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Medina-Rodriguez M, Villagran D, Luque-Ambrosiani AC, Cabezas-Rodríguez JA, Ainz-Gómez L, Baena Palomino P, Pardo-Galiana B, Zamora A, de Albóniga-Chindurza A, Aguilar-Perez M, González A, Moniche F, Zapata-Arriaza E. Tirofiban versus aspirin to prevent in-stent thrombosis after emergent carotid artery stenting in acute ischemic stroke. J Neurointerv Surg 2024:jnis-2024-021845. [PMID: 38906690 DOI: 10.1136/jnis-2024-021845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 05/31/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Several antithrombotic treatments during emergent carotid artery stenting (eCAS) have been proposed, but an appropriate protocol to balance risk-benefit is not well known. OBJECTIVE To investigate the efficacy and safety of tirofiban compared with aspirin in patients with acute ischemic stroke undergoing eCAS. METHODS We conducted a retrospective single-center study of the prospective ARTISTA Registry, including patients with atherosclerotic internal carotid artery occlusion treated with eCAS. Two groups, according to antiplatelet drug, were studied: aspirin (250-500 mg single-dose) versus tirofiban (500 μg bolus+200 μg/h). Primary outcomes were the rate of in-stent thrombosis and symptomatic intracranial hemorrhage (sICH) within the first 24 hours. RESULTS During the period 2019-2023, 181 patients were included, 103 received aspirin, 78 tirofiban; 149 (82.3%) had tandem lesions. The primary efficacy outcome occurred in 9 (9.4%) in the aspirin group, as compared with 1 (1.3%) in the tirofiban group (adjusted odds ratio (aOR)=0.11, 95% CI 0.01 to 0.98; P=0.048). The primary safety outcome was detected in 12 (11.7%) in the aspirin group, as compared with 2 (2.6%) in the tirofiban group (aOR=0.16, 95% CI 0.03 to 0.87; P=0.034). The tirofiban group presented a lower risk of parenchymal hemorrhage (18 (17.4%) vs 4 (5.2%), aOR=0.27, 95% CI 0.09 to 0.88; P=0.029) and an increased rate of excellent recanalization (expanded Treatment in Cerebral Infarction (eTICI) 2c-3) (50 (48.5%) vs 54 (69.2%); aOR=2.15, 95% CI 1.12 to 4.13; P=0.02). There were no differences in functional outcomes or mortality at 3 months. CONCLUSIONS Periprocedural antithrombotic therapy with tirofiban was associated with a lower risk of in-stent thrombosis and sICH at 24 hours from eCAS compared with aspirin. Prospective randomized clinical trials are needed to confirm our results.
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Affiliation(s)
- Manuel Medina-Rodriguez
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Diego Villagran
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
| | | | - Juan Antonio Cabezas-Rodríguez
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Leire Ainz-Gómez
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Pablo Baena Palomino
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Blanca Pardo-Galiana
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Aynara Zamora
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Asier de Albóniga-Chindurza
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
- Department of Radiology, Interventional Neuroradiology, Virgen del Rocío University Hospital, Seville, Spain
| | - Marta Aguilar-Perez
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
- Department of Radiology, Interventional Neuroradiology, Virgen del Rocío University Hospital, Seville, Spain
| | - Alejandro González
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
- Department of Radiology, Interventional Neuroradiology, Virgen del Rocío University Hospital, Seville, Spain
| | - Francisco Moniche
- Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
| | - Elena Zapata-Arriaza
- Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
- Department of Radiology, Interventional Neuroradiology, Virgen del Rocío University Hospital, Seville, Spain
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Tekieli L, Dzierwa K, Grunwald IQ, Mazurek A, Urbanczyk-Zawadzka M, Wiewiorka L, Banys RP, Dabrowski W, Podlasek A, Weglarz E, Stefaniak J, Nizankowski RT, Musialek P. Outcomes in acute carotid-related stroke eligible for mechanical reperfusion: SAFEGUARD-STROKE Registry. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:231-248. [PMID: 39007556 DOI: 10.23736/s0021-9509.24.13093-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
BACKGROUND Carotid-related strokes (CRS) are largely unresponsive to intravenous thrombolysis and are often large and disabling. Little is known about contemporary CRS referral pathways and proportion of eligible patients who receive emergency mechanical reperfusion (EMR). METHODS Referral pathways, serial imaging, treatment data, and neurologic outcomes were evaluated in consecutive CRS patients presenting over 18 months in catchment area of a major carotid disease referral center with proximal-protected CAS expertise, on-site neurology, and stroke thrombectomy capability (Acute Stroke of CArotid Artery Bifurcation Origin Treated With Use oF the MicronEt-covered CGUARD Stent - SAFEGUARD-STROKE Registry; companion to SAFEGUARD-STROKE Study NCT05195658). RESULTS Of 101 EMR-eligible patients (31% i.v.-thrombolyzed, 39.5% women, age 39-89 years, 94.1% ASPECTS 9-10, 90.1% pre-stroke mRS 0-1), 57 (56.4%) were EMR-referred. Referrals were either endovascular (Comprehensive Stroke Centre, CSC, 21.0%; Stroke Thrombectomy-Capable CAS Centre, STCC, 70.2%) or to vascular surgery (VS, 1.8%), with >1 referral attempt in 7.0% patients (CSC/VS or VS/CSC or CSC/VS/STCC). Baseline clinical and imaging characteristics were not different between EMR-treated and EMR-untreated patients. EMR was delivered to 42.6% eligible patients (emergency carotid surgery 0%; STCC rejections 0%). On multivariable analysis, non-tandem CRS was a predictor of not getting referred for EMR (OR 0.36; 95%CI 0.14-0.93, P=0.03). Ninety-day neurologic status was profoundly better in EMR-treated patients; mRS 0-2 (83.7% vs. 34.5%); mRS 3-5 (11.6% vs. 53.4%), mRS 6 (4.6% vs. 12.1%); P<0.001 for all. CONCLUSIONS EMR-treatment substantially improves CRS neurologic outcomes but only a minority of EMR-eligible patients receive EMR. To increase the likelihood of brain-saving treatment, EMR-eligible stroke referral and management pathways, including those for CSC/VS-rejected patients, should involve stroke thrombectomy-capable centres with endovascular carotid treatment expertise.
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Affiliation(s)
- Lukasz Tekieli
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland -
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland -
| | - Karolina Dzierwa
- Cardiovascular Imaging Laboratory, St. John Paul II Hospital, Krakow, Poland
| | - Iris Q Grunwald
- Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, UK
- Department of Radiology, University of Dundee Ninewells Hospital, Dundee, UK
| | - Adam Mazurek
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
| | | | - Lukasz Wiewiorka
- Department of Radiology, St. John Paul II Hospital, Krakow, Poland
| | - R Pawel Banys
- Department of Radiology, St. John Paul II Hospital, Krakow, Poland
| | - Wladyslaw Dabrowski
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Precison Imaging Beacon, Radiological Sciences, University of Nottingham, Nottingham, UK
| | - Ewa Weglarz
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Nursing, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Justyna Stefaniak
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Krakow, Poland
| | - Rafal T Nizankowski
- Quality Promotion in Healthcare, Sano Center for Computational Medicine, Krakow, Poland
| | - Piotr Musialek
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
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3
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Khanafer A, Henkes H, Bücke P, Hennersdorf F, Bäzner H, Forsting M, von Gottberg P. Triple platelet inhibition in intracranial thrombectomy with additional acute cervical stent angioplasty due to tandem lesion: a retrospective single-center analysis. BMC Neurol 2024; 24:99. [PMID: 38500074 PMCID: PMC10946095 DOI: 10.1186/s12883-024-03597-0] [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: 01/09/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Acute stroke treatment with intracranial thrombectomy and treatment of ipsilateral carotid artery stenosis/occlusion ("tandem lesion", TL) in one session is considered safe. However, the risk of stent restenosis after TL treatment is high, and antiplatelet therapy (APT) preventing restenosis must be well balanced to avoid intracranial hemorrhage. We investigated the safety and 90-day outcome of patients receiving TL treatment under triple-APT, focused on stent-patency and possible disadvantageous comorbidities. METHODS Patients receiving TL treatment in the setting of acute stroke between 2013 and 2022 were analyzed regarding peri-/postprocedural safety and stent patency after 90 days. All patients received intravenous eptifibatide and acetylsalicylic acid and one of the three drugs prasugrel, clopidogrel, or ticagrelor. Duplex imaging was performed 24 h after treatment, at discharge and 90 days, and digital subtraction angiography was performed if restenosis was suspected. RESULTS 176 patients were included. Periprocedural complications occurred in 2.3% of the patients at no periprocedural death, and in-hospital death in 13.6%. Discharge mRS score was maintained or improved at the 90-day follow-up in 86%, 4.54% had an in-stent restenosis requiring treatment at 90 days. No recorded comorbidity considered disadvantageous for stent patency showed statistical significance, the duration of the endovascular procedure had no significant effect on outcome. CONCLUSION In our data, TL treatment with triple APT resulted in a low restenosis rate, low rates of sICH and a comparably high number of patients with favorable outcome. Aggressive APT in the initial phase may therefore have the potential to prevent recurrent stroke better than restrained platelet inhibition. Comorbidities did not influence stent patency.
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Affiliation(s)
- Ali Khanafer
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, University of Tübingen, Tübingen, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp von Gottberg
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.
- Klinik für Neuroradiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany.
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4
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Marnat G, Lapergue B, Gory B, Kyheng M, Labreuche J, Turc G, Olindo S, Sibon I, Caroff J, Smadja D, Chausson N, Clarençon F, Seners P, Bourcier R, Pop R, Olivot JM, Mazighi M, Moulin S, Janot K, Cognard C, Alamowitch S, Gerschenfeld G. Intravenous thrombolysis with tenecteplase versus alteplase combined with endovascular treatment of anterior circulation tandem occlusions: A pooled analysis of ETIS and TETRIS. Eur Stroke J 2024; 9:124-134. [PMID: 37837202 PMCID: PMC10916828 DOI: 10.1177/23969873231206894] [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: 06/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Tandem occlusions are a singular large vessel occlusion entity involving specific endovascular and perioperative antithrombotic management. In this context, data on safety and efficacy of prior intravenous thrombolysis (IVT) with tenecteplase is scarce. We aimed to compare IVT with tenecteplase or alteplase in patients with acute tandem occlusions intended for endovascular treatment. PATIENTS AND METHODS A retrospective pooled analysis of two large observational registries (ETIS (Endovascular Treatment of Ischemic Stroke) and TETRIS (Tenecteplase Treatment in Ischemic Stroke)) was performed on consecutive patients presenting with anterior circulation tandem occlusion treated with IVT using either alteplase (ETIS) or tenecteplase (TETRIS) followed by endovascular treatment between January 2015 and June 2022. Sensitivity analyses on atherosclerosis related tandem occlusions and on patient treated with emergent carotid stenting were conducted. Propensity score overlap weighting analyses were performed. RESULTS We analyzed 753 patients: 124 in the tenecteplase and 629 in the alteplase group. The overall odds of favorable outcome (3-month modified Rankin score 0-2) were comparable between both groups (49.4% vs 47.1%; OR = 1.10, 95%CI 0.85-1.41). Early recanalization, final successful recanalization and mortality favored the use of tenecteplase. The occurrence of any intracranial hemorrhage (ICH) was more frequent after tenecteplase use (OR = 2.24; 95%CI 1.75-2.86). However, risks of symptomatic ICH and parenchymal hematoma remained similar. In atherosclerotic tandems, favorable outcome, mortality, parenchymal hematoma, early recanalization, and final successful recanalization favored the tenecteplase group. In the carotid stenting subgroup, PH were less frequent in the tenecteplase group (OR = 0.18; 95%CI 0.05-0.69). CONCLUSION In patients with tandem occlusions, IVT with tenecteplase seemed reasonably safe in particular with increased early recanalization rates. These findings remain preliminary and should be further confirmed in randomized trials.
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Affiliation(s)
- Gaultier Marnat
- Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | | | - Benjamin Gory
- Neuroradiology, Nancy University Hospital, Université de Lorraine, IADI, INSERM U1254, Nancy, France
| | - Maeva Kyheng
- Biostatistics, Lille University Hospital, Lille, France
| | | | - Guillaume Turc
- Neurology, GHU Paris Psychiatrie et Neurosciences, INSERM U1266, Université Paris Cité, FHU NeuroVasc, Paris, France
| | | | - Igor Sibon
- Neurology, Bordeaux University Hospital, Bordeaux, France
| | - Jildaz Caroff
- Interventional Neuroradiology − NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Didier Smadja
- Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes, France
| | - Nicolas Chausson
- Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes, France
| | | | - Pierre Seners
- Neurology, Fondation Rothschild, Paris, Île-de-France, France
| | | | - Raoul Pop
- Neuroradiology, Strasbourg University Hospital, Strasbourg, France
| | | | - Mikael Mazighi
- Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris Cité, INSERM 1144, FHU Neurovasc, Paris, France
| | - Solène Moulin
- Neurology, Stroke Unit; Reims University Hospital, Reims, France
| | - Kevin Janot
- Neuroradiology, Tours University Hospital, Tours, France
| | | | - Sonia Alamowitch
- Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France; STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Gaspard Gerschenfeld
- Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France; STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
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5
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Diana F, Abdalkader M, Behme D, Li W, Maurer CJ, Pop R, Hwang YH, Bartolini B, Da Ros V, Bracco S, Cirillo L, Marnat G, Katsanos AH, Kaesmacher J, Fischer U, Aguiar de Sousa D, Peschillo S, Zini A, Tomasello A, Ribo M, Nguyen TN, Romoli M. Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data. J Neurointerv Surg 2024; 16:243-247. [PMID: 37185107 DOI: 10.1136/jnis-2023-020204] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND The periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of antithrombotics following eCAS. METHODS We followed PRISMA guidelines and searched MEDLINE, Embase, and Scopus from January 1, 2004 to November 30, 2022 for studies evaluating eCAS in tandem occlusion. The primary endpoint was 90-day good functional outcome. Secondary outcomes were symptomatic intracerebral hemorrhage, in-stent thrombosis, delayed stent thrombosis, and successful recanalization. Meta-analysis of proportions and meta-analysis of odds ratios were implemented. RESULTS 34 studies with 1658 patients were included. We found that the use of no antiplatelets (noAPT), single antiplatelet (SAPT), dual antiplatelets (DAPT), or glycoprotein IIb/IIIa inhibitors (GPI) yielded similar rates of good functional outcomes, with a marginal benefit of GPI over SAPT (OR 1.88, 95% CI 1.05 to 3.35, Pheterogeneity=0.31). Sensitivity analysis and meta-regression excluded a significant impact of intravenous thrombolysis and Alberta Stroke Program Early CT Score (ASPECTS). We observed no increase in symptomatic intracerebral hemorrhage (sICH) with DAPT or GPI compared with noAPT or SAPT. We also found similar rates of delayed stent thrombosis across groups, with acute in-stent thrombosis showing marginal, non-significant benefits from GPI and DAPT over SAPT and noAPT. CONCLUSIONS In AIS due to tandem occlusion, the periprocedural antithrombotic regimen of eCAS seems to have a marginal effect on good functional outcome. Overall, high intensity antithrombotic therapy may provide a marginal benefit on good functional outcome and carotid stent patency without a significant increase in risk of sICH.
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Affiliation(s)
- Francesco Diana
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
| | | | - Daniel Behme
- Neuroradiology, University Hospital Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
| | - Wei Li
- Neurology, Hainan Medical University, Haikou, Hainan, China
| | - Christoph Johannes Maurer
- Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Yang-Ha Hwang
- Neurology and Radiology, Kyungpook National University Hospital, Daegu, Korea (the Republic of)
| | - Bruno Bartolini
- Diagnostic and Interventional Radiology, Interventional Neuroradiology Unit, CHUV - Lausanne University Hospital, Lausanne, Switzerland
| | - Valerio Da Ros
- Biomedicine and Prevention, Diagnostic Imaging Unit, Fondazione PTV Policlinico Tor Vergata, Roma, Italy
| | - Sandra Bracco
- Neurology and Human Movement Sciences, Interventional Neuroradiology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Luigi Cirillo
- Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Aristeidis H Katsanos
- Neurology Division, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada
| | - Johannes Kaesmacher
- Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Diana Aguiar de Sousa
- Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/ CHULN, University of Lisbon, Lisboa, Portugal
| | - Simone Peschillo
- Endovascular Neurosurgery, Pia Fondazione Cardinale G Panico Hospital, Tricase, Italy
- UniCamillus International Medical University, Rome, Italy
| | - Andrea Zini
- Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Emilia-Romagna, Italy
| | - Alejandro Tomasello
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
| | - Marc Ribo
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Thanh N Nguyen
- Radiology, Boston Medical Center, Boston, Massachusetts, USA
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michele Romoli
- Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Emilia-Romagna, Italy
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6
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Pop R, Burel J, Finitsis SN, Papagiannaki C, Severac F, Mangin PH, Mihoc D, Leonard-Lorant I, Gheoca R, Wolff V, Chibbaro S, Sibon I, Richard S, Beaujeux R, Marnat G, Gory B. Comparison of three antithrombotic strategies for emergent carotid stenting during stroke thrombectomy: a multicenter study. J Neurointerv Surg 2023; 15:e388-e395. [PMID: 36759180 DOI: 10.1136/jnis-2022-019875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Periprocedural antithrombotic treatment is a key determinant for the risk-benefit balance of emergent carotid artery stenting (eCAS) during stroke thrombectomy. We aimed to assess the safety and efficacy of three types of antithrombotic treatment. METHODS Retrospective review of prospectively collected endovascular databases in four comprehensive stroke centers, including consecutive cases of eCAS for tandem lesion strokes between January 2019 and July 2021. During this period, each center prospectively applied one of three periprocedural protocols: (a) two centers administered aspirin (250 mg IV); (b) one center administered aspirin and heparin (bolus+24 hours infusion); and (c) one center applied an aggressive antiplatelet strategy consisting of aspirin and clopidogrel (loading doses), with added intravenous tirofiban if in-stent thrombosis was observed during thrombectomy. Dichotomized comparisons of outcomes were performed between aggressive versus non-aggressive strategy (aspirin±heparin) and aspirin+heparin versus aspirin-alone groups. RESULTS Among 161 included patients, 62 received aspirin monotherapy, 38 aspirin+heparin, and 61 an aggressive treatment. Aggressive antiplatelet treatment was associated with an increased rate of excellent (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) recanalization and reduced carotid stent thrombosis at day 1 (3.5% vs 16.3%), compared with non-aggressive strategy. There were no significant differences in hemorrhagic transformation or 90-day mortality. There was a tendency towards better clinical outcome with aggressive treatment, without reaching statistical significance. Addition of heparin to aspirin was not associated with an increased rate of carotid stent patency. CONCLUSIONS Aggressive antiplatelet treatment was associated with improved intracranial recanalization and carotid stent patency, without safety concerns. These findings have implications for randomized trials and may be of utility for clinicians when making antithrombotic treatment choices.
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Affiliation(s)
- Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
- Interventional Radiology, Institut de Chirurgie Guidée par l'Image, Strasbourg, France
- INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, F-67065, University of Strasbourg, Strasbourg, France
| | - Julien Burel
- Radiology, University Hospital Centre Rouen, Rouen, France
| | | | | | - Francois Severac
- Public Healthcare Department, University Hospitals Strasbourg, Strasbourg, France
| | - Pierre H Mangin
- INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, F-67065, University of Strasbourg, Strasbourg, France
| | - Dan Mihoc
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Ian Leonard-Lorant
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Roxana Gheoca
- Neurology, University Hospitals Strasbourg, Strasbourg, France
| | - Valerie Wolff
- Neurology, University Hospitals Strasbourg, Strasbourg, France
| | | | - Igor Sibon
- Neurology, University Hospital Center Bordeaux, Bordeaux, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Remy Beaujeux
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, University Hospital Centre Bordeaux, Bordeaux, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, Centre hospitalier regional universitaire de Nancy, Nancy, France
- Université de Lorraine, Nancy, France
- IADI, INSERM U1254, Nancy, France
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7
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Gory B, Finitsis S, Desilles JP, Consoli A, Mazighi M, Marnat G, Sibon I, Pop R, Raposo N, Wolff V, Cognard C, Richard S, Moulin S, Soize S, Lapergue B, Olivot JM. Successful Thrombectomy Improves Functional Outcome in Tandem Occlusions with a Large Ischemic Core. World Neurosurg 2023; 178:e282-e291. [PMID: 37473866 DOI: 10.1016/j.wneu.2023.07.043] [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: 04/18/2023] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Emergent stenting in tandem occlusions and mechanical thrombectomy (MT) of acute ischemic stroke related to large vessel occlusion (LVO-AIS) with a large core are tested independently. We aim to assess the impact of reperfusion with MT in patients with LVO-AIS with a large core and a tandem occlusion and to compare the safety of reperfusion between large core with tandem and nontandem occlusions in current practice. METHODS We analyzed data of all consecutive patients included in the prospective Endovascular Treatment in Ischemic Stroke Registry in France between January 2015 and March 2023 who presented with a pretreatment ASPECTS (Alberta Stroke Program Early CT Score) of 0-5 and angiographically proven tandem occlusion. The primary end point was a favorable outcome defined by a modified Rankin Scale (mRS) score of 0-3 at 90 days. RESULTS Among 262 included patients with a tandem occlusion and ASPECTS 0-5, 203 patients (77.5%) had a successful reperfusion (modified Thrombolysis in Cerebral Infarction grade 2b-3). Reperfused patients had a favorable shift in the overall mRS score distribution (adjusted odds ratio [aOR], 1.57 [1.22-2.03]; P < 0.001), higher rates of mRS score 0-3 (aOR, 7.03 [2.60-19.01]; P < 0.001) and mRS score 0-2 at 90 days (aOR, 3.85 [1.39-10.68]; P = 0.009) compared with nonreperfused. There was a trend between the occurrence of successful reperfusion and a decreased rate of symptomatic intracranial hemorrhage (aOR, 0.5 [0.22-1.13]; P = 0.096). Similar safety outcomes were observed after large core reperfusion in tandem and nontandem occlusions. CONCLUSIONS Successful reperfusion was associated with a higher rate of favorable outcome in large core LVO-AIS with a tandem occlusion, with a safety profile similar to nontandem occlusion.
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Affiliation(s)
- Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, IADI, INSERM U1254, CHRU-Nancy, Nancy, France.
| | - Stephanos Finitsis
- Department of Neuroradiology, Aristotle University of Thessaloniki, Ahepa Hospital, Thessaoniki, Greece
| | | | - Arturo Consoli
- Department of Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Department of Neurology, Stroke Center, University Hospital of Bordeaux, Bordeaux, France
| | - Raoul Pop
- Department of Interventional Neuroradiology, University Hospital of Strasbourg, Strasbourg, France
| | - Nicolas Raposo
- Department of Neurology, Acute Stroke Unit, CIC 1436-UMR 1214, CHU Toulouse, Toulouse, France
| | - Valérie Wolff
- Stroke Unit, University Hospital of Strasbourg, Strasbourg, France
| | | | - Sébastien Richard
- Department of Neurology, Stroke Unit, Université de Lorraine, INSERM U1116, CHRU-Nancy, Nancy, France
| | - Solène Moulin
- Department of Neurology, Hôpital Maison Blanche, University Hospital of Reims, Université Reims Champagne-Ardenne, Reims, France
| | - Sébastien Soize
- Department of Neuroradiology, Hôpital Maison Blanche, University Hospital of Reims, Université Reims Champagne-Ardenne, Reims, France
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Jean-Marc Olivot
- Department of Neurology, Acute Stroke Unit, CIC 1436-UMR 1214, CHU Toulouse, Toulouse, France
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Lai Z, Peng M, He H, Li Y, Bai X, Cai J. Percutaneous transluminal angioplasty and stenting vs aggressive medical management on stroke or intracranial atherosclerotic stenosis: a systematic review and meta-analysis. Sci Rep 2023; 13:7567. [PMID: 37161029 PMCID: PMC10169842 DOI: 10.1038/s41598-023-34663-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/05/2023] [Indexed: 05/11/2023] Open
Abstract
There are currently two main treatment strategies mainly for high-risk patients: percutaneous transluminal angioplasty and stenting (PTAS) and aggressive medical management (AMM). However, the choice between PTAS or AMM remains controversial for patients with stroke or intracranial atherosclerotic stenosis (ICAS). The investigators searched the PubMed, Web of Science, Embase, Scopus, and Cochrane library databases. Randomized controlled trial (RCT) comparing PTAS and AMM for patients with stroke or ICAS were selected. RevMan 5.3 was used to analyze the results and assess risk of bias. The primary endpoints are stroke and death within 30 days after enrollment, or ischemic stroke in the territory of the qualifying artery beyond 30 days, and entire follow-up endpoints. The secondary outcomes were the disabling or fatal stroke, and incidence of death within 3 years. Four studies, 989 patients were included in this article. The AMM group was superior in the entire follow-up endpoint (OR 0.56; 95% CI 0.40, 0.79). The AMM also better in primary endpoint within 30 days (OR 0.32; 95% CI 0.17, 0.61). There was no significant difference beyond 30 days (OR 1.08; 95% CI 0.63, 1.86). The remaining outcomes, such as stroke and death, were not significantly different (P > 0.05). This meta-analysis shows AMM is significantly more effective than PTAS in subjects with ICAS due to the high rate of periprocedural stroke (OR 0.32; 95% CI 0.17, 0.61) and stroke during the entire follow-up (OR 0.56; 95% CI 0.40, 0.79) associated with PTAS. Furthermore, PTAS offers no additional benefits over AMM beyond 30 days (OR 1.08; 95% CI 0.63, 1.86).
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Affiliation(s)
- Zhiyu Lai
- Diagnosis and Treatment Center of Encephalopathy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
- Department of Cerebrovascular Surgery, Hospital of Guangzhou University Mega Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, China
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Mingqiang Peng
- Diagnosis and Treatment Center of Encephalopathy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
- Department of Cerebrovascular Surgery, Hospital of Guangzhou University Mega Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, China
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Haoming He
- Diagnosis and Treatment Center of Encephalopathy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
- Department of Cerebrovascular Surgery, Hospital of Guangzhou University Mega Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, China
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Yingbin Li
- Diagnosis and Treatment Center of Encephalopathy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
- Department of Cerebrovascular Surgery, Hospital of Guangzhou University Mega Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, China
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Xiaoxin Bai
- Diagnosis and Treatment Center of Encephalopathy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
- Department of Cerebrovascular Surgery, Hospital of Guangzhou University Mega Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, China
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Jun Cai
- Diagnosis and Treatment Center of Encephalopathy, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China.
- Department of Cerebrovascular Surgery, Hospital of Guangzhou University Mega Center, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510006, China.
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China.
- Department of Neurosurgery, Hospital of Guangzhou Higher Education Mega Center, Guangdong Provincial Hospital of Chinese Medicine, No. 55 Neihuan Xi Road, Guangzhou, 510006, Guangdong, China.
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Masoud HE, Nguyen TN, Broderick JP. Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease. Stroke 2023; 54:132-134. [PMID: 36542069 DOI: 10.1161/strokeaha.122.040879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Hesham E Masoud
- Department of Neurology, Neurosurgery and Radiology, Upstate Medical University, Syracuse, NY (H.E.M.)
| | - Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, MA (T.N.N.)
| | - Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH (J.P.B.)
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