Safety of antithrombotic therapy for patients with acute ischemic stroke harboring unruptured intracranial aneurysm

Pretreatment with a dual antiplatelet and anticoagulant (APAC) reduces ischemia-reperfusion injury in a mouse model of temporary middle cerebral artery occlusion-implications for neurovascular procedures

BACKGROUND

Several neurovascular procedures require temporary occlusion of cerebral arteries, leading to ischemia of unpredictable length, occasionally causing brain infarction. Experimental models of cerebral ischemia-reperfusion injury have established that platelet adhesion and coagulation play detrimental roles in reperfusion injury following transient cerebral ischemia. Therefore, in a model of cerebral ischemia-reperfusion injury (IRI), we investigated the therapeutic potential of a dual antiplatelet and anticoagulant (APAC) heparin proteoglycan mimetic which is able to bind to vascular injury sites.

METHODS

Brain ischemia was induced in mice by transient occlusion of the right middle cerebral artery for 60 min. APAC, unfractionated heparin (UFH) (both at heparin equivalent doses of 0.5 mg/kg), or vehicle was intravenously administered 10 min before or 60 min after the start of ischemia. At 24 h later, mice were scored for their neurological and motor behavior, and brain damage was quantified.

RESULTS

Both APAC and UFH administered before the onset of ischemia reduced brain injury. APAC and UFH pretreated mice had better neurological and motor functions (p < 0.05 and p < 0.01, respectively) and had significantly reduced cerebral infarct sizes (p < 0.01 and p < 0.001, respectively) at 24 h after transient occlusion compared with vehicle-treated mice. Importantly, no macroscopic bleeding complications were observed in either APAC- or UFH-treated animals. However, when APAC or UFH was administered 60 min after the start of ischemia, the therapeutic effect was lost, but without hemorrhaging either.

CONCLUSIONS

Pretreatment with APAC or UFH was safe and effective in reducing brain injury in a model of cerebral ischemia induced by transient middle cerebral artery occlusion. Further studies on the use of APAC to limit ischemic injury during temporary occlusion in neurovascular procedures are indicated.

Treatment Strategy of Intracranial Anterior Circulation Aneurysm Presenting with Cerebral Ischemia: A Single-Center Experience

OBJECTIVE

To investigate the clinical characteristics and treatment strategy of anterior circulation aneurysm presenting with cerebral ischemia.

METHODS

We performed a retrospective review of patients with intracranial anterior circulation aneurysms presenting with cerebral ischemia examined in the Fifth Ward of the Neurosurgery Department of Tianjin Huanhu Hospital between September 2016 and September 2023. Data were reviewed for age, sex, presentation, type and size, location, treatment modalities, postoperative complications, clinical and imaging outcomes, and follow-up outcomes.

RESULTS

Among the 13 patients, there were 8 males and 5 females (1.6:1). Their presentations included ischemic stroke (69.23%, 9/13) and transient ischemic attack (TIA) (30.77%, 4/13). The aneurysms were dissecting (46.15%, 6/13), saccular (30.77%, 4/13), and saccular combined with thrombosis (23.08%, 3/13) in shape. There were 6 giant aneurysms, 4 large aneurysms, and 3 microaneurysms. Three (23.08%, 3/13) aneurysms were located at the internal carotid artery (ICA) and 10 (76.92%, 10/13) were located in the middle cerebral artery (MCA). A preoperative magnetic resonance perfusion (MRP) examination was performed in all patients, and 9 (69.23%, 9/13) patients showed hypoperfusion. Treatment modalities included stent-assisted embolization, direct clipping, clipping combined with bypass, resection combined with bypass, isolated combined with bypass, proximal occlusion combined with bypass, and the internal carotid artery constriction combined with bypass. Twelve (92.31%, 12/13) patients had no postoperative complications, and temporary complications occurred in 1 (7.69%, 1/13) patient. Aneurysms disappeared in 11 cases and shrank in 2 cases postoperatively. All patients were followed up for 1 to 72 months. We found no new cerebral infarction, no subarachnoid hemorrhage, and no recurrence or enlargement of aneurysms during the follow-up.

CONCLUSIONS

Intracranial anterior circulation aneurysm presenting with cerebral ischemia is rare. Saccular aneurysms with wide neck or thrombosis and dissected aneurysms of the anterior circulation may result in cerebral ischemic attack caused by distal vascular embolism. Individualized treatment should be performed, and cerebral revascularization is an effective treatment for patients with intracranial anterior circulation aneurysms presenting with cerebral ischemia.

Prevalence and prognosis of acute ischemic stroke coexisting with unruptured intracranial aneurysms

Objectives

The prevalence of unruptured intracranial aneurysms (UIAs) in the acute ischemic stroke (AIS) cohort is probably higher than in the general population. This study investigated the prevalence of UIAs in AIS patients and the management risk and prognosis when treating AIS.

Methods

From January 2020 to January 2023, we conducted a single-center retrospective study at Tianjin Huanhu Hospital. Each patient underwent both brain MRI and MRA/CTA to diagnose AIS and UIAs. Clinical, radiologic, and therapeutic data during hospitalization and prognosis were analyzed. Propensity-score matching (PSM) was performed to evaluate the risk of in-hospital adverse events, unfavorable outcomes at discharge when receiving post-stroke treatment and stroke recurrence.

Results

In all, 2,181 AIS patients were included, of whom 270 had UIAs (12.4%; 95%CI 11.0-13.8%). From the unmatched and matched cohort, the incidence of in-hospital adverse events and unfavorable outcomes at discharge in patients with UIAs were not significantly different; the risk of stroke recurrence was significantly higher in patients with UIAs than in those without (unmatched: aHR, 1.71 [1.08-2.70]; matched: aHR, 2.55 [1.16-5.58]). Multivariable Cox regression models showed that aneurysm size and the presence of homoregional infarction associated with higher risk of recurrence (unmatched: aHR, 1.31 [1.21-1.41] and aHR, 3.50 [1.52-8.10]; matched: aHR, 1.28 [1.18-1.40]; p < 0.001 and aHR, 3.71 [1.12-12.34]).

Conclusion

The UIAs may not increase the risk of in-hospital adverse events and unfavorable outcomes at discharge in receiving post-stroke treatment, but it may associated with a high risk of stroke recurrence.

Prevalence and risk factors of unruptured intracranial aneurysms in ischemic stroke patients - A global meta-analysis

Background

Unruptured intracranial aneurysms (UIAs) have an estimated global prevalence of 2.8% in the adult population; however, UIA was identified among more than 10% of ischemic stroke patients. Many epidemiological studies and reviews have pointed to the presence of UIA among patients with ischemic stroke; yet, the extent of this association is not fully known. We performed a systematic review and meta-analysis to determine the prevalence of UIA in patients admitted to hospitals with ischemic stroke and transient ischemic attack (TIA) at both global and continental levels and evaluate factors associated with UIA in this population.

Methods

We identified, in five databases, all studies describing UIA in ischemic stroke and TIA patients between January 1, 2000, and December 20, 2021. Included studies were of observational and experimental design.

Results

Our search yielded 3581 articles of which 23 were included, with a total of 25,420 patients. The pooled prevalence of UIA was 5% (95% confidence interval [CI] = 4-6%) with stratified results showing 6% (95% CI = 4-9%), 6% (95% CI = 5-7%), and 4% (95% CI = 2-5%) in North America, Asia, and Europe, respectively. Significant risk factors were large vessel occlusion (odds ratios [OR] = 1.22, 95% CI = 1.01-1.47) and hypertension (OR = 1.45, 95% CI = 1.24-1.69), while protective factors were male sex (OR = 0.60, 95% CI = 0.53-0.68) and diabetes (OR = 0.82, 95% CI = 0.72-0.95).

Conclusion

The prevalence of UIA is notably higher in ischemic stroke patients than the general population. Physicians should be aware of common risk factors in stroke and aneurysm formation for appropriate prevention.

Aneurysmal Subarachnoid Hemorrhage in Hospitalized Patients on Anticoagulants-A Two Center Matched Case-Control Study

Objective-Direct oral anticoagulants (DOAC) are replacing vitamin K antagonists (VKA) for the prevention of ischemic stroke and venous thromboembolism. We set out to assess the effect of prior treatment with DOAC and VKA in patients with aneurysmal subarachnoid hemorrhage (SAH). Methods-Consecutive SAH patients treated at two (Aachen, Germany and Helsinki, Finland) university hospitals were considered for inclusion. To assess the association between anticoagulant treatments on SAH severity measure by modified Fisher grading (mFisher) and outcome as measured by the Glasgow outcome scale (GOS, 6 months), DOAC- and VKA-treated patients were compared against age- and sex-matched SAH controls without anticoagulants. Results-During the inclusion timeframes, 964 SAH patients were treated in both centers. At the time point of aneurysm rupture, nine patients (0.93%) were on DOAC treatment, and 15 (1.6%) patients were on VKA. These were matched to 34 and 55 SAH age- and sex-matched controls, re-spectively. Overall, 55.6% of DOAC-treated patients suffered poor-grade (WFNS_4-5) SAH compared to 38.2% among their respective controls (p = 0.35); 53.3% of patients on VKA suffered poor-grade SAH compared to 36.4% in their respective controls (p = 0.23). Neither treatment with DOAC (aOR 2.70, 95%CI 0.30 to 24.23; p = 0.38), nor VKA (aOR 2.78, 95%CI 0.63 to 12.23; p = 0.18) were inde-pendently associated with unfavorable outcome (GOS_1-3) after 12 months. Conclusions-Iatrogenic coagulopathy caused by DOAC or VKA was not associated with more severe radiological or clinical subarachnoid hemorrhage or worse clinical outcome in hospitalized SAH patients.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Cardiac Myxoma: A Case Series and Pooled Analysis

Background and Purpose

Acute ischemic stroke (AIS) is a major life-threatening consequence of cardiac myxoma (CM) and leads to a poor prognosis. Although intravenous thrombolysis (IVT) is the first-line treatment for AIS, its efficacy and safety in CM-AIS have not been established. Currently, there are only limited data from case reports. Our study aimed to investigate the clinical characteristics of CM-AIS and evaluate the safety and efficacy of IVT for CM-AIS patients.

Methods

Fourteen CM-AIS patients who received IVT between January 2016 and December 2021 were identified from our multicenter stroke registry databases. Clinical, neuroimaging and outcome data were analyzed. We then performed a pooled analysis of the published literature from inception to December 2021.

Results

Of the 14 CM-AIS patients, nine were treated with IVT alone, and five were treated with bridging therapy (BT). The median age was 51.5 years, and 57.1% were female. The median onset-to-needle time was 160 min. The median National Institute of Health Stroke Score (NIHSS) decreased from 15.5 at presentation to 13 24 h after IVT. Very early neurological improvement (VENI) was observed in one patient. Hemorrhagic transformation (HT) was observed in five (35.7%) patients, and only one patient was symptomatic (7.1%). Three-month favorable outcomes were achieved in six patients (66.7%) who underwent IVT alone and three patients (60%) who received BT, which resulted in a total proportion of favorable outcomes of 64.3%. None of the patients died at 3 months follow-up. Forty-seven cases (15 BT patients) were included for the pooled analysis. The median NIHSS score was 16.5, and VENI was observed in 10 (21.3%) patients. HT was detected in 11 patients (23.4%), and four (8.5%) patients were symptomatic. Favorable outcomes at 3 months were achieved in 61.7% of patients, 56.3% of patients who underwent IVT alone, and 73.3% of patients who received BT. The 3-month mortality rate was 4.3%.

Conclusions

IVT is a potentially safe and efficient treatment for CM-AIS patients. Further studies with larger sample sizes are required to provide more evidence on the safety and efficacy of IVT and BT in CM-AIS patients.

Mechanical Thrombectomy for Acute Ischemic Stroke in Patients With Cardiac Myxoma: A Case Series and Pooled Analysis

Background and Purpose

Acute ischemic stroke (AIS) is a common and life-threatening complication of patients with cardiac myxoma (CM). The role of the mechanical thrombectomy (MT) technique in CM-AIS patients remains unclear, and no guidelines exist for this population. Therefore, we conducted a case series study of MT in CM-AIS patients to investigate its safety and efficacy via a pooled analysis of published literature.

Methods

Eleven CM-AIS patients who underwent MT between 2016 and 2021 were screened from multicenter stroke databases. Clinical, procedural, and outcome data were obtained from medical records. A systematic review was conducted to identify additional cases from published studies by searching PubMed and China National Knowledge Infrastructure databases. We then performed a pooled analysis of the published cases.

Results

In the case series study, most patients were male (81.8%), with a median age of 51 years. All patients had CM located in the left atrium. The rate of successful reperfusion using the first-line thrombectomy technique was 100% with stent retriever (SR) and 66.7% with direct aspiration (DA), which resulted in overall successful reperfusion in 94.1% of all occlusions. The retrieved emboli of the five patients who underwent histopathology examination were identified as myxoma components. Hemorrhagic transformation was observed in five (45.5%) patients, of whom one was symptomatic (9.1%). Three-month favorable functional outcomes were achieved in five (45.5%) patients with a 3-month mortality rate of 18.2%. For the literature review, 35 cases with 51 target vessel occlusions were identified and included in the pooled analysis. The rate of successful reperfusion following first-line thrombectomy did not differ between SR (30 patients, 90.9%) and DA (10 patients, 83.3%). The overall successful reperfusion rate was 91.8% of all occlusions. Three-month favorable functional outcomes were achieved in 21 (60.0%) patients, and the mortality rate was 8.6%.

Conclusions

Our findings suggest that MT is not only an effective technique but also a safe option for CM-AIS patients with large vessel occlusion. MT has several advantages for this population, which include a high recanalization rate, low bleeding risk, and the ability to evaluate the source of emboli and the etiology of stroke.

Acute ischemic stroke due to unruptured small aneurysm of internal carotid artery: A case report

RATIONALE

Intracranial small aneurysm is a rare cause of ischemic stroke, and been described only in sparse case reports. The exact pathophysiology, treatment strategies, and prognosis remain incompletely understood.

PATIENT CONCERNS

A 42-year-old man presented with an acute onset weakness of the right limbs.

DIAGNOSES

Neuroimaging evaluation confirmed a diagnosis of acute ischemic stroke and left internal carotid artery (ICA) small aneurysm.

INTERVENTIONS

The patient underwent oral anti-platelet therapy (100 mg aspirin daily).

OUTCOMES

The patient recovered to normal status within 4 weeks following antiplatelet treatment. During a follow-up period of 1 year, he remained neurologically asymptomatic and led a virtually normal life.

LESSONS

It is crucial for clinicians to be aware of this entity, as cerebral infarction caused by small cerebral aneurysm is extremely rare.

Fatal intracranial aneurysm rupture after thrombolytic treatment for ischemic stroke: a case report and literature review

Intravenous thrombolysis is a proven treatment of acute ischemic stroke. Its complications include intracranial hemorrhage; the risk may be increased in the presence of an unruptured aneurysm. We present a case report of a patient who suffered fatal subarachnoid hemorrhage after thrombolysis from a known aneurysm. A history of recent previously inexperienced headaches was revealed retrospectively, suggestive of sentinel bleedings. A similar patient was identified in the literature; we thus propose that this history should be excluded in patients harboring an aneurysm considered for thrombolytic treatment.