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El Naamani K, Abbas R, Ghanem M, Mounzer M, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour PM. Resuming Anticoagulants in Patients With Intracranial Hemorrhage: A Meta-Analysis and Literature Review. Neurosurgery 2024; 94:14-19. [PMID: 37459580 DOI: 10.1227/neu.0000000000002625] [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: 03/20/2023] [Accepted: 05/24/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intracerebral hemorrhage (ICH) is one of the most disabling cerebrovascular events. Several studies have discussed oral anticoagulant (OAC)-related ICH; however, the optimal timing of resuming OAC in patients with ICH is still a dilemma. In this literature review/meta-analysis, we will summarize, discuss, and provide the results of studies pertaining to OAC resumption in patients with ICH. METHODS Using PubMed, Ovid Medline, and Web science, a systemic literature review was performed in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses statement on December 20, 2022. Inclusion criteria for the meta-analysis were all studies reporting mean, median, and standard deviation for the duration of anticoagulants resumption after ICH. Thirteen studies met the above criteria and were included in the meta-analysis. RESULTS Of the 271 articles found in the literature, pooled analysis was performed in 13 studies that included timing of OAC resumption after ICH. The pooled mean duration to OAC resumption after the index ICH was 31 days (95% CI: 13.7-48.3). There was significant variation among the mean duration to OAC resumption reported by the studies as observed in the heterogeneity test ( P -value ≈0). CONCLUSION Based on our meta-analysis, the average time of resuming OAC in patients with ICH is around 30 days. Several factors including the type of intracranial hemorrhage, the type of OAC, and the indication for OACs should be taken into consideration for future studies to try and identify the best time to resume OAC in patients with ICH.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Marc Ghanem
- The Lebanese American University Gilbert and Rose-Marie Chaghoury School of Medicine, Beirut, Lebanon
| | - Marc Mounzer
- Drexel University, Philadelphia , Pennsylvania , USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
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Ozaki S, Akimoto T, Iida Y, Miyake S, Suzuki R, Shimohigoshi W, Hori S, Suenaga J, Shimizu N, Nakai Y, Sakata K, Yamamoto T. Complications and outcomes of carotid artery stenting in high-risk cases. J Stroke Cerebrovasc Dis 2023; 32:107329. [PMID: 37657401 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107329] [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: 03/02/2023] [Revised: 05/21/2023] [Accepted: 08/24/2023] [Indexed: 09/03/2023] Open
Abstract
OBJECTIVES Carotid artery stenting is sometimes adapted for some at-risk cases; however, appropriate treatment timing with stroke onset is controversial. This study aims to identify factors that have an impact on complications and outcomes, especially in patients at high risk. MATERIALS AND METHODS We examined the characteristics of 152 consecutive patients treated by carotid artery stenting between January 2018 and March 2022 and retrospectively analyzed the risk factors for complications and poor outcomes (modified-Rankin-Scale deterioration), such as patient background, carotid artery stenting risks (access route tortuosity, severe calcification, vulnerable plaque, estimated glomerular filtration rate <30 mL/min/1.73 m2, etc.), characteristics of the stenosis, details of treatment, and treatment timing. RESULTS The average North American Symptomatic Carotid Endarterectomy Trial criteria score was 68.3% and the lesion length was 20.5±9.7mm. Among patients, 107 (70.4%) had a carotid artery stenting risk. In high-risk carotid artery stenting cases, symptomatic complications occurred in 32 (30.0%), and the 90-day modified Rankin scale score deteriorated in 15 cases (14.0%). Multivariate analysis showed that cases with triple antithrombotic therapy (p=0.003), stenting within 7 days (p=0.0032), and after 28+ days (p=0.0035) of stroke onset were independently associated factors for complications. CONCLUSIONS This study showed that among risk factors, triple antithrombotic therapy in particular was a risk factor for perioperative complications. Carotid artery stenting for patients with stroke after 28 days of onset affects the prognosis. Therefore, although further study is warranted, waiting more than one month for treatment in patients requiring carotid artery stenting is a potential risk.
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Affiliation(s)
- So Ozaki
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan
| | - Taisuke Akimoto
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan; Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan.
| | - Yu Iida
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Shigeta Miyake
- Department of Neurosurgery, Yokohama Brain and Spine Center, 1-2-1, Takigashira, Isogo, Yokohama, Kanagawa 2350012, Japan
| | - Ryosuke Suzuki
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Wataru Shimohigoshi
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan
| | - Satoshi Hori
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan; Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Jun Suenaga
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Nobuyuki Shimizu
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
| | - Yasunobu Nakai
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan; Department of Neurosurgery, Yokohama Brain and Spine Center, 1-2-1, Takigashira, Isogo, Yokohama, Kanagawa 2350012, Japan
| | - Katsumi Sakata
- Department of Neurosurgery, Yokohama City University Medical Center, 4-57 Urafune, Minami, Yokohama 2320024, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
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Liu C, Wang S, Xue Y, Wang J, Li H. Safety and Efficacy of Tirofiban Bridging Therapy During a Hybrid Carotid Artery Stenting and Off-Pump Coronary Artery Bypass Grafting Surgery: A Single-Center Study. Clin Ther 2023; 45:292-298. [PMID: 36801114 DOI: 10.1016/j.clinthera.2023.01.012] [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: 05/29/2022] [Revised: 12/14/2022] [Accepted: 01/22/2023] [Indexed: 02/19/2023]
Abstract
PURPOSE The optimal perioperative antithrombosis management for carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) hybrid surgeries remains unclear; however, a more aggressive antithrombotic therapy might be required after a hybrid CAS + CABG duo stent-related intimal injury or the use of protamine-neutralizing heparin. This study evaluated the safety and efficacy of tirofiban as a bridging therapy after a hybrid CAS + CABG surgery. METHODS Between June 2018 and February 2022, a total of 45 patients undergoing a hybrid CAS + off-pump CABG surgery were divided into either the control group (standard dual antiplatelet therapy postsurgery, n = 27) or the tirofiban group (tirofiban bridging + dual antiplatelet therapy, n = 18). The 30-day outcome was compared between the 2 groups, and the primary end points included stroke, postoperative myocardial infarction, and death. FINDINGS Two patients (7.41%) from the control group experienced a stroke. There was a trend toward a lower rate of composite end points, including stroke, postoperative myocardial infarction, and death, within the tirofiban group that did not reach statistical significance (0% vs 11.1%; P = 0.264). The need for a transfusion was similar between the 2 groups (33.33% vs 29.63%; P = 0.793). There were no major bleeding events in the 2 groups. IMPLICATIONS Tirofiban bridging therapy was safe, with a trend toward reducing the risk of ischemic events after a hybrid CAS + off-pump CABG surgery. Tirofiban might be a feasible periprocedural bridging protocol in high-risk patients.
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Affiliation(s)
- Changcheng Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shipan Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuan Xue
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jiantao Wang
- Department of Neurosurgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haiyang Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Elfil M, Ghaith HS, Elsayed H, Aladawi M, Elmashad A, Patel N, Medicherla C, El-Ghanem M, Amuluru K, Al-Mufti F. Intravenous thrombolysis plus mechanical thrombectomy versus mechanical thrombectomy alone for acute ischemic stroke: A systematic review and updated meta-analysis of clinical trials. Interv Neuroradiol 2022:15910199221140276. [PMID: 36437809 DOI: 10.1177/15910199221140276] [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] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the gold standard treatment for large vessel occlusion (LVO). A vital factor that might influence MT outcomes is the use of intravenous thrombolysis (IVT). A few clinical trials in this domain thus far have not yielded consistent outcomes. We conducted this meta-analysis to synthesize collective evidence in this regard. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines were followed, and we performed a comprehensive literature search of four databases (PubMed, Scopus, Web of Science, Cochrane CENTRAL). For outcomes constituting continuous data, the mean difference (MD) and its standard deviation (SD) were pooled. For outcomes constituting dichotomous data, the frequency of events and the total number of patients were pooled as the risk ratio (RR). RESULTS Seven clinical trials with a total of 2317 patients are included in this meta-analysis. Six trials are randomized, and one trial was nonrandomized. No significant differences were found between MT plus IVT and MT alone in successful recanalization (RR 1.04, 95% Confidence Interval (CI) [0.92 to 1.17], P = 0.53), 90-day functional independence (RR 1.03, 95% CI [0.90 to 1.19], P = 0.65), symptomatic intracranial hemorrhage (sICH) (RR 1.22, 95% CI [0.84 to 1.75], P = 0.30), or mortality (RR 0.94, 95% CI [0.76 to 1.18], P = 0.61). CONCLUSION The current evidence does not favor either MT plus IVT or MT alone for LVO except for the procedural time. More trials are needed in this regard, and certain factors should be considered when comparing the two approaches.
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Affiliation(s)
- Mohamed Elfil
- Department of Neurological Sciences, 12284University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Hazem S Ghaith
- Faculty of Medicine, 68820Al-Azhar University, Cairo, Egypt
| | - Hanaa Elsayed
- Faculty of Medicine, 68799Zagazig University, Zagazig, Egypt
| | - Mohammad Aladawi
- Department of Neurological Sciences, 12284University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ahmed Elmashad
- Department of Neurology, University of Connecticut, Farmington, Connecticut, USA
| | - Neisha Patel
- Department of Neurology, 8138Westchester Medical Center, Valhalla, New York, USA
| | - Chaitanya Medicherla
- Department of Neurology, 8138Westchester Medical Center, Valhalla, New York, USA
| | - Mohammad El-Ghanem
- Neuroendovascular Surgery, HCA Houston Northwest/University of Houston College of Medicine, Houston, Texas, USA
| | - Krishna Amuluru
- 178242Goodman Campbell Brain and Spine, Ascension St Vincent Medical Center, Carmel, Indiana, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, 8138Westchester Medical Center, Valhalla, New York, USA
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Cirillo L, Romano DG, Vornetti G, Frauenfelder G, Tamburrano C, Taglialatela F, Isceri S, Saponiero R, Napoletano R, Gentile M, Romoli M, Princiotta C, Simonetti L, Zini A. Acute ischemic stroke with cervical internal carotid artery steno-occlusive lesion: multicenter analysis of endovascular approaches. BMC Neurol 2021; 21:362. [PMID: 34535118 PMCID: PMC8447719 DOI: 10.1186/s12883-021-02393-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Occlusion of the internal carotid artery (ICA), whether isolated or in the setting of a tandem lesion (TL) have a poor response to treatment with intravenous thrombolysis. Previous studies have demonstrated the superiority of mechanical thrombectomy in the treatment of acute ischemic stroke (AIS) following large vessel occlusion, compared to standard intravenous fibrinolysis. The aim of our study was to describe endovascular treatment (EVT) in AIS due to isolated ICA occlusion or TL. METHODS We assessed the association between 90-day outcome and clinical, demographic, imaging, and procedure data in 51 consecutive patients with acute isolated ICA occlusion or TL who underwent EVT. We evaluated baseline NIHSS and mRS, ASPECTS, type of occlusion, stent placement, use of stent retrievers and/or thromboaspiration, duration of the procedure, mTICI, postprocedural therapy and complications. RESULTS A favorable 90-day outcome (mRS 0-2) was achieved in 34 patients (67 %) and was significantly associated with the use of dual antiplatelet therapy after the procedure (p = 0.008), shorter procedure duration (p = 0.031), TICI 2b-3 (p < 0.001) and lack of post-procedural hemorrhagic transformation (p = 0.001). Four patients did not survive, resulting in a mortality rate of 8 %. CONCLUSIONS Our study has shown that EVT in the treatment of AIS due to ICA occlusion is safe, and effective in determining a good functional outcome. ICA stenting led to good angiographic results and therapy with a glycoprotein IIb / IIIa inhibitor immediately after stent release did not result in a greater risk of hemorrhage. The use of post-procedural dual antiplatelet therapy was associated with favorable outcome, without a significant increase in hemorrhagic transformation.
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Affiliation(s)
- Luigi Cirillo
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Bologna, Italy. .,UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy.
| | | | - Gianfranco Vornetti
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Bologna, Italy
| | - Giulia Frauenfelder
- UOC Neuroradiologia AOU S. Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Chiara Tamburrano
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Bologna, Italy
| | - Francesco Taglialatela
- UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Salvatore Isceri
- UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Renato Saponiero
- UOC Neuroradiologia AOU S. Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Rosa Napoletano
- UOC Neurologia AOU S. Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Mauro Gentile
- UOC Neurologia e Rete Stroke metropolitana Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Michele Romoli
- UOC Neurologia e Rete Stroke metropolitana Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Ciro Princiotta
- UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Luigi Simonetti
- UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Andrea Zini
- UOC Neurologia e Rete Stroke metropolitana Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
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Comparing Endovascular Treatment Methods in Acute Ischemic Stroke Due to Tandem Occlusion Focusing on Clinical Aspects. Life (Basel) 2021; 11:life11050458. [PMID: 34065422 PMCID: PMC8160775 DOI: 10.3390/life11050458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction: Acute ischemic strokes (AIS) due to tandem occlusion (TO) of intracranial anterior large vessel and concomitant extracranial internal carotid artery (EICA) are represent in 15–20% of all ischemic strokes. The endovascular treatment (EVT) strategy for those patients is still unclear. Although the intracranial mechanical thrombectomy (MT) is considered as a standard treatment approach, the EICA lesion stent necessity remains a matter of debate. We sought to assess the efficacy and safety of EVT in tandem lesions, particularly the EICA stenting management. Methods: We retrospectively analyzed all patients with anterior circulation stroke associated with EICA lesion and receiving EVT in the three participated stroke centers between November 2017 and December 2020. Patients’ data were collected from our prospective stroke registry (STAY ALIVE). Patients enrolled in our study were divided into two groups depending on whether acute carotid stenting (ACS) or balloon angioplasty only (BAO) technique was used. Our primary outcome was the 90-day functional outcome assessed by modified Rankin scale (mRS). Mortality at 90 days and symptomatic intracranial hemorrhage (sICH) were considered as secondary outcomes. Results: A total of 101 patients (age: 67 ± 10 years, 38.6% female) were enrolled in our study, including 29 (28.3%) BAO cases, and 72 (71.3%) patients treated with ACS. Patients in the BAO group were slightly older (70 ± 9 years vs. 66 ± 10 years, p = 0.054), and had higher prevalence of comorbidities such as hypertension (100.0% vs. 59.4%, p < 0.001). There was no significant difference in favorable outcomes (51.7% vs. 54.4%, p = 0.808) between the groups. However, we observed a trend towards higher rates of sICH (8.3% vs. 3.4%, p = 0.382) and 90-day mortality (23.5% vs. 13.8%, p = 0.278) with significantly higher frequency of distal embolization (39.1% vs. 17.9%, p = 0.043) in patients with ACS. In the overall population age (p = 0.013), atrial fibrillation (AF) (p = 0.008), National Institutes of Health Stroke Scale (NIHSS) baseline (p = 0.029), and successful recanalization (p = 0.023) were associated with favorable outcome. Conclusion: Endovascular approach of EICA in addition to MT was safe and effective in tandem occlusion of anterior circulation. Furthermore, our results suggest that balloon angioplasty technique without acute stenting shows a comparable favorable outcome rate to ACS with moderately less hemorrhagic events and mortality rates.
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Woo HG, Lee HA, Ryu DR, Song TJ. Association of Mortality with Antiplatelet Treatment in Patients with Stent Placement or Angioplasty: A Population-Based Nested Case-Control Study. Yonsei Med J 2021; 62:75-85. [PMID: 33381937 PMCID: PMC7820450 DOI: 10.3349/ymj.2021.62.1.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/22/2020] [Accepted: 10/19/2020] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Antiplatelet drugs are essential in patients with cardiovascular disease who undergo stent placement. We hypothesized that risks of mortality would differ according to adherence to antiplatelet agents, number of antiplatelet agents, and antiplatelet regimens in patients undergoing stent placement or angioplasty. MATERIALS AND METHODS Between 2002 and 2013, we initially enrolled 8671 subjects who underwent stent placement or angioplasty in the National Health Insurance Service-National Sample Cohort in Korea. Using the International Classification of Diseases, 10th revision, the incidence of all-cause death, including cardiovascular disease, cerebrovascular disease, and cancer, was defined. Using a nested case-control study design, controls were matched to cases at a ratio of 4:1, and a total of 5415 subjects were eligible for this study. RESULTS During a median follow-up period of 3.51 years, the incidence rate of all-cause death was 40 per 1000 person-years. We found that adherence to antiplatelet monotherapy significantly decreased risk of death by cerebro-cardiovascular disease, compared with discontinuation of antiplatelets [adjusted odds ratio (OR) 0.62, 95% confidence interval (CI) (0.41-0.96)]. Compared with dual antiplatelet therapy (DAPT), aspirin and clopidogrel monotherapy significantly reduced death by cerebro-cardiovascular disease [adjusted OR 0.65, 95% CI (0.44-0.95) and adjusted OR 0.58, 95% CI (0.35-0.96), respectively]. There was no significant difference of mortality between aspirin monotherapy and clopidogrel monotherapy. CONCLUSION Our study demonstrated that adherence to antiplatelet therapy and antiplatelet monotherapy, compared with DAPT, in patients with stent placement or angioplasty may have a beneficial effect on mortality in cerebro-cardiovascular disease.
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Affiliation(s)
- Ho Geol Woo
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Hye Ah Lee
- Clinical Trial Center, Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Dong Ryeol Ryu
- Department of Nephrology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Tae Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea.
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8
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Brandel MG, Elsawaf Y, Rennert RC, Steinberg JA, Santiago-Dieppa DR, Wali AR, Olson SE, Pannell JS, Khalessi AA. Antiplatelet therapy within 24 hours of tPA: lessons learned from patients requiring combined thrombectomy and stenting for acute ischemic stroke. J Cerebrovasc Endovasc Neurosurg 2020; 22:1-7. [PMID: 32596137 PMCID: PMC7307608 DOI: 10.7461/jcen.2020.22.1.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/24/2020] [Accepted: 03/02/2020] [Indexed: 01/01/2023] Open
Abstract
Objective Although stroke guidelines recommend antiplatelets be started 24 hours after tissue plasminogen activator (tPA), select mechanical thrombectomy (MT) patients with luminal irregularities or underlying intracranial atherosclerotic disease may benefit from earlier antiplatelet administration. Methods We explore the safety of early (<24 hours) post-tPA antiplatelet use by retrospectively reviewing patients who underwent MT and stent placement for acute ischemic stroke from June 2015 to April 2018 at our institution. Results Six patients met inclusion criteria. Median presenting and pre-operative National Institutes of Health Stroke Scale scores were 14 (Interquartile Range [IQR] 5.5–17.3) and 16 (IQR 13.7–18.7), respectively. Five patients received standard intravenous (IV) tPA and one patient received intra-arterial tPA. Median time from symptom onset to IV tPA was 120 min (IQR 78–204 min). Median time between tPA and antiplatelet administration was 4.9 hours (IQR 3.0–6.7 hours). Clots were successfully removed from the internal carotid artery (ICA) or middle cerebral artery (MCA) in 5 patients, the anterior cerebral artery (ACA) in one patient, and the vertebrobasilar junction in one patient. All patients underwent MT before stenting and achieved thrombolysis in cerebral infarction 2B recanalization. Stents were placed in the ICA (n=4), common carotid artery (n=1), and basilar artery (n=1). The median time from stroke onset to endovascular access was 185 min (IQR 136–417 min). No patients experienced symptomatic post-procedure intracranial hemorrhage (ICH). Median modified Rankin Scale score on discharge was 3.5. Conclusions Antiplatelets within 24 hours of tPA did not result in symptomatic ICH in this series. The safety and efficacy of early antiplatelet administration after tPA in select patients following mechanical thrombectomy warrants further study.
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Affiliation(s)
- Michael G Brandel
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Yasmeen Elsawaf
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Jeffrey A Steinberg
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | | | - Arvin R Wali
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Scott E Olson
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - J Scott Pannell
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
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9
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Complication Rates Using CASPER Dual-Layer Stents for Carotid Artery Stenting in Acute Stroke : A 3-Year Single Center Experience. Clin Neuroradiol 2019; 31:173-179. [PMID: 31822934 DOI: 10.1007/s00062-019-00860-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE The number of acute and early stent occlusions after emergency stenting of the internal carotid artery (ICA) in patients with tandem lesions is unclear and only mentioned in a small number of publications, ranging from 0-20%. A recent article by Yilmaz et al. reported a high rate of acute in-stent occlusions of 45% within 72 h after deployment of CASPER dual layer stents. METHODS All patients with acute ischemic stroke treated with a CASPER stent between August 2014 and April 2018 were retrospectively evaluated for occlusion rates, periinterventional medication and early complications. A total of 66 patients, 45 with tandem pathologies and 21 with proximal ICA stenosis only were enrolled. RESULTS Thrombotic complications occurred in 16 out of 66 patients (24%) and hemorrhagic complications in 8/66 (12%) and 15 of the 16 thrombotic complications and 7/8 symptomatic intracranial hemorrhages (sICH) occurred in patients with tandem lesions and accessory intracranial thrombectomy. Of the patients with sICH five were treated in a prolonged or unknown time window. In patients with intraprocedural thrombotic complications ultrasound imaging showed patent stents in 13 of the 14 patients CONCLUSIONS: The CASPER stent system showed a high technical success rate in patients with acute stroke. The number of patients with sICH was not higher than the numbers reported in the published literature despite the early use of Gp IIb/IIIA inhibitors, whereas the number of thrombotic complications was smaller than that reported in recent studies. The majority of sICH occurred in patients treated because of tandem lesions in an unknown or prolonged time window.
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Abstract
CLINICAL ISSUE Acute strokes caused by tandem occlusions include an atherosclerotic or dissective stenosis/occlusion of the extracranial internal carotid artery (eICA) in combination with an intracranial vessel occlusion. STANDARD TREATMENT Endovascular treatment can be technically challenging but is definitely superior to intravenous thrombolysis alone and achieves good clinical results comparable to those from solitary intracranial occlusions. LATEST STUDY RESULTS Although there are still no prospectively randomized studies on endovascular treatment for tandem occlusions, currently available data favor acute stenting of the eACI followed by intracranial thrombectomy. PURPOSE OF THE ARTICLE This review discusses endovascular treatment options for tandem occlusions based on currently available data.
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Abstract
Antiplatelet agents used to treat neurovascular disease include aspirin; P2Y12 receptor antagonists clopidogrel, prasugrel, and ticagrelor; ADP antagonist ticlopidine; phosphodiesterase inhibitor dipyridamole; and glycoprotein IIb/IIIa inhibitors abciximab, eptifibatide, and tirofiban. Numerous studies have been performed evaluating their efficacy in stroke, extracranial carotid artery disease and dissection, intracranial atherosclerotic disease, and moyamoya disease. The rapid technological advancements in endovascular neurosurgical devices have also made antiplatelet therapy a necessary part of treating intracranial aneurysms. This article presents the relevant data supporting the use of antiplatelet agents in vascular neurosurgery and recommendations based on the described studies.
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Affiliation(s)
- Amanda S Zakeri
- Department of Neurological Surgery, Ohio State University Medical Center, N-1014 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Shahid M Nimjee
- Department of Neurological Surgery, Ohio State University Medical Center, N-1014 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA.
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Tsujimoto M, Enomoto Y, Miyai M, Egashira Y, Iwama T. Optimal platelet function test for in-stent tissue protrusion following carotid artery stenting. J Int Med Res 2018; 46:1866-1875. [PMID: 29552932 PMCID: PMC5991223 DOI: 10.1177/0300060518762949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose To determine the best platelet function test for in-stent tissue protrusion following carotid artery stenting (CAS). Methods Patients who underwent CAS were recruited prospectively in this observational study. Combination of aspirin 100 mg/day and clopidogrel 75 mg/day was administered for a minimum of 7 days prior to procedure. Platelet aggregation was measured by light transmittance aggregometry (LTA) following stimulation by adenosine diphosphate (ADP), collagen, and thrombin receptor activating peptide (TRAP) and by the point of care assay, VerifyNow which measures aspirin and thienopyridine reaction units. Results In-stent tissue protrusion with maximum projection area of ≥1 mm2 was detected by optical coherence tomography (OCT) in 10/28 (36%) patients. Baseline characteristics were not significantly different between the two in-stent size groups (i.e., ≥1 mm2 vs. <1 mm2) but after stimulation by collagen at 10 and 20 μg/ml, platelet reactivity as measured by LTA was significantly higher in the ≥1 mm2 group compared with the <1 mm2 group. No other differences in platelet function were detected. Conclusions Collagen-induced platelet reactivity was related to in-stent tissue protrusion size following CAS.
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Affiliation(s)
- Masanori Tsujimoto
- 1 Department of Neurosurgery, 73882 Daiyukai General Hospital, Sakura, Ichinomiya city, Aichi, Japan.,2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
| | - Yukiko Enomoto
- 2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
| | - Masafumi Miyai
- 2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
| | - Yusuke Egashira
- 2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
| | - Toru Iwama
- 2 Department of Neurosurgery, Gifu University Graduate School of Medicine, Yanagido, Gifu city, Gifu, Japan
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Jolobe OM. The challenge of coprescription of antiplatelet therapy and oral anticoagulants. Am J Emerg Med 2017; 35:1782-1783. [DOI: 10.1016/j.ajem.2017.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 05/21/2017] [Indexed: 11/29/2022] Open
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Han YF, Dai QL, Chen XL, Xiong YY, Yin Q, Xu GL, Zhu WS, Zhang RL, Ma MM, Liu WH, Liu XF. Emergent loading dose of antiplatelets for stenting after IV rt-PA in acute ischemic stroke: a feasibility study. Int J Neurosci 2017; 128:311-317. [PMID: 28830290 DOI: 10.1080/00207454.2017.1367295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND A loading dose of antiplatelets reduces in-stent thrombosis after stent implantation. However, whether it is safe in patients undergoing acute stenting after intravenous recombinant tissue plasminogen activator (rt-PA) is unclear. METHODS A case series of acute ischemic stroke patients treated with intravenous rt-PA followed by emergent stenting were prospectively included in Jinling Hospital Stroke Unit. An emergent loading dose of antiplatelets (aspirin 300 mg and clopidogrel 300 mg) were administered to all patients through a nasogastric tube immediately before stenting. Clinical and angiographic outcomes were evaluated in these patients. RESULTS A total of 12 patients were included. The median of NIHSS score on admission was 15 points (interquartile range 11-19). The median of time from stroke symptom onset to start IV rt-PA and stent placement was 172 min (interquartile range 123.75-189) and 311.5 min (interquartile range 285.5-349.5), respectively. All patients reached complete or partial recanalization (TICI ≥2a). One patient occurred hemorrhagic transformation at 24 h following the emergent loading dose of antiplatelets. A favorable outcome as defined by mRS ≤2 at 90 days was obtained in 58.3% (7/12) of all patients. CONCLUSION Our finding preliminary suggested that an emergent loading dose of antiplatelets may be safe and feasible for acute stenting after IV rt-PA.
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Affiliation(s)
- Yun-Fei Han
- a Department of Neurology, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Qi-Liang Dai
- a Department of Neurology, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Xiang-Liang Chen
- a Department of Neurology, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Yun-Yun Xiong
- a Department of Neurology, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Qin Yin
- a Department of Neurology, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Ge-Lin Xu
- a Department of Neurology, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Wu-Sheng Zhu
- a Department of Neurology, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Ren-Liang Zhang
- a Department of Neurology, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Min-Min Ma
- a Department of Neurology, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Wen-Hua Liu
- a Department of Neurology, Jinling Hospital , Medical School of Nanjing University , Nanjing , China.,b Department of Neurology, Wuhan No. 1 Hospital , Wuhan , China
| | - Xin-Feng Liu
- a Department of Neurology, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
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Broeg-Morvay A, Mordasini P, Slezak A, Liesirova K, Meisterernst J, Schroth G, Arnold M, Jung S, Mattle HP, Gralla J, Fischer U. Does Antiplatelet Therapy during Bridging Thrombolysis Increase Rates of Intracerebral Hemorrhage in Stroke Patients? PLoS One 2017; 12:e0170045. [PMID: 28095449 PMCID: PMC5240999 DOI: 10.1371/journal.pone.0170045] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 12/28/2016] [Indexed: 11/18/2022] Open
Abstract
Background Symptomatic intracerebral hemorrhage (sICH) after bridging thrombolysis for acute ischemic stroke is a devastating complication. We aimed to assess whether the additional administration of aspirin during endovascular intervention increases bleeding rates. Methods We retrospectively compared bleeding complications and outcome in stroke patients who received bridging thrombolysis with (tPA+ASA) and without (tPA-ASA) aspirin during endovascular intervention between November 2008 and March 2014. Furthermore, we analyzed bleeding complications and outcome in antiplatelet naïve patients with those with prior or acute antiplatelet therapy. Results Baseline characteristics, previous medication, and dosage of rtPA did not differ between 50 tPA+ASA (39 aspirin naïve, 11 preloaded) and 181 tPA-ASA patients (p>0.05). tPA+ASA patients had more often internal carotid artery (ICA) occlusion (p<0.001), large artery disease (p<0.001) and received more often acute stenting of the ICA (p<0.001). 10/180 (5.6%) tPA-ASA patients and 3/49 (6.1%) tPA+ASA patients suffered a sICH (p = 1.0). Rates of asymptomatic intracerebral hemorrhage, systemic bleeding complications and outcome did not differ between both groups (p>0.1). There were no differences in bleeding complications and mortality among 112 bridging patients with antiplatelet therapy (62 preloaded, 39 acute administration, 11 both) and 117 antiplatelet naïve patients. In a logistic regression analysis, aspirin administration during endovascular procedure was not a predictor of sICH. Conclusion Antiplatelet therapy before or during bridging thrombolysis in patients with acute ischemic stroke did not increase the risk of bleeding complications and had no impact on outcome. This finding has to be confirmed in larger studies.
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Affiliation(s)
- Anne Broeg-Morvay
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Agnieszka Slezak
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Kai Liesirova
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Julia Meisterernst
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Heinrich P. Mattle
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- * E-mail:
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Kuliha M, Roubec M, Goldírová A, Hurtíková E, Jonszta T, Procházka V, Gumulec J, Herzig R, Školoudík D. Laboratory-Based Markers as Predictors of Brain Infarction During Carotid Stenting: a Prospective Study. J Atheroscler Thromb 2016; 23:839-47. [PMID: 26783048 DOI: 10.5551/jat.31799] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AIM New ischemic lesions in the brain can be detected in approximately 50% of patients undergoing carotid artery stenting (CAS). We wished to discover the laboratory-based predictors of new infarctions in the brain after CAS. METHODS All consecutive patients with internal carotid artery stenosis of ≥70% with indication for CAS were enrolled in a prospective study for 16 months. All patients used dual antiplatelet therapy for ≥7 days before CAS. Neurologic examination and magnetic resonance imaging (MRI) of the brain were undertaken before and at 24 h after CAS. Samples of venous blood were collected at <24 h before CAS for the evaluation of hematology, reticulocytes, coagulation markers (PT, APTT, Fbg, Clauss), vWF antigen, PAI-1 activity, PAI-1 polymorphism 4G/5G, and the multiplate (aspirin and clopidogrel) resistance test. Blood samples for the assessment of anti-Xa activity were collected during CAS. Differences in the values of laboratory markers between patients with and without new ischemic lesions of the brain on control MRI were evaluated. RESULTS The cohort comprised 81 patients (53 males; mean age, 67.3±7.2 years). New ischemic infarctions in the brain on control MRI were found in 46 (56.8%) patients. Three of seven patients with resistance to aspirin or clopidogrel had a new ischemic infarction in the brain. No significant differences for particular markers were found between patients with and without an ischemic lesion in the brain. CONCLUSION A high risk of a new ischemic infarction in the brain was detected in patients undergoing CAS, but a laboratory-based predictor of such an infarction could not be identified.
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Affiliation(s)
- Martin Kuliha
- Department of Neurology, Comprehensive Stroke Center, University Hospital Ostrava
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Tsujimoto M, Enomoto Y, Kokuzawa J, Iwama T. Diabetes mellitus and carotid artery plaques exhibiting high-intensity signals on MR angiography are related to increased platelet reactivity after carotid artery stenting. J Neurointerv Surg 2016; 9:106-110. [PMID: 27370776 PMCID: PMC5264231 DOI: 10.1136/neurintsurg-2016-012419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/07/2016] [Accepted: 06/15/2016] [Indexed: 11/25/2022]
Abstract
Background Increased platelet reactivity after carotid artery stenting (CAS) may cause thromboembolic complications. Objective This study aimed to investigate the incidence of increased platelet reactivity after CAS and to determine the factors related to it. Methods Patients who underwent CAS were recruited prospectively. They received pre-procedural antiplatelet therapy comprising some combination of aspirin (100 mg/day), clopidogrel (75 mg/day), and/or cilostazol (200 mg/day) for a minimum of 7 days. ADP- and collagen-induced platelet aggregation were measured before and 4 days after CAS. Changes in platelet reactivity were reported as changes in the categorized platelet reactivity grade based on the effective dose 50%. Clinical characteristics of patients with and without increased platelet reactivity were compared. Results Among 38 consecutive patients who underwent CAS, 18 (47%) exhibited increased platelet reactivity. Diabetes mellitus (OR 15.0; 95% CI 2.1 to 106.5; p=0.007) and carotid artery plaques exhibiting high-intensity signals (HIS) on time-of-flight MR angiography (TOF-MRA) (OR 25.2; 95% CI 2.0 to 316.2; p=0.013) were independently associated with increased platelet reactivity in a multivariate analysis. Conclusions Increased platelet reactivity occurred in nearly half of the studied patients subjected to CAS and was independently associated with diabetes mellitus and carotid artery plaques exhibiting HIS on TOF-MRA.
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Affiliation(s)
- Masanori Tsujimoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Jouji Kokuzawa
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
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Biondi-Zoccai G, Frati G, Coscioni E, Giordano A. Commentary: Cilostazol and Carotid Stenting: A Merry Marriage? J Endovasc Ther 2016; 23:196-8. [PMID: 26763261 DOI: 10.1177/1526602815619405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy Eleonora Lorillard Spencer Cenci Foundation, Rome, Italy
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy
| | - Enrico Coscioni
- Division of Cardiac Surgery, San Giovanni di Dio e Ruggi D'Aragona Hospital, Salerno, Italy
| | - Arturo Giordano
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy Unità Operativa di Emodinamica, Casa di Salute Santa Lucia, San Giuseppe Vesuviano, Italy
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