests are used extensively to test platelet function before endovascular aneurysm treatment, their use and validity are still debated. We compared the results of two point-of-care tests (VerifyNow® and Multiplate®) for assessing patients treated with stents and flow diverters and determined their relation to periprocedural complications. METHODS All patients undergoing treatment of intracranial aneurysms were tested using both methods and were retrospectively evaluated. Patients with acute subarachnoid hemorrhage and those who had to be maintained on anticoagulants for unrelated diseases were excluded. An acceptable level of platelet inhibition was required on both tests to commence with treatment, otherwise antiplatelet medication was adjusted to reach this level. RESULTS Mean PRU (platelet reactivity units) and ADP AUC (adenosine diphosphate area under the aggregation curve) were 68 ± 66 and 23 ± 15, respectively, in 295 patients. Both tests showed a good correlation (r = 0.45). Both tests were able to predict hemorrhagic events but not ischemic events. When patients with very low reactivity (PRU < 60) were compared to the rest of the group, there were more hemorrhagic events in the first group but the overall rate of complications were similar (p = 0.27). CONCLUSION In this largest study comparing two widely used commercial platelet function tests, the correlation between the tests were less than ideal; however, the very low platelet reactivity attained by the help of dual platelet testing did not result in an increased overall complication rate.
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Affiliation(s)
- Halitcan Batur
- Department of Radiology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | | | - Sinan Balci
- Department of Radiology, Hacettepe University Hospitals, Ankara, Turkey
| | - Ethem M Arsava
- Department of Neurology, Hacettepe University Hospitals, Ankara, Turkey
| | - Anil Arat
- Department of Radiology, Hacettepe University Hospitals, Ankara, Turkey.
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24
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Pearce S, Maingard JT, Kuan Kok H, Barras CD, Russell JH, Hirsch JA, Chandra RV, Jhamb A, Thijs V, Brooks M, Asadi H. Antiplatelet Drugs for Neurointerventions: Part 2 Clinical Applications. Clin Neuroradiol 2021; 31:545-558. [PMID: 33646319 DOI: 10.1007/s00062-021-00997-4] [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: 12/02/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Abstract
Endovascular techniques have expanded to include balloon and stent-assistance, flow diversion and individualized endovascular occlusion devices, to widen the treatment spectrum for more complex aneurysm morphologies. While usually well-tolerated by patients, endovascular treatment of intracranial aneurysms carries the risk of complications, with procedure-related ischemic complications being the most common. Several antiplatelet agents have been studied in a neurointerventional setting for both prophylaxis and in the setting of intraprocedural thrombotic complications. Knowledge of these antiplatelet agents, evidence for their use and common dosages is important for the practicing neurointerventionist to ensure the proper application of these agents.Part one of this two-part review focused on basic platelet physiology, pharmacology of common antiplatelet medications and future directions and therapies. Part two focuses on clinical applications and evidence based therapeutic regimens.
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Affiliation(s)
- Samuel Pearce
- Department of Radiology, Western Health, 160 Gordon St, 3011, Footscray, Victoria, Australia. .,Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.
| | - Julian T Maingard
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Hong Kuan Kok
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Interventional Radiology Service, Northern Health Radiology, Melbourne, Victoria, Australia
| | - Christen D Barras
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jeremy H Russell
- Department of Neurosurgery, Austin Health, Melbourne, Victoria, Australia
| | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Imaging, Monash University, Melbourne, Victoria, Australia
| | - Ash Jhamb
- Interventional Neuroradiology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Austin Health, Melbourne, Victoria, Australia
| | - Mark Brooks
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Interventional Neuroradiology service, Radiology Department, Austin Health, Melbourne, Victoria, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Interventional Neuroradiology service, Radiology Department, Austin Health, Melbourne, Victoria, Australia
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25
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Weinberg JH, Sweid A, Hammoud B, Asada A, Greco-Hiranaka C, Piper K, Gooch MR, Tjoumakaris S, Herial N, Hasan D, Zarzour H, Rosenwasser RH, Jabbour P. A comparative study of transradial versus transfemoral approach for flow diversion. Neuroradiology 2021; 63:1335-1343. [PMID: 33560470 DOI: 10.1007/s00234-021-02672-4] [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] [Received: 10/11/2020] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Data in neurointerventional literature is extremely limited regarding the safety and efficacy of flow diversion using transradial access (TRA). We aim to demonstrate the safety and efficacy of intracranial aneurysm treatment with the Pipeline Embolization Device (PED) using TRA compared to transfemoral access (TFA). METHODS We conducted a retrospective analysis of a prospectively maintained database and identified 79 consecutive patients who underwent neuroendovascular embolization for cerebral aneurysms using the PED from April 2018 through October 2019. Patients were divided into 2 groups: TRA (32 patients) and TFA (47 patients). A comparative analysis was performed between the two groups. RESULTS There was no significant difference in postoperative intracranial hemorrhage (p>.99), symptomatic ischemic stroke (p=.512), access site complications (p=.268), or other complications (p=.512). However, there was a significant increase in overall complications (14.9% vs. 0.0%, p=.038) and procedure duration (71.4 min ± 31.2 vs. 58.5 ± 20.3, p=.018) in the TFA group. There was no significant difference in complete occlusion at latest follow-up (19/25, 76.0% vs. 35/40, 87.5%; p=.311), 6-month follow-up (17/23, 73.9% vs. 33/38, 86.8%; p=.303), or 12-month follow-up (8/8, 100.0% vs. 5/6, 83.3%; p=.429). There was also no significant difference in rate of retreatment (p>.99), morbidity (p=.512), mortality (p>.99), latest follow-up (p=.985), or loss of follow-up (p=.298). CONCLUSIONS The feasibility and efficacy of flow diversion with the PED via TRA for the treatment of intracranial aneurysms is comparable to TFA. Widespread adoption of this approach may be facilitated by improvements in device navigation and manipulation via radial-specific engineering.
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Affiliation(s)
- Joshua H Weinberg
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Batoul Hammoud
- Department of Pediatric Endocrinology, Children Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ashlee Asada
- Drexel University College of Medicine, Drexel University, Philadelphia, PA, USA
| | | | - Keenan Piper
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nabeel Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - David Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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26
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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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27
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Cortese J, Rasser C, Even G, Bardet SM, Choqueux C, Mesnier J, Perrin ML, Janot K, Caroff J, Nicoletti A, Michel JB, Spelle L, Caligiuri G, Rouchaud A. CD31 Mimetic Coating Enhances Flow Diverting Stent Integration into the Arterial Wall Promoting Aneurysm Healing. Stroke 2021; 52:677-686. [PMID: 33412905 DOI: 10.1161/strokeaha.120.030624] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Beyond aneurysmal occlusion, metallic flow diverters (FDs) can induce an adverse endovascular reaction due to the foreignness of metal devices, hampering FD endothelialization across the aneurysm neck, and arterial healing of intracranial aneurysms. Here, we evaluated the potential benefits of an FD coating mimicking CD31, a coreceptor critically involved in endothelial function and endovascular homeostasis, on the endothelialization of FDs implanted in vivo. METHODS Nitinol FD (Silk Vista Baby) and flat disks were dip-coated with a CD31-mimetic peptide via an intermediate layer of polydopamine. Disks were used to assess the reaction of endothelial cells and blood elements in vitro. An aneurysm rabbit model was used to compare in vivo effects on the arterial wall of CD31-mimetic-coated (CD31-mimetic, n=6), polydopamine-coated (polydopamine, n=6), and uncoated FDs (bare, n=5) at 4 weeks post-FD implantation. In addition, long-term safety was assessed at 12 weeks. RESULTS In vitro, CD31-mimetic coated disks displayed reduced adhesion of blood elements while favoring endothelial cell attachment and confluence, compared to bare and polydopamine disks. Strikingly, in vivo, the neoarterial wall formed over the CD31-mimetic-FD struts at the aneurysm neck was characteristic of an arterial tunica media, with continuous differentiated endothelium covering a significantly thicker layer of collagen and smooth muscle cells as compared to the controls. The rates of angiographic complete occlusion and covered branch arterial patency were similar in all 3 groups. CONCLUSIONS CD31-mimetic coating favors the colonization of metallic endovascular devices with endothelial cells displaying a physiological phenotype while preventing the adhesion of platelets and leukocytes. These biological properties lead to a rapid and improved endothelialization of the neoarterial wall at the aneurysm neck. CD31-mimetic coating could therefore represent a valuable strategy for FD biocompatibility improvement and aneurysm healing.
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Affiliation(s)
- Jonathan Cortese
- NEURI Center, Hôpital Bicêtre, APHP-Université Paris Sud, Kremlin-Bicêtre, France (J. Cortese, J. Caroff, L.S.).,Laboratory for Vascular Translational Science, Université de Paris, INSERM U1148, France (J. Cortese, C.R., G.E., C.C., J.M., A.N., J.-B.M., G.C.)
| | - Charlotte Rasser
- Laboratory for Vascular Translational Science, Université de Paris, INSERM U1148, France (J. Cortese, C.R., G.E., C.C., J.M., A.N., J.-B.M., G.C.)
| | - Guillaume Even
- Laboratory for Vascular Translational Science, Université de Paris, INSERM U1148, France (J. Cortese, C.R., G.E., C.C., J.M., A.N., J.-B.M., G.C.)
| | - Sylvia M Bardet
- University of Limoges, XLIM UMR CNRS 7252, France (S.M.B., M.-L.P., A.R.)
| | - Christine Choqueux
- Laboratory for Vascular Translational Science, Université de Paris, INSERM U1148, France (J. Cortese, C.R., G.E., C.C., J.M., A.N., J.-B.M., G.C.)
| | - Jules Mesnier
- Laboratory for Vascular Translational Science, Université de Paris, INSERM U1148, France (J. Cortese, C.R., G.E., C.C., J.M., A.N., J.-B.M., G.C.)
| | - Marie-Laure Perrin
- University of Limoges, XLIM UMR CNRS 7252, France (S.M.B., M.-L.P., A.R.)
| | - Kevin Janot
- Department of Interventional Neuroradiology, Limoges University Hospital, France (K.J., A.R.)
| | - Jildaz Caroff
- NEURI Center, Hôpital Bicêtre, APHP-Université Paris Sud, Kremlin-Bicêtre, France (J. Cortese, J. Caroff, L.S.)
| | - Antonino Nicoletti
- Laboratory for Vascular Translational Science, Université de Paris, INSERM U1148, France (J. Cortese, C.R., G.E., C.C., J.M., A.N., J.-B.M., G.C.)
| | - Jean-Baptiste Michel
- Laboratory for Vascular Translational Science, Université de Paris, INSERM U1148, France (J. Cortese, C.R., G.E., C.C., J.M., A.N., J.-B.M., G.C.)
| | - Laurent Spelle
- NEURI Center, Hôpital Bicêtre, APHP-Université Paris Sud, Kremlin-Bicêtre, France (J. Cortese, J. Caroff, L.S.)
| | - Giuseppina Caligiuri
- Laboratory for Vascular Translational Science, Université de Paris, INSERM U1148, France (J. Cortese, C.R., G.E., C.C., J.M., A.N., J.-B.M., G.C.)
| | - Aymeric Rouchaud
- Department of Interventional Neuroradiology, Limoges University Hospital, France (K.J., A.R.).,University of Limoges, XLIM UMR CNRS 7252, France (S.M.B., M.-L.P., A.R.)
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Scerrati A, Visani J, Flacco ME, Ricciardi L, Trungu S, Raco A, Dones F, De Bonis P, Sturiale CL. Endovascular Treatment of Ruptured Intracranial Blister Aneurysms: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2020; 42:538-545. [PMID: 33361375 DOI: 10.3174/ajnr.a6924] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 09/29/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Endovascular treatment of blister aneurysms is a promising approach, even though they are vascular lesions challenging to treat due to their angioarchitectural characteristics. PURPOSE Our aim was to investigate clinical and radiologic outcomes after endovascular treatment of ruptured blister aneurysms. DATA SOURCES PubMed, Ovid MEDLINE, Ovid EMBASE, Scopus, and the Web of Science were screened. STUDY SELECTION We performed a comprehensive review of the literature from 2010 to 2019 reporting series of patients with blister aneurysms treated with an endovascular approach. DATA ANALYSIS Event rates were pooled across studies using a random effects meta-analysis. DATA SYNTHESIS A total of 32 studies reporting on 684 patients (707 aneurysms) were included. Stent placement, stent-assisted coiling, and flow diversion were the most commonly described treatments (282, 256, and 155 patients, respectively). The long-term complete occlusion rate was 76.9% (95% CI, 69.2%-83.9%). The perioperative complication rate was 8.9%, and clinical outcome at final follow-up was mRS <2 in 76.6% (95% CI, 68.2%-84.2%) of patients. The mortality rate was 4.7% (95% CI, 2.30%-7.80%). Among the different techniques, stent-assisted coiling is the one that had the higher rate of immediate occlusion (63.4%); however, the occlusion rate at the final follow-up was comparable among the different techniques. LIMITATIONS Different techniques were described and data were reported in a nonhomogeneous way, possibly representing a bias in the present study. CONCLUSIONS This study suggests that endovascular treatment of blister aneurysms is associated with good long-term occlusion rates and reasonable complication and mortality rates. There is no consensus on the best endovascular techniques in blister aneurysm management.
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Affiliation(s)
- A Scerrati
- From the Department of Neurosurgery (A.S., J.V., F.D., P.D.B.), S. Anna University Hospital, Ferrara, Italy.,Departments of Morphology, Surgery, and Experimental Medicine (A.S., P.D.B.)
| | - J Visani
- From the Department of Neurosurgery (A.S., J.V., F.D., P.D.B.), S. Anna University Hospital, Ferrara, Italy
| | - M E Flacco
- Medical Sciences (M.E.F.), University of Ferrara, Ferrara, Italy
| | - L Ricciardi
- Unità operativa di Neurochirurgia (L.R., S.T.), Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, Lecce, Italy .,Unità operativa complessa di Neurochirurgia (L.R., S.T., A.R.), Dipartimento di Neuroscienze Salute Mentale e Organi di Senso, Azienda Ospedaliera Sant'Andrea, Sapienza, Rome, Italy
| | - S Trungu
- Unità operativa di Neurochirurgia (L.R., S.T.), Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, Lecce, Italy.,Unità operativa complessa di Neurochirurgia (L.R., S.T., A.R.), Dipartimento di Neuroscienze Salute Mentale e Organi di Senso, Azienda Ospedaliera Sant'Andrea, Sapienza, Rome, Italy
| | - A Raco
- Unità operativa complessa di Neurochirurgia (L.R., S.T., A.R.), Dipartimento di Neuroscienze Salute Mentale e Organi di Senso, Azienda Ospedaliera Sant'Andrea, Sapienza, Rome, Italy
| | - F Dones
- From the Department of Neurosurgery (A.S., J.V., F.D., P.D.B.), S. Anna University Hospital, Ferrara, Italy
| | - P De Bonis
- From the Department of Neurosurgery (A.S., J.V., F.D., P.D.B.), S. Anna University Hospital, Ferrara, Italy.,Departments of Morphology, Surgery, and Experimental Medicine (A.S., P.D.B.)
| | - C L Sturiale
- Department of Neurosurgery (C.L.S.), Fondazione Policlinico Universitario A. Gemelli Istituto di ricovero e cura a carattere scientifico, Rome, Italy
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29
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Wu Q, Shao Q, Li L, Liang X, Chang K, Li T, He Y. Prophylactic administration of tirofiban for preventing thromboembolic events in flow diversion treatment of intracranial aneurysms. J Neurointerv Surg 2020; 13:835-840. [PMID: 33199539 DOI: 10.1136/neurintsurg-2020-016878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/21/2020] [Accepted: 10/23/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Flow diverter (FD) is widely used in the treatment of intracranial aneurysms. However, thromboembolic events (TEs) continue to be the major complications during the periprocedural phase. To evaluate the safety and efficacy of the prophylactic use of tirofiban, combined with the conventional dual antiplatelet therapy (DAT), as a new antiplatelet protocol in patients with intracranial aneurysms treated with FDs. METHODS At least 3-5 days before the procedure, daily DAT were administrated to the patients. Tirofiban was administered as an intravenous bolus (5 µg/kg) over a 3 min period during or immediately after FD deployment, followed by a 0.05 µg/kg/min maintenance infusion for 24-48 hours. Periprocedural TEs and hemorrhagic events (HEs) were recorded. RESULTS A total of 331 patients were included, including 229 (69.2%) who received tirofiban administration (tirofiban group) and 102 (30.8%) who received only DAT (non-tirofiban group). Periprocedural TEs occurred in 12 (3.6%) patients, including eight (7.8%) in the non-tirofiban group and four (1.7%) in the tirofiban group. In multivariate analysis, patients receiving tirofiban administration had significantly lower TEs as compared with those who received only DAT (P=0.004). Balloon angioplasty and longer procedure time (>137 min) were also risk factors for TEs. Also, no increase was observed in the rate of HEs related to tirofiban administration. CONCLUSIONS The current study suggested that prophylactic administration of tirofiban combined with conventional oral DAT seems safe and efficient for preventing TEs during FD treatment of unruptured intracranial aneurysms. Balloon angioplasty and prolonged procedure are associated with a high risk of TEs.
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Affiliation(s)
- Qiaowei Wu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
| | - Qiuji Shao
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
| | - Li Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
| | - Xiaodong Liang
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
| | - Kaitao Chang
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
| | - Yingkun He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan Provincial People's Hospital and Henan University People's Hospital, Zhengzhou, China
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30
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Pressman E, De la Garza CA, Chin F, Fishbein J, Waqas M, Siddiqui A, Snyder K, Davies JM, Levy E, Kan P, Ren Z, Mokin M. Nuisance bleeding complications in patients with cerebral aneurysm treated with Pipeline embolization device. J Neurointerv Surg 2020; 13:247-250. [PMID: 32620576 DOI: 10.1136/neurintsurg-2020-016245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/03/2020] [Accepted: 06/15/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Patients with cerebral aneurysms treated with the Pipeline embolization device (PED) are maintained on dual antiplatelet therapy (DAPT) to prevent thromboembolic complications. Rates of minor, "nuisance" bleeding in these patients remain unknown. We sought to evaluate the frequency and factors associated with this bleeding and its effect on DAPT compliance. METHODS We performed a multicenter retrospective cohort study on consecutive cases of intracranial aneurysms treated with PED. Patient characteristics, aneurysm characteristics, and bleeding complications were analyzed. Severity of bleeding was defined according to a previously published classification defining nuisance bleeding as easy bruising, bleeding from small cuts, petechia, and ecchymosis. RESULTS 245 PED aneurysm procedures on 243 patients were retrospectively collected from three academic centers over a 4.25-year period. Sixty-seven patients (27%) had nuisance bleeds. Patients with a higher risk of nuisance bleeding were older (59.1±3.4 vs . 54.7±2.2, P=0.032). Patients with nuisance bleeds were more likely to have their DAPT regimen changed or dose lowered (29% vs 8.3%, P<0.001), were on DAPT for less time (10.0 months±2.60 vs. 14.6 months±1.95, P=0.005) and were more likely to have aneurysm occlusion at 6 months (P<0.001). Stepwise logistic regression found age predictive of a nuisance bleed (OR=1.033) CONCLUSIONS: Nuisance bleeding was a common complaint of PED-treated aneurysm patients maintained on DAPT. Increasing age and aneurysmal occlusion at 6 months were the only factors predictive of nuisance bleeds. Clinicians were more likely to adjust antiplatelet regimens or stop DAPT early given a nuisance bleed.
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Affiliation(s)
- Elliot Pressman
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA
| | - Carlos A De la Garza
- Neurology, Baylor College of Medicine Department of Neurology, Houston, Texas, USA
| | - Felix Chin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Jacob Fishbein
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA
| | - Muhammad Waqas
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Adnan Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Kenneth Snyder
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Jason M Davies
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Elad Levy
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Zeguang Ren
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA.,Neurosciences Group, Tampa General Hospital, Tampa, FL, USA
| | - Maxim Mokin
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA .,Neurosciences Group, Tampa General Hospital, Tampa, FL, USA
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31
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Griessenauer CJ, Enriquez-Marulanda A, Xiang S, Hong T, Zhang H, Taussky P, Grandhi R, Waqas M, Tutino VM, Siddiqui AH, Levy EI, Ogilvy CS, Thomas AJ, Ulfert C, Möhlenbruch MA, Renieri L, Limbucci N, Parra-Fariñas C, Burkhardt JK, Kan P, Rinaldo L, Lanzino G, Brinjikji W, Spears J, Müller-Thies-Broussalis E, Killer-Oberpfalzer M, Islak C, Kocer N, Sonnberger M, Engelhorn T, Ghuman M, Yang VX, Salehani A, Harrigan MR, Radovanovic I, Pereira VM, Krings T, Matouk CC, Chen K, Aziz-Sultan MA, Ghorbani M, Schirmer CM, Goren O, Dalal SS, Koch MJ, Stapleton CJ, Patel AB, Finkenzeller T, Holtmannspötter M, Buhk JH, Foreman PM, Cress M, Hirschl R, Reith W, Simgen A, Janssen H, Marotta TR, Dmytriw AA. Comparison of PED and FRED flow diverters for posterior circulation aneurysms: a propensity score matched cohort study. J Neurointerv Surg 2020; 13:153-158. [PMID: 32611622 DOI: 10.1136/neurintsurg-2020-016055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/14/2020] [Accepted: 05/25/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Flow diversion is a common endovascular treatment for cerebral aneurysms, but studies comparing different types of flow diverters are scarce. OBJECTIVE To perform a propensity score matched cohort study comparing the Pipeline Embolization Device (PED) and Flow Redirection Intraluminal Device (FRED) for posterior circulation aneurysms. METHODS Consecutive aneurysms of the posterior circulation treated at 25 neurovascular centers with either PED or FRED were collected. Propensity score matching was used to control for age, duration of follow-up imaging, adjunctive coiling, and aneurysm location, size, and morphology; previously ruptured aneurysms were excluded. The two devices were compared for the following outcomes: procedural complications, aneurysm occlusion, and functional outcome. RESULTS A total of 375 aneurysms of the posterior circulation were treated in 369 patients. The PED was used in 285 (77.2%) and FRED in 84 (22.8%) procedures. Aneurysms treated with the PED were more commonly fusiform and larger than those treated with FRED. To account for these important differences, propensity score matching was performed resulting in 33 PED and FRED unruptured aneurysm pairs. No differences were found in occlusion status and neurologic thromboembolic or hemorrhagic complications between the two devices. The proportion of patients with favorable functional outcome was higher with FRED (100% vs 87.9%, p=0.04). CONCLUSION Comparative analysis of PED and FRED for the treatment of unruptured posterior circulation aneurysms did not identify significant differences in aneurysm occlusion or neurologic complications. Variations in functional outcomes warrant additional investigations.
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Affiliation(s)
- Christoph J Griessenauer
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA .,Research Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria
| | | | - Sissi Xiang
- Department of Neurosurgery, Xuanwu Hospital, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Beijing, China
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Muhammad Waqas
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Vincent M Tutino
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Christopher S Ogilvy
- Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christian Ulfert
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Leonardo Renieri
- Interventional Neuroradiology, University Hospital Careggi, Firenze, Toscana, Italy
| | - Nicola Limbucci
- Interventional Neuroradiology, University Hospital Careggi, Firenze, Toscana, Italy
| | | | - Jan-Karl Burkhardt
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Lorenzo Rinaldo
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Julian Spears
- Therapeutic Neuroradiology & Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Erasmia Müller-Thies-Broussalis
- Research Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria.,Department of Neurology, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Research Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria.,Department of Neurology, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria
| | - Civan Islak
- Department of Radiology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Naci Kocer
- Department of Radiology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Michael Sonnberger
- Department of Neuroradiology, Johannes Kepler Universitat Linz, Linz, Austria
| | - Tobias Engelhorn
- Department of Neuroradiology, Friedrich Alexander University Erlangen Nuremberg Faculty of Medicine, Erlangen, Bayern, Germany
| | - Mandeep Ghuman
- Neuroradiology & Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Victor Xd Yang
- Neuroradiology & Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Mark R Harrigan
- Department of Neurosurgery, UAB Hospital, Birmingham, Alabama, USA
| | - Ivan Radovanovic
- Interventional Neuroradiology & Neurosurgery, Toronto Western Hospital, Toronto, ON, Canada
| | - Vitor M Pereira
- Interventional Neuroradiology & Neurosurgery, Toronto Western Hospital, Toronto, ON, Canada
| | - Timo Krings
- Interventional Neuroradiology & Neurosurgery, Toronto Western Hospital, Toronto, ON, Canada
| | - Charles C Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Karen Chen
- Neurointerventional Radiology and Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Mohammad Ghorbani
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA.,Research Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Oded Goren
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA
| | - Shamsher S Dalal
- Department of Radiology, Geisinger Health System, Danville, Pennsylvania, USA
| | - Matthew J Koch
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | - Jan Hendrik Buhk
- Department of Diagnostic and Interventional Neuroradiology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | - Wolfgang Reith
- Department of Neuroradiology, Universitatsklinikum des Saarlandes und Medizinische Fakultat der Universitat des Saarlandes, Homburg, Germany
| | - Andreas Simgen
- Department of Neuroradiology, Universitatsklinikum des Saarlandes und Medizinische Fakultat der Universitat des Saarlandes, Homburg, Germany
| | - Hendrik Janssen
- Department of Neuroradiology, Nuremberg Hospital, Nurnberg, Bayern, Germany
| | - Thomas R Marotta
- Therapeutic Neuroradiology & Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Adam A Dmytriw
- Therapeutic Neuroradiology & Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada.,Neuroradiology & Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interventional Neuroradiology & Neurosurgery, Toronto Western Hospital, Toronto, ON, Canada
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Entezami P, Holden DN, Boulos AS, Paul AR, Field NC, Nourollahzadeh E, Yamamoto J, Dalfino JC. Cangrelor dose titration using platelet function testing during cerebrovascular stent placement. Interv Neuroradiol 2020; 27:88-98. [PMID: 32611215 DOI: 10.1177/1591019920936923] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Optimal antiplatelet inhibition is vital during cerebrovascular stenting procedures, yet no standardized recommendation exists for antithrombotic therapy in these scenarios. Cangrelor is an intravenous P2Y12 inhibitor with a favorable pharmacokinetic profile for use during neuroendovascular stenting. METHODS A retrospective review of all neuroendovascular patients who underwent stenting between 1 January 2019 and 22 March 2020 and were treated with cangrelor was conducted. Thirty-seven patients met inclusion criteria. RESULTS All patients were administered a bolus of 5 mcg/kg of cangrelor followed by a maintenance infusion. Antiplatelet effects of cangrelor were monitored using platelet reactivity units (PRU). Based on the initial PRU, seven patients' doses were adjusted with subsequent PRUs in or near the goal range of 50-150. One patient experienced an acute intraprocedural occlusion likely related to a subtherapeutic PRU which subsequently resolved with cangrelor dose adjustment and intra-arterial tirofiban administration, and one patient experienced a post-procedure stent occlusion which required a thrombectomy and intra-arterial tirofiban administration. No hemorrhagic complications occurred. DISCUSSION Cangrelor utilization during neuroendovascular stenting with maintenance doses of <2 mcg/kg/min with dose adjustments based on platelet function testing has not been previously described. Cangrelor presents many advantages compared to standard therapy in patients undergoing stent placement related to its pharmacokinetic profile, rapid onset of action, ease of transition to oral P2Y12 antiplatelet agents, and measurability. CONCLUSION Cangrelor is a promising alternative to currently available therapies, especially in patients with a high hemorrhagic risk.
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Affiliation(s)
- Pouya Entezami
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Devin N Holden
- Department of Pharmacy, Albany Medical Center, Albany, NY, USA
| | - Alan S Boulos
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Alexandra R Paul
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Nicholas C Field
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Emad Nourollahzadeh
- Department of Neurosurgery, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Junichi Yamamoto
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - John C Dalfino
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
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Neyens R, Donaldson C, Andrews C, Kellogg R, Spiotta A. Platelet Function Testing with a VerifyNow-Directed Personalized Antiplatelet Strategy and Associated Rates of Thromboembolic Complications After Pipeline Embolization for Complex Cerebral Aneurysms. World Neurosurg 2020; 138:e674-e682. [DOI: 10.1016/j.wneu.2020.03.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 11/29/2022]
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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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Safety and efficacy of a pre-treatment antiplatelet regimen of unruptured intracranial aneurysms: a single-center experience. Neuroradiology 2020; 62:1029-1041. [PMID: 32170373 DOI: 10.1007/s00234-020-02387-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 02/26/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Endovascular treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents requires a prophylactic antiplatelet premedication to avoid thrombo-embolic complications. Guidelines for optimal antiplatelet regimens are poorly defined. The aim of this study is to report our experience using a high dosage antiplatelet premedication regimen for patients with unruptured intracranial aneurysms undergoing endovascular treatment by stent-assisted coiling or flow diverter stents. METHODS From a retrospective analysis of a prospectively maintained database, we collected clinical and angiographic data of 400 procedures in 362 patients treated by stent-assisted coiling or flow diverter stents for 419 unruptured intracranial aneurysms. Descriptive and analytic statistics were performed to report morbidity, mortality, and complication rates and to demonstrate associations between variables and outcomes. Logistic multivariable regression was performed to rule out confounding factors between subgroups. RESULTS Thrombo-embolic complications occurred in 23/400 procedures (5.75%) and hemorrhagic complications in 19/400 procedures (4.75%). The majority of complications were minor and transient with overall procedure-related morbidity and mortality rates of 1.75% (n = 7/400) and 1.25% (n = 5/400) respectively. The co-existence of multiple cardiovascular risk factors among smoking, hypertension, dyslipidemia, and age > 65 years old was significantly associated with permanent procedure-related morbidity (p = 0.006) and thrombo-embolic complications occurrence (p = 0.034). Age alone was associated with higher permanent morbidity (p = 0.029) and was the only variable associated with higher hemorrhagic complication (p = 0.024). CONCLUSION In this study, the use of a high dosage antiplatelet premedication was safe and effective for the treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents. Mortality and morbidity rates compare favorably with the current literature. The thrombo-embolic complications rate is low and most of them were clinically silent. However, the hemorrhagic complications rate was substantial and a significant proportion of them were associated with mortality.
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Corliss BM, Freedman R, Brennan MM, Smith J, Nerva JD, Harris NS, Polifka AJ, Hoh BL, Fox WC. Laboratory assessments of therapeutic platelet inhibition in endovascular neurosurgery: complication prediction using the VerifyNow P2Y12 assay and thromboelastography with platelet mapping. J Neurosurg 2020; 134:884-892. [PMID: 32084635 DOI: 10.3171/2019.12.jns192396] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/02/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Inhibition of platelet aggregation is universally used to prevent thromboembolic complications related to stent placement in endovascular neurosurgery, but excessive inhibition potentiates hemorrhagic complications. Previously, the authors demonstrated that two different commercially available measures of adenosine diphosphate (ADP)-dependent platelet inhibition-the VerifyNow P2Y12 clopidogrel assay (measured in platelet reactivity units [PRU]) and maximal amplitude (MA) attributable to ADP activity (MA-ADP) derived from thromboelastography (TEG) with platelet mapping (PM)-yielded wildly different results. This study sought to analyze observed complications to quantify the ideal therapeutic windows for both tests. METHODS Ninety-one patients with simultaneous or near-simultaneous PRU and TEG-PM results who underwent craniocervical endovascular stenting at the authors' institution between September 2015 and November 2017 were identified and retrospectively enrolled. From November 2017 until June 2019, 109 additional patients were prospectively enrolled. For this study, in-hospital thrombotic and hemorrhagic complications (both CNS and non-CNS) were tabulated, and receiver operating characteristic (ROC) curve analysis was used to identify threshold values of the PRU and MA-ADP for predicting each type of complication. RESULTS Of the 200 patients enrolled, 7 were excluded because of anemia or thrombocytopenia outside of the test manufacturer's specified ranges and 1 was excluded because they did not have a TEG-PM result. Including complications of all severities, there were a total of 15 CNS thrombotic complications, 1 access-site thrombotic complication, 3 CNS hemorrhages, 8 access-site hemorrhagic complications, and 3 hemorrhagic complications not affecting either the CNS or the access site. ROC curve analysis yielded therapeutic threshold values of 118-144 PRU. The results demonstrated PRU has a significant dose-dependent effect on the rates of thrombosis and hemorrhage. Logistic regression models did not demonstrate statistically significant relationships between the MA-ADP and either thrombosis or hemorrhage. ROC analysis based on these models is of little value and did not identify significant threshold values for MA-ADP. CONCLUSIONS There continues to be poor correlation between the results of TEG-PM and PRU. PRU accurately predicted complications, with a relatively narrow ideal value range of 118-144. The MA-ADP alone does not appear able to accurately predict either hemorrhagic or thrombotic complications in this group.
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Affiliation(s)
| | - Rachel Freedman
- 2University of Florida College of Medicine, Gainesville, Florida; and
| | | | | | - John D Nerva
- 4Department of Neurological Surgery, Tulane University, Metairie, Louisiana
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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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Katzman BM, Wockenfus AM, Scott RJ, Bryant SC, Jaffe AS, Karon BS. Estimating short- and long-term reference change values and index of individuality for tests of platelet function. Clin Biochem 2019; 74:54-59. [PMID: 31669512 DOI: 10.1016/j.clinbiochem.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/30/2019] [Accepted: 10/07/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND In order to manage risks of bleeding and thrombosis after some surgical procedures, platelet function is often measured repeatedly over days or weeks using laboratory tests of platelet function. To interpret test results in the perioperative period, it is necessary to understand analytical, biological and between-person variation. METHODS We collected three separate blood specimens from 16 healthy volunteers on the first study day, and one additional specimen from each volunteer 1, 2, and 3 months later. Arachidonic acid-induced and adenosine diphosphate (ADP)-induced platelet function were measured in duplicate by whole blood impedance aggregometry using Multiplate (ASPI/ADP tests) and VerifyNow (Aspirin Reaction Units [ARU] and P2Y12 Reaction Units [PRU]). The analytical variation (CVA), within-subject variation (CVI), between-subject variation (CVG), index of individuality (II), and reference change values (RCV) were calculated. RESULTS VerifyNow ARU demonstrated the smallest short-term and long-term variability (CVA, CVI, and CVG ~1%), resulting in short- and long-term RCV values <5%. II was also higher (1.92) for VerifyNow ARU than other platelet function tests. Multiplate ASPI and ADP tests had the highest RCV both short-(19.0% and 25.2%, respectively) and long-term (32.1% and 39.6%, respectively) due to increased CVA (>5%) and CVI (3.9-13.1%). VerifyNow PRU had a lower RCV than Multiplate ADP; but was the only test with II <0.6. CONCLUSIONS VerifyNow ARU results can be interpreted relative to a fixed cut-off or population-based reference interval; or relative to small changes in an individual's previous values. VerifyNow PRU and Multiplate ASPI and ADP tests should only be interpreted based upon relative change; and can only distinguish relatively large (>23%) changes over several weeks.
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Affiliation(s)
- Brooke M Katzman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Amy M Wockenfus
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Renee J Scott
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Sandra C Bryant
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Allan S Jaffe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Cardiology, Mayo Clinic, Rochester, MN, United States
| | - Brad S Karon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
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Comparison of two preventive dual antiplatelet regimens for unruptured intracranial aneurysm embolization with flow diverter/disrupter: A matched-cohort study comparing clopidogrel with ticagrelor. J Neuroradiol 2019; 46:378-383. [DOI: 10.1016/j.neurad.2019.01.094] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 01/14/2023]
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40
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Corliss BM, Polifka AJ, Harris NS, Hoh BL, Fox WC. Laboratory assessments of therapeutic platelet inhibition in endovascular neurosurgery: comparing results of the VerifyNow P2Y12 assay to thromboelastography with platelet mapping. J Neurosurg 2019; 129:1160-1165. [PMID: 29271717 DOI: 10.3171/2017.6.jns17535] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/05/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVEInhibition of platelet aggregation is vital to preventing thromboembolic complications related to stent placement in endovascular neurosurgery, but excessive inhibition potentiates hemorrhagic complications. Recent evidence suggests an ideal inhibition range of 70-150 P2Y12 response units (PRU) as measured on the VerifyNow assay, which relies on photometric measurements of platelet aggregation. Thromboelastography (TEG) with platelet mapping (PM) is an alternative assay that directly measures clot formation and mechanical strength. This study compares the results of PRU to TEG-PM.METHODSPatients with simultaneous or near-simultaneous PRU and TEG-PM results who underwent cervical carotid artery stenting, intracranial stent-assisted aneurysm coiling, or flow diversion at the authors' institution between August 2015 and November 2016 were identified. PRU results were compared with the TEG maximal amplitude (MA) attributable to adenosine diphosphate (ADP) activity (MA-ADP) as measured by TEG-PM. Platelet inhibition was considered therapeutic for MA-ADP values < 50 mm or PRU < 194. The Pearson correlation coefficient was calculated, and the sensitivity and specificity of PRU were calculated assuming that the results of TEG-PM reflected the true degree of platelet inhibition.RESULTSTwenty-three patients were identified with a total of 37 matched sets of TEG-PM and PRU. Three of these pairs were excluded due to anemia outside of the PRU manufacturer's recommended range. The Pearson correlation coefficient for these values was 0.50 (p = 0.0026). The prevalence of clopidogrel nonresponders determined by TEG-PM (9%) matched reported rates (5%-12%); PRU demonstrated much higher prevalence (39%). For detecting a therapeutic level of platelet inhibition, PRU demonstrated a sensitivity of 0.59, specificity of 0.50, positive predictive value of 0.95, and negative predictive value of 0.07. Ideal inhibition was concordant in only 25% of observations in which at least one of the results was ideal.CONCLUSIONSAgreement between TEG-PM and PRU regarding the degree of platelet inhibition is poor. PRU likely overestimates clopidogrel resistance, as 93% of patients with PRU > 194 demonstrate a therapeutic level of platelet inhibition on TEG.
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Affiliation(s)
| | | | - Neil S Harris
- 2Pathology, University of Florida, Gainesville, Florida
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Blackburn SL, Cawley CM, Guzman R. Wider Adoption of Flow Diversion for Intracranial Aneurysms. Stroke 2019; 50:3333-3334. [PMID: 31587661 DOI: 10.1161/strokeaha.119.027086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Spiros L Blackburn
- From the Department of Neurosurgery, University of Texas Health Science Center, Houston, TX (S.L.B.)
| | - C Michael Cawley
- Department of Neurosurgery, Emory University, Atlanta, GA (C.M.C.)
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital Basel, Switzerland (R.G.)
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Podlasek A, Al Sultan AA, Assis Z, Kashani N, Goyal M, Almekhlafi MA. Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis. J Neurointerv Surg 2019; 12:148-155. [DOI: 10.1136/neurintsurg-2019-014996] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/30/2019] [Accepted: 06/02/2019] [Indexed: 01/15/2023]
Abstract
BackgroundThromboembolic complications are not uncommon in patients undergoing neurointerventional procedures. The use of flow diverting stents is associated with higher risks of these complications despite current dual antiplatelet regimens.ObjectiveTo explore contemporary evidence on the safety of emerging dual antiplatelet regimens in flow diverting stenting procedures.MethodsWe performed a systematic review and meta-analysis to identify relevant articles in electronic databases, and relevant references. Studies reporting the complications and mortality of flow diverting stenting procedures using acetyl salicylic acid (ASA) + ticagrelor or ASA + prasugrel compared with ASA + clopidogrel were included.ResultsOf 452 potentially relevant studies, we identified 49 studies (2526 patients) which reported the safety of ticagrelor or prasugrel for pooled analysis, and five studies (1005 patients) for meta-analysis. The pooled overall mortality in all studies was 2.14%, ischemic complications 6.89%, and hemorrhagic complications 3.68%. The use of ticagrelor or prasugrel was associated with a lower risk of mortality compared with clopidogrel (RR=4.57, 95% CI 1.23 to 16.99; p=0.02). Considering ischemic events, ASA + clopidogrel was as safe as ASA + prasugrel (RR=0.55, 95% CI 0.11 to 2.74; p=0.47) and ASA + ticagrelor (RR=0.74, 95% CI 0.32 to 1.74; p=0.49). ASA +ticagrelor was not associated with a higher risk of hemorrhagic complications (RR=0.92, 95% CI 0.27 to 3.16; p=0.89).ConclusionsEvidence suggests that dual antiplatelet regimens including ticagrelor or prasugrel are safe for patients undergoing flow diversion procedures. Regimens using ticagrelor were associated with better survival than those using clopidogrel in the included studies.
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Griffin A, Reese V, Hüseyinoglu Z, Niedzwiecki D, Yang L, Cutler A, Gonzalez LF, Zomorodi A, Smith T, Hauck EF. Predictors of Clinical Outcome After Treatment of Intracranial Aneurysms with the Pipeline Embolization Device. World Neurosurg 2019; 130:e666-e671. [PMID: 31276854 DOI: 10.1016/j.wneu.2019.06.185] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/22/2019] [Accepted: 06/24/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Flow-diverting stents have revolutionized the endovascular treatment of intracranial aneurysms. The purpose of this study is to identify predictors of adverse outcomes associated with the pipeline embolization device (PED). METHODS A retrospective analysis of all patients treated with PED at a single high-volume center from January 2014 to September 2018. Patient outcomes, neurologic morbidity/mortality, and other clinical variables were analyzed. RESULTS We treated 204 aneurysms in 170 patients with PED. Mean length of follow-up was 11 months. Most (181) aneurysms (89%) were located in the anterior circulation, and 23 (11%) were found in the posterior circulation. Most aneurysms were saccular (82%), followed by fusiform (11%), blister (4%), and dissecting pseudoaneurysms (3%). Mean aneurysm size was 8.2 + 5.7 mm with 145 (71%) small aneurysms (≤10 mm), 53 (26%) large aneurysms (between 10 and 25 mm), and 6 (3%) giant aneurysms (≥25 mm). Ninety-two percent of aneurysms were unruptured, and 8% were ruptured. The overall major neurologic morbidity/mortality was 4.7% and 1.8%, respectively. The all-cause mortality was 2.9%. Predictors of neurologic morbidity/mortality included the baseline modified Rankin Scale (P = 0.001), aneurysm neck size (P = 0.003), aneurysm size (P = 0.006), anterior versus posterior location (P = 0.02), and rupture at presentation (0.006). The P2Y12 Reactivity Unit, parent vessel diameter, and patient age did not correlate with adverse events. CONCLUSIONS The PED has a satisfactory safety profile in both on- and off-label indications. A poor clinical patient baseline, wider aneurysm neck or larger size, and rupture predict an increased risk of an unfavorable outcome.
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Affiliation(s)
- Andrew Griffin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
| | - Vanessa Reese
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Zeynep Hüseyinoglu
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Donna Niedzwiecki
- Department of Biostatistics, Duke University Medical Center, Durham, North Carolina, USA
| | - Lexie Yang
- Department of Biostatistics, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrew Cutler
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Ali Zomorodi
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Tony Smith
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Erik F Hauck
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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Use of the PulseRider Device in the Treatment of Ruptured Intracranial Aneurysms: A Case Series. World Neurosurg 2019; 127:e149-e154. [DOI: 10.1016/j.wneu.2019.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 03/01/2019] [Accepted: 03/02/2019] [Indexed: 11/21/2022]
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Oran I, Cinar C, Gok M, Duzgun F. Aggregometry Response to Half-dose Prasugrel in Flow-diverting Stent Implantation. Clin Neuroradiol 2019; 30:463-469. [DOI: 10.1007/s00062-019-00804-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 05/21/2019] [Indexed: 11/28/2022]
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46
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Chen J, Zhang Y, Tian Z, Li W, Zhang Q, Zhang Y, Liu J, Yang X. Relationship between haemodynamic changes and outcomes of intracranial aneurysms after implantation of the pipeline embolisation device: a single centre study. Interv Neuroradiol 2019; 25:671-680. [PMID: 31088244 DOI: 10.1177/1591019919849673] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Intracranial aneurysms are increasingly being treated by the placement of flow diverters; however, the factors affecting the outcome of aneurysms treated using flow diverters remain unclarified. METHODS The present study investigated 94 aneurysms treated with pipeline embolisation device placement, and used a computational fluid dynamics method to explore the factors influencing the outcome of aneurysms. RESULTS Seventy-six completely occluded aneurysms and 18 incompletely occluded aneurysms were analysed. Before treatment, inflow jets were found in 13 (72.2%) aneurysms in the incompletely occluded group and 34 (44.7%) in the completely occluded group (P = 0.292). After deployment of the pipeline embolisation device, inflow jets remained in nine (50%) aneurysms in the incompletely occluded group and nine (11.8%) in the completely occluded group (P = 0.001). In the incompletely occluded group, regions with inflow jets after treatment corresponded with the patent areas shown on follow-up digital subtraction angiography. The mean reduction ratios of velocity in the whole aneurysm and on the neck plane were lower in the incompletely occluded than in the completely occluded group (P = 0.003; P = 0.017). Multivariate analysis revealed that the only independent risk factors for incomplete aneurysm occlusion were the reduction ratios of velocity (in the whole aneurysm, threshold 0.362, P = 0.005; on the neck plane, threshold 0.273, P = 0.015). CONCLUSIONS After pipeline embolisation device placement, reduction ratios of velocity in the whole aneurysm of less than 0.362 and on the neck plane of less than 0.273 are significantly associated with a greater risk of aneurysm incomplete occlusion. In addition, the persistence of inflow jets in aneurysms is associated with incomplete occlusion in the inflow jet area.
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Affiliation(s)
- Junfan Chen
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
| | - Zhongbin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
| | - Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
| | - Qianqian Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing, China
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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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Iosif C, Biondi A. Braided stents and their impact in intracranial aneurysm treatment for distal locations: from flow diverters to low profile stents. Expert Rev Med Devices 2019; 16:237-251. [DOI: 10.1080/17434440.2019.1575725] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Christina Iosif
- Department of Neuroradiology and Endovascular Treatment, Jean-Minjoz University Hospital, Besancon, France
- Department of Interventional Neuroradiology, Erasmus University Hospital, Brussels, Belgium
- Associate Professor in Radiology, European University of Cyprus, Nicosia, Cyprus
| | - Alessandra Biondi
- Department of Neuroradiology and Endovascular Treatment, Jean-Minjoz University Hospital, Besancon, France
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Ares WJ, Tonetti DA, Greene S, Sharma MS, Xavier F, Jankowitz BT, Jadhav A. Pipeline Embolization of an Infectious Basilar Artery Aneurysm in a 2-Year-Old Child: Case Report, Discussion of the Literature and Perioperative Considerations. Oper Neurosurg (Hagerstown) 2019; 17:E224-E228. [DOI: 10.1093/ons/opz002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/11/2019] [Indexed: 11/13/2022] Open
Abstract
AbstractBACKGROUND AND IMPORTANCEFlow diversion of intracranial aneurysms has been rarely described in the pediatric population. Here we discuss the technical and perioperative complexities inherent in the flow diversion of an infectious basilar apex aneurysm in a 2-yr-old child with significant medical comorbidities.CLINICAL PRESENTATIONFollowing judicious oral administration of dual anti-platelet agents and intra-arterial administration of calcium channel blockers to treat vasospasm, standard endovascular procedures were used to place a flow diverting stent across the neck of a rapidly enlarging infectious aneurysm of the basilar apex.Following the uncomplicated procedure, the patient demonstrated progressive thrombosis of the previously noted basilar apex aneurysm over a 3-mo period. The patient was therefore felt to be safe to proceed with, and eventually underwent, uncomplicated orthotopic heart transplant.CONCLUSIONFlow diversion of complex intracranial aneurysms in pediatric patients with significant medical comorbidities is feasible and safe; however, considerations have to be made in the pre- and perioperative care of these patients given the propensity for low-weight and complicated systemic disease processes.
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Affiliation(s)
- William J Ares
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Daniel A Tonetti
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephanie Greene
- Department of Neurological Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mahesh S Sharma
- Division of Pediatric Cardiothoracic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Frederico Xavier
- Division of Pediatric Hematology/Oncology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian T Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ashutosh Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Al Kasab S, Guerrero WR, Nakagawa D, Samaniego EA, Ortega-Gutierrez S, Hasan D. Safety and Efficacy of the Pipeline Embolization Device Use in the Outside Circle of Willis Located Intracranial Aneurysms: A Single-Center Experience. INTERVENTIONAL NEUROLOGY 2019; 8:83-91. [PMID: 32508889 DOI: 10.1159/000495074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 11/02/2018] [Indexed: 11/19/2022]
Abstract
Background The use of Pipeline Embolization Device (PED) is approved by the US Food and Drug Administration (FDA) to treat aneurysms located between the petrous and superior hypophyseal segments of the internal carotid artery. The purpose of this study is to evaluate the feasibility and efficacy of treating aneurysms outside the FDA approved anatomical locations. Furthermore, we analyze the safety of our antiplatelet protocol. Methods Data on all patients treated with PED at our center from March 2015 to December 2017 were reviewed. Only patients with aneurysms treated with PED as off label use were included. Procedural complications and long-term functional outcome measured by modified Rankin Scale (mRS) were recorded. Tirofiban maintenance infusion was administered intravenously after PED deployment. None of the patients had platelet function testing. Results A total of 36 patients harboring 36 aneurysms were included in the study. Mean age was 58.2 years ±14.6. Nineteen were women (52.8%) and most aneurysms were unruptured (80.6%). There were no intraoperative complications. Five patients experienced postoperative complications - 4 ischemic strokes and one groin hematoma. None led to any significant disability at follow-up. Thirty-one patients (86.1%) achieved an mRS of 0-2 at follow-up. A Raymond-Roy classification of 1 was achieved in 78.9% of patients. Conclusion The use of PED to treat aneurysms located outside the circle of Willis is feasible and effective. Our novel antiplatelet protocol did not require platelet function assay testing and did not lead to a higher rate of thrombo-embolic events compared to what has been previously reported.
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Affiliation(s)
- Sami Al Kasab
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Waldo R Guerrero
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Daichi Nakagawa
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Edgar A Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - David Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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