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Goertz L, Hohenstatt S, Vollherbst DF, Weyland CS, Nikoubashman O, Gronemann C, Pflaeging M, Siebert E, Bohner G, Zopfs D, Schlamann M, Liebig T, Dorn F, Wiesmann M, Möhlenbruch MA, Kabbasch C. Safety and efficacy of coated flow diverters in the treatment of cerebral aneurysms during single antiplatelet therapy: A multicenter study. Interv Neuroradiol 2024:15910199241286542. [PMID: 39360399 DOI: 10.1177/15910199241286542] [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: 10/04/2024] Open
Abstract
OBJECTIVE This multicenter study evaluates the safety and efficacy of coated flow diverters (cFDs) for the treatment of cerebral aneurysms under single antiplatelet therapy (SAPT). METHODS This is a retrospective, observational study of 41 patients (median age: 58 years) with 41 aneurysms (median size: 7 mm, 29 [71%] saccular, 9 [22%] ruptured) treated with cFDs at four neurovascular centers between 2020 and 2023. Scheduled cases received continuous SAPT starting seven days before the procedure. Emergency cases were treated with tirofiban followed by SAPT loading. The safety endpoint was ischemic complications occurring during the procedure and within four months of clinical follow-up. RESULTS The Pipeline Vantage or Flex Shield was used in 26 (63%) procedures, the FRED X in 12 (29%), the p48/64 Hydrophilic Polymer Coating in 2 (5%), and the Derivo Embolization Device 2heal in 1 (2%). Single antiplatelet therapy consisted of prasugrel in 27 (66%) patients, ticagrelor in 9 (22%), and ASA in 5 (12%). There were 2 (5%) early ischemic complications (one minor stroke and one transient ischemic attack). There were no late ischemic complications in the four-month follow-up of 35 patients. The six dropouts included four nontreatment-related deaths after subarachnoid hemorrhage and two patients with a poor outcome after subarachnoid hemorrhage. Complete and favorable occlusion rates (median: 7 months) were 75% (27/36) and 89% (32/36), respectively. CONCLUSIONS Coated flow diverter implantation in the setting of SAPT was safe and effective and warrants confirmation in a prospective comparative trial.
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Affiliation(s)
- Lukas Goertz
- University of Cologne, Faculty of Medicine and University Hospital, Department of Radiology and Neuroradiology, Cologne, Germany
| | - Sophia Hohenstatt
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital Aachen, Aachen, Germany
| | | | - Muriel Pflaeging
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, University Hospital Berlin (Charité), Berlin, Germany
| | - Georg Bohner
- Department of Neuroradiology, University Hospital Berlin (Charité), Berlin, Germany
| | - David Zopfs
- University of Cologne, Faculty of Medicine and University Hospital, Department of Radiology and Neuroradiology, Cologne, Germany
| | - Marc Schlamann
- University of Cologne, Faculty of Medicine and University Hospital, Department of Radiology and Neuroradiology, Cologne, Germany
| | - Thomas Liebig
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital Aachen, Aachen, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Kabbasch
- University of Cologne, Faculty of Medicine and University Hospital, Department of Radiology and Neuroradiology, Cologne, Germany
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Schwab R, Kabbasch C, Goertz L, Kaschner M, Weiss D, Loehr C, Wensing H, Bester M, Simgen A, Kemmling A, Wendl C, Fuchs E, Thormann M, Behme D, Nordmeyer H. The DERIVO 2 Heal Embolization Device in the Treatment of Ruptured and Unruptured Intracranial Aneurysms: a Retrospective Multicenter Study. Clin Neuroradiol 2024:10.1007/s00062-024-01446-8. [PMID: 39172220 DOI: 10.1007/s00062-024-01446-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 07/11/2024] [Indexed: 08/23/2024]
Abstract
BACKROUND The use of flow diverting stents in the treatment of intracranial aneurysms is associated with a risk of neurological morbidity due to their thrombogenicity. To reduce this risk different surface modifications have been developed. The Derivo 2 Embolization Device (Acandis, Pforzheim, Germany) has proven to be a safe and effective flow diverter. To overcome the risk of thrombo-embolism, the device was modified by adding an anti-thrombogenic fibrin-heparin coating. We aimed to assess the safety and effectiveness of the Derivo 2 heal Embolization Device. METHODS Retrospective multicenter data from nine German neurovascular centers between February 2022 until December 2023 were used. Patients treated with the Derivo 2 heal Embolization Device for unruptured or ruptured intracranial aneurysms were included. Peri- and postprocedural adverse events, clinical outcomes, and angiographic follow-up results were evaluated. RESULTS 84 patients (73.8% female; mean age 58.7 years) with 89 aneurysms (mean size 9.8 mm) were included. 87.6% were located in the anterior circulation. Most of them were sidewall aneurysms (88.8%). 96 flow diverters were used. 99.0% were successfully implanted. An in-stent balloon angioplasty was performed in 6.0% of the cases. An additional coiling was performed in 28.6%. Technical difficulties were present in 12.0% of the cases. Thrombotic events occurred in 4.8% with no neurological sequelae. Mortality and morbidity were 0 and 1.2% respectively. Adequate aneurysm occlusion was achieved in 80.7% with a mean follow-up time of 6.6 months. CONCLUSION The Derivo 2 heal Embolization Device showed a satisfying aneurysm occlusion and safety with a low rate of neurological morbidity.
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Affiliation(s)
- Roland Schwab
- University Clinic for Neuroradiology, Medical Faculty and University Hospital, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.
- Research Campus STIMULATE, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.
| | - Christoph Kabbasch
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Lukas Goertz
- Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Marius Kaschner
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - Daniel Weiss
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - Christian Loehr
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - Hauke Wensing
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Simgen
- Department for Neuroradiology, Westpfalz-Klinikum Kaiserslautern, Kaiserslautern, Germany
| | - André Kemmling
- Department of Neuroradiology, University Marburg, Marburg, Germany
| | - Christina Wendl
- University Hospital Regensburg, Institute of Radiology, Regensburg, Germany
| | - Erelle Fuchs
- University Clinic for Neuroradiology, Medical Faculty and University Hospital, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Maximilian Thormann
- University Clinic for Neuroradiology, Medical Faculty and University Hospital, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Daniel Behme
- University Clinic for Neuroradiology, Medical Faculty and University Hospital, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
- Research Campus STIMULATE, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Hannes Nordmeyer
- Department of Neuroradiology Städtisches Klinikum Solingen, Solingen, Germany
- Medical School, Department of Health, Witten/Herdecke University, Witten, Germany
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3
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Zoppo CT, Mocco J, Manning NW, Bogdanov AA, Gounis MJ. Surface modification of neurovascular stents: from bench to patient. J Neurointerv Surg 2024; 16:908-913. [PMID: 37793794 DOI: 10.1136/jnis-2023-020620] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
Flow-diverting stents (FDs) for the treatment of cerebrovascular aneurysms are revolutionary. However, these devices require systemic dual antiplatelet therapy (DAPT) to reduce thromboembolic complications. Given the risk of ischemic complications as well as morbidity and contraindications associated with DAPT, demonstrating safety and efficacy for FDs either without DAPT or reducing the duration of DAPT is a priority. The former may be achieved by surface modifications that decrease device thrombogenicity, and the latter by using coatings that expedite endothelial growth. Biomimetics, commonly achieved by grafting hydrophilic and non-interacting polymers to surfaces, can mask the device surface with nature-derived coatings from circulating factors that normally activate coagulation and inflammation. One strategy is to mimic the surfaces of innocuous circulatory system components. Phosphorylcholine and glycan coatings are naturally inspired and present on the surface of all eukaryotic cell membranes. Another strategy involves linking synthetic biocompatible polymer brushes to the surface of a device that disrupts normal interaction with circulating proteins and cells. Finally, drug immobilization can also impart antithrombotic effects that counteract normal foreign body reactions in the circulatory system without systemic effects. Heparin coatings have been explored since the 1960s and used on a variety of blood contacting surfaces. This concept is now being explored for neurovascular devices. Coatings that improve endothelialization are not as clinically mature as anti-thrombogenic coatings. Coronary stents have used an anti-CD34 antibody coating to capture circulating endothelial progenitor cells on the surface, potentially accelerating endothelial integration. Similarly, coatings with CD31 analogs are being explored for neurovascular implants.
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Affiliation(s)
- Christopher T Zoppo
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - J Mocco
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathan W Manning
- The MIRI Centre, Ingham Institute for Applied Medical Science, Sydney, New South Wales, Australia
- Department of Interventional Radiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Alexei A Bogdanov
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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King RM, Peker A, Epshtein M, Arends JM, Brochu AB, Raskett CM, Slazas KJ, Puri AS, Arthur AS, Fiorella D, Gounis MJ, Anagnostakou V. Active drug-coated flow diverter in a preclinical model of intracranial stenting. J Neurointerv Surg 2024; 16:731-736. [PMID: 37399337 DOI: 10.1136/jnis-2023-020391] [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: 04/06/2023] [Accepted: 06/18/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Flow diverters carry the risk of thromboembolic complications (TEC). We tested a coating with covalently bound heparin that activates antithrombin to address TEC by locally downregulating the coagulation cascade. We hypothesized that the neuroimaging evidence of TEC would be reduced by the coating. METHODS 16 dogs were implanted with overlapping flow diverters in the basilar artery, separated into two groups: heparin-coated (n=9) and uncoated (n=7). Following implantation, high-frequency optical coherence tomography (HF-OCT) was acquired to quantify acute thrombus (AT) formation on the flow diverters. MRI was performed postoperatively and repeated at 1, 2, 3, 4, and 8 weeks, consisting of T1-weighted imaging, time-0f-flight (ToF), diffusion weighted imaging (DWI), susceptibility weighted imaging (SWI), and fluid attenuated inversion recovery (FLAIR) sequences. Neurological examinations were performed throughout the 8-week duration of the study. RESULTS The mean AT volume on coated devices was lower than uncoated (0.014 vs 0.018 mm3); however, this was not significant (P=0.3). The mean number of foci of magnetic susceptibility artifacts (MSAs) on SWI was significantly different between the uncoated and coated groups at the 1-week follow-up (P<0.02), and remained statistically different throughout the duration of the study. The AT volume showed a direct linear correlation with the MSA count and 80% of the variance in the MSA could be explained by the AT volume (P<0.001). Pathological analysis showed evidence of ischemic injury at locations of MSA. CONCLUSIONS Heparin-coated flow diverters significantly reduced the number of new MSAs after 1 week follow-up, showing the potential to reduce TEC.
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Affiliation(s)
- Robert M King
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Ahmet Peker
- Radiology, Koç University Hospital, Istanbul, Turkey
| | - Mark Epshtein
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | | | - Alice B Brochu
- Research and Development, Stryker Neurovascular, Fremont, California, USA
| | - Christopher M Raskett
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Kimiko J Slazas
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Ajit S Puri
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Vania Anagnostakou
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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5
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Hohenstatt S, Saatci I, Jesser J, Çekirge HS, Koçer N, Islak C, Lücking H, DuPlessis J, Rautio R, Bendszus M, Vollherbst DF, Möhlenbruch MA. Prasugrel Single Antiplatelet Therapy versus Aspirin and Clopidogrel Dual Antiplatelet Therapy for Flow Diverter Treatment for Cerebral Aneurysms: A Retrospective Multicenter Study. AJNR Am J Neuroradiol 2024; 45:592-598. [PMID: 38453414 PMCID: PMC11288545 DOI: 10.3174/ajnr.a8163] [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: 10/27/2023] [Accepted: 01/07/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND PURPOSE The optimal antiplatelet regimen after flow diverter treatment of cerebral aneurysms is still a matter of debate. A single antiplatelet therapy might be advantageous in determined clinical scenarios. This study evaluated the efficacy and safety of prasugrel single antiplatelet therapy versus aspirin and clopidogrel dual antiplatelet therapy. MATERIALS AND METHODS We performed a post hoc analysis of 4 retrospective multicenter studies including ruptured and unruptured aneurysms treated with flow diversion using either prasugrel single antiplatelet therapy or dual antiplatelet therapy. Primary end points were the occurrence of any kind of procedure- or device-related thromboembolic complications and complete aneurysm occlusion at the latest radiologic follow-up (mean, 18 months). Dichotomized comparisons of outcomes were performed between single antiplatelet therapy and dual antiplatelet therapy. Additionally, the influence of various patient- and aneurysm-related variables on the occurrence of thromboembolic complications was investigated using multivariable backward logistic regression. RESULTS A total of 222 patients with 251 aneurysms were included, 90 (40.5%) in the single antiplatelet therapy and 132 (59.5%) in the dual antiplatelet therapy group. The primary outcome-procedure- or device-related thromboembolic complications-occurred in 6 patients (6.6%) of the single antiplatelet therapy and in 12 patients (9.0%) of the dual antiplatelet therapy group (P = .62; OR, 0.712; 95% CI, 0.260-1.930). The primary treatment efficacy end point was reached in 82 patients (80.4%) of the single antiplatelet therapy and in 115 patients (78.2%) of the dual antiplatelet therapy group (P = .752; OR, 1.141; 95% CI, 0.599-2.101). Logistic regression showed that non-surface-modified flow diverters (P = .014) and fusiform aneurysm morphology (P = .004) significantly increased the probability of thromboembolic complications. CONCLUSIONS Prasugrel single antiplatelet therapy after flow diverter treatment may be as safe and effective as dual antiplatelet therapy and could, therefore, be a valid alternative in selected patients. Further prospective comparative studies are required to validate our findings.
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Affiliation(s)
- Sophia Hohenstatt
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - Işıl Saatci
- Interventional Neuroradiology Section (I.S., H.S.C.), Koru and Bayindir Private Hospitals, Ankara, Turkey
| | - Jessica Jesser
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - H Saruhan Çekirge
- Interventional Neuroradiology Section (I.S., H.S.C.), Koru and Bayindir Private Hospitals, Ankara, Turkey
| | - Naci Koçer
- Department of Neuroradiology (N.K., CI.), Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Civan Islak
- Department of Neuroradiology (N.K., CI.), Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Hannes Lücking
- Department of Neuroradiology (H.L.), University of Erlangen-Nuremberg, Erlangen, Germany
| | - Johannes DuPlessis
- Department of Clinical Neurosciences (J.D.), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Riitta Rautio
- Department of Interventional Radiology (R.R.), Turku University Hospital, Turku, Finland
| | - Martin Bendszus
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - Dominik F Vollherbst
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Möhlenbruch
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
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6
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Enomoto Y, Matsubara H, Ishihara T, Shoda K, Mizutani D, Egashira Y, Ishii A, Sakamoto M, Sumita K, Nakagawa I, Higashi T, Yoshimura S. Optimal duration of dual antiplatelet therapy for stent-assisted coiling or flow diverter placement. J Neurointerv Surg 2024; 16:491-497. [PMID: 37344176 PMCID: PMC11041548 DOI: 10.1136/jnis-2023-020285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/04/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is necessary to prevent thromboembolic complications after stent-assisted coiling (SAC) or flow-diversion (FD) for cerebral aneurysms, but the optimal antiplatelet regimen remains unclear. OBJECTIVE To determine the optimal DAPT duration in patients with SAC/FD. METHODS This multicenter cohort study enrolled patients who received SAC/FD for cerebral aneurysms at seven Japanese institutions between January 2010 and December 2020. The primary outcome was the time from procedure to the occurrence of a composite of target vessel-related thromboembolic events, procedure-unrelated major bleeding events, or death. The cumulative event-free survival rates were analyzed using a Kaplan-Meier curve, and the differences in each outcome between the groups dichotomized by the duration of DAPT were analyzed using the log-rank test. RESULTS Of 632 patients (median observational period, 646 days), primary outcome occurred in 63 patients (10.0%), most frequently within 30 days after the procedure. The cumulative event-free survival rates at 30 days, 1 year, and 2 years after the procedure were 93.3% (91.4 to 95.3%), 91.5% (89.3 to 93.7%), and 89.5% (87.0 to 92.0%), respectively. The cumulative event-free survival rates after switching to monotherapy were similar for the >91 and <90 days DAPT groups in the population limited to patients who were switched from DAPT to monotherapy without major clinical events. CONCLUSIONS Thromboembolic events rarely occurred beyond 30 days after SAC/FD. The duration of DAPT may be shortened if patients have a periprocedural period without events. Further prospective studies are warranted to determine the optimal duration of antiplatelet therapy. TRIAL REGISTRATION NUMBER UMIN000044122 :https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000050384.
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Affiliation(s)
- Yukiko Enomoto
- Neurosurgery, Gifu Univeristy Graduate School of Medicine, Gifu, Japan
| | | | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Kenji Shoda
- Neurosurgery, Gifu Univeristy Graduate School of Medicine, Gifu, Japan
| | - Daisuke Mizutani
- Neurosurgery, Gifu Univeristy Graduate School of Medicine, Gifu, Japan
| | - Yusuke Egashira
- Neurosurgery, Gifu Univeristy Graduate School of Medicine, Gifu, Japan
| | - Akira Ishii
- Neurosurgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Makoto Sakamoto
- Division of Neurosurgery, Department of Neurological Sciences, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Kazutaka Sumita
- Endovascular surgery, Tokyo Medical and Dental University, Bunkyo-ku, Japan
| | - Ichiro Nakagawa
- Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Toshio Higashi
- Neurosurgery, Fukuoka University Chikushi Hospital, Chikushino, Japan
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Al-Salihi MM, Saha R, Gillani SA, Al-Jebur MS, Al-Salihi Y, Roy A, Dalal SS, Saleh A, Siddiq F, Ayyad A, Qureshi AI. Ticagrelor Versus Clopidogrel in Endovascular Therapy for Cerebral Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 184:310-321.e5. [PMID: 38342169 DOI: 10.1016/j.wneu.2024.02.013] [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: 12/26/2023] [Accepted: 02/03/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Antiplatelet therapy is pivotal in endovascular treatment for intracranial aneurysms. However, there is a lack of studies comparing ticagrelor to clopidogrel in patients with aneurysms undergoing endovascular therapy. Additionally, the existing literature lacks adequate sample size, significant subgrouping, and follow-up, making our study important to cover these gaps. METHODS We searched 5 databases to collect all relevant studies. Categorical outcomes were pooled as relative risk (R.R.) with a 95% confidence interval (CI). In the single-arm meta-analysis, outcomes were pooled as proportions and their corresponding 95% CI. RESULTS This comprehensive analysis of 18 studies involving 2,427 patients. For thromboembolic events, the pooled (R.R.) did not show significant differences, whether considering overall events. A similar pattern was observed for thromboembolic events stratified by aneurysmal rupture status, with no significant differences in overall events. Hemorrhagic events did not also exhibit significant differences in previously mentioned stratifications. Furthermore, there were no substantial differences in death and mRS (0-2) on discharge between Ticagrelor and Clopidogrel. Single-arm meta-analyses for Ticagrelor demonstrated low rates of thromboembolic events, hemorrhage, death, and favorable mRS scores, with associated confidence intervals (CIs). Main line of endovascular treatment did not significantly affect either thromboembolic or hemorrhagic outcomes with Ticagrelor and Clopidogrel. CONCLUSIONS We found no significant differences in key outcomes like thromboembolic events, hemorrhagic events, mortality rates, and favorable mRS (0-2) upon discharge in the studied patients between Ticagrelor and Clopidogrel. Moreover, the single-arm meta-analysis for Ticagrelor revealed low rates of thromboembolic events, hemorrhage, mortality, and high rates of favorable mRS scores.
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Affiliation(s)
- Mohammed Maan Al-Salihi
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA.
| | - Ram Saha
- Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Syed A Gillani
- Zeenat Qureshi Stroke Institute, University of Missouri, Columbia, Missouri, USA
| | | | | | - Anil Roy
- Department of Neurosurgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Shamser Singh Dalal
- Department of Radiology, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Ahmed Saleh
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar
| | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Ali Ayyad
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, University of Missouri, Columbia, Missouri, USA
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8
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Kass-Hout O, Stern J, D Tangonan R, Morsi RZ, Thind S, Kass-Hout T, Guterman L. An alternative reduced dose regimen of ticagrelor for neuroendovascular patients. Vascular 2023; 31:902-907. [PMID: 35466828 DOI: 10.1177/17085381221092858] [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] [Indexed: 10/11/2023]
Abstract
OBJECTIVE There is a growing use of ticagrelor in patients undergoing neuroendovascular procedures, especially those who demonstrate clopidogrel resistance. While multiple dosages are studied in the cardiology literature, the optimal dose for patients with neurological pathology has yet to be established. Here, we describe a single center experience involving 39 patients who underwent neuroendovascular procedures that then received an adjusted lower dose of ticagrelor. METHODS A retrospective chart review was performed between 2013 and 2017 for patients on dual anti-platelet therapy (DAPT) for either cervical or intracranial vascular pathologies, as well as stenting of the neurovasculature, including carotid arteries. Patients were placed on ticagrelor if their measured P2Y12 reaction units (PRU) responses to clopidogrel were outside the expected range in our center using the VerifyNow™ P2Y12 test. All patients were maintained on a dose of 45 mg twice daily except for one patient who received 22.5 mg twice daily. Responsiveness to ticagrelor were measured utilizing the VerifyNow™ P2Y12 test. RESULTS The mean number of days for follow-up post treatment initiation was 532 days. A total of 39 patients were included in the analysis. Of these, 8 patients (21%) received implantation of intracranial stents (5 patients received pipeline embolization devices, 1 patient received stent-assisted coiling, and 2 patients received intracranial stents for atherosclerotic disease). Fourteen patients (35%) received carotid angioplasty and stenting. Seventeen patients (44%) did not receive permanent implantation of a stent. All patients on the lower dose ticagrelor of 45 mg twice daily achieved responsiveness (i.e., PRU < 194). Hemorrhagic transformation of ischemic stroke occurred in one patient (2.5%). No other hemorrhagic complications were encountered. No thromboembolic events were recorded aside from one patient (2.5%) with intracranial atherosclerotic disease who had an ischemic event. CONCLUSIONS A lower dose of ticagrelor (45 mg twice daily) appears to be safe and effective in this small cohort of patients who are resistant to clopidogrel per P2Y12 testing and who have increased risk of ischemic or hemorrhagic strokes due to neurovascular pathologies and implants. Further randomized studies are required to confirm these findings.
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Affiliation(s)
- Omar Kass-Hout
- Department of Neurology, UNC REX Healthcare, Raleigh, NC, USA
| | - Joseph Stern
- Neurosciences Department, Mercy Hospital, Buffalo, NY, USA
| | - Ruth D Tangonan
- Department of Neurology, University of Chicago Medicine, Chicago, IL, USA
| | - Rami Z Morsi
- Department of Neurology, University of Chicago Medicine, Chicago, IL, USA
| | - Sonam Thind
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago Medicine, Chicago, IL, USA
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Lee Guterman
- Neurosciences Department, Mercy Hospital, Buffalo, NY, USA
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9
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de Castro-Afonso LH, Machado JP, Nakiri GS, Abud TG, Monsignore LM, Freitas RK, de Oliveira RS, Colli BO, Abud DG. Two year follow-up of distal unruptured intracranial aneurysms treated with a surface modified flow diverter under prasugrel monotherapy. J Neurointerv Surg 2023:jnis-2023-020397. [PMID: 37524519 DOI: 10.1136/jnis-2023-020397] [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: 04/02/2023] [Accepted: 07/21/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND A new generation of modified surface flow diverters (FDs) and monotherapy using new antiplatelets may reduce both ischemic and hemorrhagic complications during the treatment of intracranial aneurysms. Previous preliminary safety analysis of distal unruptured intracranial aneurysms treated with the FD p48 MW HPC (phenox-Wallaby, Bochum, Germany) under antiplatelet monotherapy with prasugrel showed promising results. However, the long term outcomes of distal intracranial aneurysms treated with FDs under antiplatelet monotherapy are not known. METHODS This was a single center, prospective, pivotal, open single arm study. The primary (safety) endpoint was absence of any new neurological deficits after treatment until the 24 month follow-up. The primary (efficacy) endpoint was the incidence of complete aneurysm occlusion 24 months after treatment. The secondary (efficacy) endpoints were any incidence of aneurysm dome reduction 24 months after treatment. RESULTS 21 patients harboring 27 distal aneurysms of the anterior circulation were included. No patient had neurologic deficits in the time from treatment to the 24 month follow-up. Complete aneurysm occlusion occurred in 20 (74%) of 27 aneurysms at the 24 month follow-up. Four aneurysms (14.8%) had dome reduction, and three aneurysms (11.1%) remained unchanged. CONCLUSIONS In this pilot trial, treatment of distal unruptured intracranial aneurysms with an FD under monotherapy with prasugrel, followed by monotherapy with aspirin, appeared to be safe and effective. Randomized studies with long term follow-up are needed to confirm these results.
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Affiliation(s)
- Luis Henrique de Castro-Afonso
- Interventional Neuroradiology, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - João Paulo Machado
- Interventional Neuroradiology, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - Guilherme Seizem Nakiri
- Interventional Neuroradiology, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - Thiago Giansante Abud
- Interventional Neuroradiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Lucas Moretti Monsignore
- Interventional Neuroradiology, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - Rafael Kiyuze Freitas
- Interventional Neuroradiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Ricardo Santos de Oliveira
- Division of Neurosurgery, Department of Surgery, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - Benedicto Oscar Colli
- Division of Neurosurgery, Department of Surgery, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - Daniel Giansante Abud
- Interventional Neuroradiology, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
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10
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Ma A, Detaram HD, Steinfort B, Harrington T, Nguyen TN, Abdalkader M, Siopis G, Bath PM, Dhillon PS, Podlasek A, Qureshi AI, Qiu Z, Krishnan K. Antiplatelet Therapy in Neurointervention. Semin Neurol 2023; 43:466-479. [PMID: 37562452 DOI: 10.1055/s-0043-1771383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.
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Affiliation(s)
- Alice Ma
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | | | - Brendan Steinfort
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Tim Harrington
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Centre, Boston, Massachusetts
| | | | - George Siopis
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Permesh Singh Dhillon
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom
| | - Anna Podlasek
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People's Republic of China
| | - Kailash Krishnan
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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11
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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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12
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Gawlitza M, Klisch J, Kaiser DPO, Linn J, Pierot L, Lobsien D. A Systematic Literature Review and Meta-Analysis of the Treatment of Ruptured Intracranial Aneurysms with Hydrophilic Polymer and Phosphorylcholine-Coated Flow Diverters Under Single Antiplatelet Therapy. World Neurosurg 2023; 170:e791-e800. [PMID: 36462697 DOI: 10.1016/j.wneu.2022.11.129] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE Flow diverters coated with antithrombogenic substances were recently introduced and have shown encouraging results in the preclinical setting. Our aim was to analyze their clinical application in patients with ruptured intracranial aneurysms using single antiplatelet therapy (SAPT). METHODS We performed a PRISMA-compliant systematic review and meta-analysis covering 3 major data bases until March 2022.Two reviewers independently reviewed clinical studies for eligibility.Random-effects analysis of proportions was used to pool safety outcomes (hemorrhagic, thrombembolic, and overall complications). Studies were tested for publication bias and heterogeneity. RESULTS Five studies reporting 43 patients with 46 aneurysms were identified. More than 1 stent was implanted in 16%, and additional coil embolization was performed in 53.8% of patients. SAPT with one of various acetylsalicylic acid regimens was used in 86%, altogether antiplatelet protocols were variable. The pooled risks of thromboembolic (23.9%; 95% confidence interval [CI], 9.6-47.9), hemorrhagic (9.4%; 95% CI, 3.6-22.6), and overall complications (28.3%; 95% CI, 12.4-52.5) were calculated in the absence of publication bias with low to moderate study heterogeneity measures. All complications occurred in patients under acetylsalicylic acid SAPT. Adequate aneurysm occlusion was described in 65.5% of patients.few retrospective observational studies with moderate heterogeneity, encompassing a limited number of patients treated with variable SAPT regimens. CONCLUSIONS Flow diversion for ruptured aneurysms under SAPT with coated stents is feasible. Although the risk of hemorrhagic complications was low, thromboembolic complications occurred in a significant number of patients, all under ASA SAPT.
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Affiliation(s)
- Matthias Gawlitza
- Institute of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany; EKFZ for Digital Health, Technical University Dresden, Dresden, Germany.
| | - Joachim Klisch
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Helios General Hospital Erfurt, Erfurt, Germany
| | - Daniel P O Kaiser
- Institute of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany; EKFZ for Digital Health, Technical University Dresden, Dresden, Germany
| | - Jennifer Linn
- Institute of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison Blanche, CHU Reims, Reims, France
| | - Donald Lobsien
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Helios General Hospital Erfurt, Erfurt, Germany
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13
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The Effect of Ticagrelor for Endovascular Intervention of Intracranial Aneurysm Patients with or without Clopidogrel Resistant: A Meta-Analysis. Brain Sci 2022; 12:brainsci12081077. [PMID: 36009140 PMCID: PMC9405867 DOI: 10.3390/brainsci12081077] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/01/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
Endovascular interventional is an important treatment method for intracranial aneurysms. However, due to the risk of intracranial thrombosis, prophylactic use of antiplatelet drugs is generally required. Clinically, the most commonly used drugs are aspirin and clopidogrel; although the latter can significantly reduce the incidence of thromboembolic complications, there are still some patients with clopidogrel resistance who have ischemic adverse events during antiplatelet therapy. In this study, cohort studies of PubMed, Embase and Cochrane Library Databases were retrieved to compare the efficacy and safety of ticagrelor and clopidogrel in endovascular interventional treatment of intracranial aneurysms. A total of 10 cohort studies involving 1377 patients were included in this study. All patients had intracranial aneurysms and underwent endovascular intervention. Platelet function was measured in four of the studies and switched the patients with clopidogrel resistance to ticagrelor, while the remaining six studies did not test platelet function, but were also treated with ticagrelor or clopidogrel. The results of the study showed that ticagrelor, like clopidogrel, can effectively control thrombotic complications in endovascular interventional patients, and also control the occurrence of ischemic complications in clopidogrel-resistant patients. Ticagrelor, as a novel platelet aggregation inhibitor that can reversibly bind to P2Y12 receptor, can effectively control thromboembolic complications without increasing hemorrhagic complications, and is also effective in patients with clopidogrel resistance.
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14
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Liu P, Liu L, Zhang C, Lin S, Wang T, Xie X, Zhou L, Wang C. Treatment of Blood Blister Aneurysms of the Internal Carotid Artery With Pipeline-Assisted Coil Embolization: A Single-Center Experience. Front Neurol 2022; 13:882108. [PMID: 35769367 PMCID: PMC9234106 DOI: 10.3389/fneur.2022.882108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/20/2022] [Indexed: 11/30/2022] Open
Abstract
Background Blood blister aneurysm (BBA) is a complex and rare aneurysm that presents significant treatment challenges. The application of pipeline embolization device (PED)-assisted coiling in the treatment of ruptured BBA remains controversial. This study aimed to report on our experience and assess the safety and efficacy of this strategy. Methods Between February 2019 and February 2021, 12 patients with ruptured BBAs underwent PED-assisted coil embolization. We collected detailed data about each patient, including demographic information, aneurysmal data, technical details, antiplatelet strategy, operation-related complications, and follow-up outcomes. Results A total of 12 BBA patients were treated with single PED-assisted coil embolization. One patient experienced intraoperative rupture that was controlled by rapid coiling without clinical consequences. All the patients demonstrated complete occlusion on postoperative angiography. A total of three patients had postoperative complications: left hemiparesis, Broca's aphasia, and right hemiplegia due to vasospasm, and transient hemiparesis. Follow-up angiography revealed that all BBAs were completely occluded, except one with neck residue. All patients had favorable outcomes at discharge and the most recent clinical follow-up (mRS score ≤ 2). Conclusion Endovascular treatment of BBAs of the internal carotid artery using PED-assisted coil embolization is a safe and effective strategy. This has contributed to the understanding of BBA therapy and provides a potentially optimal treatment option for this intractable lesion.
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15
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Camargo LM, Lima PCTM, Janot K, Maldonado IL. Safety of Oral P2Y12 Inhibitors in Interventional Neuroradiology: Current Status and Perspectives. AJNR Am J Neuroradiol 2021; 42:2119-2126. [PMID: 34674995 DOI: 10.3174/ajnr.a7303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/22/2021] [Indexed: 11/07/2022]
Abstract
In the field of interventional neuroradiology, antiplatelet agents are commonly used to prepare patients before the implantation of permanent endovascular materials. Among the available drugs, clopidogrel is the most frequently used one, but resistance phenomena are considered to be relatively common. Prasugrel and ticagrelor were recently added to the pharmacologic arsenal, but the safety of these agents in patients undergoing neurointerventional procedures is still a subject of discussion. The cumulative experience with both drugs is less extensive than that with clopidogrel, and the experience with patients in the neurology field is less extensive than in the cardiology domain. In the present article, we provide a narrative review of studies that investigated safety issues of oral P2Y12 inhibitors in interventional neuroradiology and discuss potential routes for future research.
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Affiliation(s)
- L M Camargo
- From the Faculdade de Medicina (L.M.C.), Universidade Salvador, Salvador, Brazil
| | - P C T M Lima
- Serviço de Clínica Médica (P.C.T.M.L.), Hospital Santo Antônio, Associação Obras Sociais Irmã Dulce, Salvador, Brazil
| | - K Janot
- Service de Neuroradiologie (K.J.), Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - I L Maldonado
- U1253, iBrain (I.L.M.), Université de Tours, Institut National de la Santé et de la Recherche Médicale, Tours, France
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16
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Tanburoglu A, Andic C. Early Treatment of Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery With Flow Diverters Using Single Antiplatelet Therapy: A Single-Center Experience With Long-Term Follow-Up. Front Neurol 2021; 12:708411. [PMID: 34630284 PMCID: PMC8492904 DOI: 10.3389/fneur.2021.708411] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Blood Blister-like aneurysms (BBAs) of the internal carotid artery (ICA) are rare entities of cerebral aneurysms. FD use in acutely ruptured aneurysms, timing of treatment and antiplatelet regimen are main debate topics in clinical practice when the treatment decision is flow diversion. The aim of this study is to report the safety and efficacy of a single-center FD treatment for ruptured BBAs in the early phase of SAH using the SAPT regimen. Material and Method: This study involved a retrospective analysis of a prospectively collected database. Records of patients admitted to our clinic and treated by endovascular route on ruptured BBA between January 2013 and December 2020 were reviewed. Ruptured supraclinoid ICA BBAs treated with FD devices with SAPT within 48 h from ictus of SAH are included. BBA of atypical anatomic locations, other endovascular techniques performed, and delayed admissions (>48 h) were excluded from the study. Demographic, clinical and angiographic features of patients and aneurysms, FD types and numbers, periprocedural complications, immediate and follow-up angiographic and clinical outcomes were recorded. Results: A total of six patients with ruptured BBAs treated via FDs within 48 h and used SAPT were included in the study. The mean age was 41.6 years (range from 34 to 45 years), and four of six patients were female. All patients were treated within 48 h after ictus, and the mean treatment day was 1.33 days. One patient received ticagrelor, and five patients received prasugrel as SAPT for one year after treatment. No procedure-related death and rebleeding were recorded. One (16.7 %) treatment responsive procedure-related complication occurred (transient ischemia). Overall good outcome rate was 83.3%. One patient died due to pneumonia. The immediate control angiograms showed complete occlusions of BBAs in one patient (16.6%). The complete occlusion rate was 100 % for five survivors at the control angiogram. The median follow-up was 49.5 months. Conclusion: This single-center experience suggests that early treatment (<2 days) within SAH of ruptured BBAs with FDs using SAPT is safe and effective in terms of clinical and radiological long-term outcomes.
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Affiliation(s)
| | - Cagatay Andic
- Radiology Department, Başkent University, Adana, Turkey
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17
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Guo Y, Song Y, Hou K, Yu J. Intracranial Fusiform and Circumferential Aneurysms of the Main Trunk: Therapeutic Dilemmas and Prospects. Front Neurol 2021; 12:679134. [PMID: 34305790 PMCID: PMC8299836 DOI: 10.3389/fneur.2021.679134] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022] Open
Abstract
Intracranial fusiform and circumferential aneurysms (IFCAs), especially those located on the main trunk, are uncommon and difficult to manage. Currently, literature focused on IFCAs on the main trunk of cerebral arteries is lacking. The treatment of IFCAs is still under debate. Therefore, in this review, we further explore the treatment of this complicated entity. In addition, we also present some interesting cases. Based on the literature review and our experience, we found that IFCAs are often located in the vertebrobasilar system and that ruptured or large symptomatic IFCAs are associated with increased mortality and higher rebleeding rates. The treatment strategies for IFCAs can be classified as deconstructive and reconstructive methods via open surgery and/or endovascular treatment (EVT). Currently, EVT is a popular method and the main therapeutic choice. In particular, flow diversion has revolutionized the treatment of IFCAs. Parent artery occlusion (PAO) with or without revascularization may still be considered a suitable choice. Complex IFCAs that cannot be resolved by EVT can also be treated via open surgery with or without extracranial–intracranial bypass. Targeted embolization for the weak points of IFCAs is a temporary or palliative choice that is rarely used. In summary, despite complications, both surgical treatment and EVT are effective options for appropriately selected cases. Due to the development of endovascular implants, EVT will have better prospects in the future.
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Affiliation(s)
- Yunbao Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Ying Song
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
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18
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Borchert RJ, Simonato D, R Hickman C, Fuschi M, Thibault L, Henkes H, Fiorella D, Tan BY, Yeo LL, D Makalanda HL, Wong K, Bhogal P. P2Y12 inhibitors for the neurointerventionalist. Interv Neuroradiol 2021; 28:92-103. [PMID: 33947251 PMCID: PMC8905084 DOI: 10.1177/15910199211015042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The use of antiplatelets is widespread in clinical practice. However, for neurointerventional procedures, protocols for antiplatelet use are scarce and practice varies between individuals and institutions. This is further complicated by the quantity of antiplatelet agents which differ in route of administration, dosage, onset of action, efficacy and ischemic and hemorrhagic complications. Clarifying the individual characteristics for each antiplatelet agent, and their associated risks, will increasingly become relevant as the practice of mechanical thrombectomy, stenting, coiling and flow diversion procedures grows. The aim of this review is to summarize the existing literature for the use of P2Y12 inhibitors in neurointerventional procedures, examine the quality of the evidence, and highlight areas in need of further research.
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Affiliation(s)
- Robin J Borchert
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Davide Simonato
- Department of Neuroradiology, Oxford University Hospital NHS Foundation Trust, Oxford, UK.,Institute of Radiology, University of Padova, Padova, Italy
| | - Charlotte R Hickman
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maurizio Fuschi
- Department of Neuroradiology, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | | | - Hans Henkes
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - David Fiorella
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Benjamin Yq Tan
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Leonard Ll Yeo
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | | | - Ken Wong
- Royal London Hospital, London, UK
| | - Pervinder Bhogal
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
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19
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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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20
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de Castro-Afonso LH, Nakiri GS, Abud TG, Monsignore LM, Freitas RK, de Oliveira RS, Colli BO, Dos Santos AC, Abud DG. Treatment of distal unruptured intracranial aneurysms using a surface-modified flow diverter under prasugrel monotherapy: a pilot safety trial. J Neurointerv Surg 2021; 13:647-651. [PMID: 33632882 DOI: 10.1136/neurintsurg-2020-017262] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Flow diverters (FDs) are effective in the treatment of carotid aneurysms. Compared with carotid aneurysms, the treatment of distal intracranial aneurysms with FDs has been associated with a relatively high incidence of complications. Low thrombogenic modified-surface FDs may reduce ischemic complications and allow for the use of a single antiplatelet medication. The aim of this study was to assess the safety and efficacy of the p48 MW HPC Flow Modulation Device (Phenox GmbH, Bochum, Germany) to treat distal intracranial aneurysms used in combination with prasugrel monotherapy. METHODS This was a single-center, prospective, pivotal, open, single-arm study. Patients were included in this study from December 2019 to September 2020. The primary endpoints were the incidence of any neurologic deficit after treatment until 1 month of follow-up, defined as National Institutes of Health Stroke Scale (NIHSS) ≥1, and the incidence of acute ischemic lesions in magnetic resonance imagin (MRI) images 48 hours after treatment. The secondary endpoint was the rate of complete occlusion of the aneurysms at the 1-month follow-up. RESULTS Twenty-one patients harboring 27 distal aneurysms of the anterior circulation were included. Mean age was 57.8 (SD 9.7) years, and 16 patients were female (80%). No patient had neurologic symptoms at the 1-month follow-up. Four patients (20%) had asymptomatic acute brain ischemic lesions on MRI. Complete aneurysm occlusion occurred in 9/27 (33.3%) aneurysms at the 1-month follow-up. CONCLUSION In this pilot safety trial, treatment of distal intracranial aneurysms with p48 MW HPC under monotherapy with prasugrel appeared to be safe.
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Affiliation(s)
- Luis Henrique de Castro-Afonso
- Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Guilherme Seizem Nakiri
- Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Thiago Giansante Abud
- Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil.,Division of Interventional Neuroradiology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Lucas Moretti Monsignore
- Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Rafael Kiyuze Freitas
- Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Ricardo Santos de Oliveira
- Division of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Benedicto Oscar Colli
- Division of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Antônio Carlos Dos Santos
- Division of Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Daniel Giansante Abud
- Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
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21
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de Castro-Afonso LH, Nakiri GS, Abud TG, Monsignore LM, de Freitas RK, Abud DG. Aspirin monotherapy in the treatment of distal intracranial aneurysms with a surface modified flow diverter: a pilot study. J Neurointerv Surg 2021; 13:336-341. [PMID: 33514613 DOI: 10.1136/neurintsurg-2020-017024] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/15/2020] [Accepted: 12/23/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Flow diverters (FDs) result in high occlusion rates of aneurysms located distally to the carotid artery. However, the complications reported are not negligible. New modified surface FDs have low thrombogenic properties that may reduce ischemic complications related to the treatment. In addition, a modified surface FD may allow for the use of a single antiplatelet medication to reduce hemorrhagic risk during the procedure. The aim of this study was to assess the safety and efficacy of the p48 MW HPC (phenox, Bochum, Germany) to treat distal intracranial aneurysms under the use of aspirin monotherapy. METHODS The primary endpoint was the incidence of any neurologic deficit after treatment after 6 months of follow-up. The secondary endpoint was the rate of the complete occlusion of the aneurysms at the 6-month follow-up. Enrollment of 20 patients was planned, but after inclusion of seven patients the study was stopped due to safety issues. RESULTS Seven patients with eight aneurysms were included. Among the seven patients, three (42.8%) had ischemic complications on the second day after FD deployment. Two patients experienced complete recovery at discharge (National Institutes of Health Stroke Scale (NIHSS) score=0), while one patient maintained mild dysarthria at discharge (NIHSS score=1) which improved after 6 months (NIHSS score=0). All three patients had no new symptoms during the 6-month follow-up. Complete aneurysm occlusion occurred in six (75%) of the eight aneurysms at the 6-month follow-up. CONCLUSIONS Antiplatelet monotherapy with aspirin for the treatment of distal intracranial aneurysms with this modified surface FD resulted in a significant incidence of ischemic complications after treatment.
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Affiliation(s)
- Luis Henrique de Castro-Afonso
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Guilherme Seizem Nakiri
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Thiago Giansante Abud
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil.,Interventional Neuroradiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Lucas Moretti Monsignore
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Rafael Kiyuze de Freitas
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Daniel Giansante Abud
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
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22
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Borota L, Nyberg C, Lenell S, Semnic R, Mahmoud E. Endovascular treatment of type 1 and type 4 non-saccular aneurysms of cerebral arteries - a single-Centre experience. Interv Neuroradiol 2021; 27:372-387. [PMID: 33467952 DOI: 10.1177/1591019920988204] [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
AIM OF THE STUDY The aim of this study was to evaluate our results regarding treatment options, complications, and outcomes in patients with non-saccular aneurysms of cerebral arteries belonging to type 1 and type 4 according to Mizutani's classification. METHODS A total of 26 aneurysms in 26 patients were treated between 2014 and 2019. There were 13 males (mean age 42.77 ± 11.73 years) and 13 females (mean age 50.84 ± 9.37 years). In 23 cases the onset was haemorrhagic and in three cases non-haemorrhagic. A combination of conventional stents and coils was used in 10 cases, conventional stents and flow diverters in three cases, flow diverters and coils in five cases, and flow diverters only were used in eight cases. Radiological results of treatment were assessed after eight months and clinical after one year. RESULTS In 24 patients, aneurysms were occluded at the end of the follow-up period. An iatrogenic dissection and two haemorrhagic complications were registered. In three cases, parent arteries were occluded due to re-growth of the aneurysm, which caused middle cerebral artery infarction in one case. A favourable clinical outcome was registered in 19, patients, and non-favourable in five. Two patients died in the early postoperative period due to extensive damage to the brain parenchyma caused by initial bleeding. CONCLUSION Our results indicate that treatment of type 1 and type 4 non-saccular aneurysms with various combination of stents and flow diverters, with or without coils, is promising, although very challenging and technically demanding.
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Affiliation(s)
- Ljubisa Borota
- Department of Surgical Sciences, University Hospital, Uppsala, Sweden
| | | | - Samuel Lenell
- Department of Surgical Sciences, University Hospital, Uppsala, Sweden
| | - Robert Semnic
- Department of Surgical Sciences, University Hospital, Uppsala, Sweden
| | - Ehab Mahmoud
- Department of Surgical Sciences, University Hospital, Uppsala, Sweden
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