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Chen K, Zhou Y, Guo G, Wu Q. Single-Centre Experience with Endovascular Therapy in Acute Occlusion of ICAS: Preferred Stent Thrombectomy Versus Preferred Angioplasty. Neurologist 2024:00127893-990000000-00147. [PMID: 39044683 DOI: 10.1097/nrl.0000000000000578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
OBJECTIVES The preferred endovascular therapy (EVT) for large-vessel occlusion in intracranial atherosclerosis (ICAS) is unknown. We compared the efficacy of preferred stent thrombectomy and preferred angioplasty in patients with acute large-vessel occlusion in ICAS. METHODS Data from consecutive EVT patients (May 2020 to September 2023) with acute middle cerebral artery occlusion in ICAS were retrospectively analyzed. Preferred angioplasty was performed if there was a preoperative "microcatheter first-pass effect;" otherwise, preferred stent thrombectomy was performed. Analyses were grouped according to the two EVT treatments. Clinical data of all patients, including the time from puncture to recanalization, rate of successful reperfusion, early neurological improvement, intracranial hemorrhage, and modified Rankin Scale score at 90 days, were recorded and analyzed. RESULTS Six-two patients were enrolled in this study (mean age was 60.66±13.21 y, 22.6% female). The preferred angioplasty group had a higher first-pass recanalization rate than the preferred stent thrombectomy group (61.3% vs. 21.9%, P<0.001) and a higher proportion of patients who were functionally independent (defined as a modified Rankin Scale score of 0 to 3) at 90 days [odds ratio,3.681; 95% confidence interval (CI):1.009 to 13.428; P=0.048]. There was no significant difference between the groups in the time from puncture to recanalization, the frequency of successful reperfusion, and early neurological improvement, or intracranial hemorrhage (P>0.05). CONCLUSIONS This study suggests that for acute middle cerebral artery occlusion in ICAS, preferred angioplasty may be a safe and effective procedure.
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Affiliation(s)
- Kechun Chen
- Department of Neurology, Zhangjiagang Hospital affiliated to Soochow University, Zhangjiagang, China
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Bae JW, Hyun DK. Endovascular Thrombectomy for Acute Ischemic Stroke : Current Concept in Management. J Korean Neurosurg Soc 2024; 67:397-410. [PMID: 38549263 PMCID: PMC11220414 DOI: 10.3340/jkns.2023.0181] [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: 08/28/2023] [Revised: 10/30/2023] [Accepted: 11/23/2023] [Indexed: 07/04/2024] Open
Abstract
Endovascular thrombectomy (EVT) has been established as the standard of care in the treatment of acute ischemic stroke (AIS) based on landmark randomized controlled trials. Nevertheless, while the strict eligibility of EVT for AIS patients restrict the wide application of EVT, a considerable population still undergoes off-label EVT. Besides, it is important to acknowledge that recanalization is not achieved in approximately 20% of procedures, and more than 50% of patients who undergo EVT still do not experience a favorable outcome. This article reviews the brief history of EVT trials and recent progressions in the treatment of AIS, with focusing on the expanding eligibility criteria, new target for EVT, and the evolution of EVT techniques.
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Affiliation(s)
- Jin Woo Bae
- Department of Neurosurgery, Inha University Hospital, Incheon, Korea
- Incheon Regional Cardio-cerebrovascular Disease Center, Incheon, Korea
| | - Dong Keun Hyun
- Department of Neurosurgery, Inha University Hospital, Incheon, Korea
- Incheon Regional Cardio-cerebrovascular Disease Center, Incheon, Korea
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A Tarek M, Damiani Monteiro M, Mohammaden MH, Martins PN, Sheth SA, Dolia J, Pabaney A, Grossberg JA, Nahhas M, A De La Garza C, Salazar-Marioni S, Rangaraju S, Nogueira RG, Haussen DC. Development and validation of a SCORing systEm for pre-thrombectomy diagnosis of IntraCranial Atherosclerotic Disease (Score-ICAD). J Neurointerv Surg 2024:jnis-2024-021676. [PMID: 38782568 DOI: 10.1136/jnis-2024-021676] [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: 03/05/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Early identification of intracranial atherosclerotic disease (ICAD) may impact the management of patients undergoing mechanical thrombectomy (MT). We sought to develop and validate a scoring system for pre-thrombectomy diagnosis of ICAD in anterior circulation large vessel/distal medium vessel occlusion strokes (LVOs/DMVOs). METHODS Retrospective analysis of two prospectively maintained comprehensive stroke center databases including patients with anterior circulation occlusions spanning 2010-22 (development cohort) and 2018-22 (validation cohort). ICAD cases were matched for age and sex (1:1) to non-ICAD controls. RESULTS Of 2870 MTs within the study period, 348 patients were included in the development cohort: 174 anterior circulation ICAD (6% of 2870 MTs) and 174 controls. Multivariable analysis β coefficients led to a 20 point scale: absence of atrial fibrillation (5); vascular risk factor burden (1) for each of hypertension, diabetes, smoking, and hyperlipidemia; multifocal single artery stenoses on CT angiography (3); absence of territorial cortical infarct (3); presence of borderzone infarct (3); or ipsilateral carotid siphon calcification (2). The validation cohort comprised 56 ICAD patients (4.1% of 1359 MTs): 56 controls. Area under the receiver operating characteristic curve was 0.88 (0.84-0.91) and 0.82 (0.73-0.89) in the development and validation cohorts, respectively. Calibration slope and intercept showed a good fit for the development cohort although with overestimated risk for the validation cohort. After intercept adjustment, the overestimation was corrected (intercept 0, 95% CI -0.5 to -0.5; slope 0.8, 95% CI 0.5 to 1.1). In the full cohort (n=414), ≥11 points showed the best performance for distinguishing ICAD from non-ICAD, with 0.71 (95% CI 0.65 to 0.78) sensitivity and 0.82 (95% CI 0.77 to 0.87) specificity, and 3.92 (95% CI 2.92 to 5.28) positive and 0.35 (95% CI 0.28 to 0.44) negative likelihood ratio. Scores ≥12 showed 90% specificity and 63% sensitivity. CONCLUSION The proposed scoring system for preprocedural diagnosis of ICAD LVOs and DMVOs presented satisfactory discrimination and calibration based on clinical and non-invasive radiological data.
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Affiliation(s)
- Mohamed A Tarek
- Neurology Department, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurology and Psychological Medicine, Sohag University Faculty of Medicine, Sohag, Egypt
| | - Mateus Damiani Monteiro
- Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Health System Marcus Stroke and Neuroscience Center, Atlanta, Georgia, USA
| | | | - Pedro N Martins
- Neurology Department, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Health System Marcus Stroke and Neuroscience Center, Atlanta, Georgia, USA
| | - Sunil A Sheth
- Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jaydevsinh Dolia
- Neurology Department, Emory University School of Medicine, Atlanta, Georgia, USA
- Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | | | - Jonathan A Grossberg
- Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael Nahhas
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Carlos A De La Garza
- Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | | | - Srikant Rangaraju
- Neurology Department, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Raul G Nogueira
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | - Diogo C Haussen
- Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
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Zhang L, He X, Li K, Ling L, Peng M, Huang L, Liu Y. Balloon angioplasty as first-choice recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion with small clot burden. Neuroradiology 2024; 66:399-407. [PMID: 38183425 DOI: 10.1007/s00234-023-03278-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 12/22/2023] [Indexed: 01/08/2024]
Abstract
PURPOSE The optimal primary recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion (ICAS-ELVO) remains controversial. We aimed to explore the safety and efficacy of balloon angioplasty as the first-choice recanalization strategy for ICAS-ELVO with small clot burden. METHODS Consecutive ICAS-ELVO patients presenting with microcatheter "first-pass effect" during endovascular treatment (EVT) were retrospectively analyzed. Patients were divided into preferred balloon angioplasty (PBA) and preferred mechanical thrombectomy (PMT) groups based on the first-choice recanalization strategy. The reperfusion and clinical outcomes between the two groups were compared. RESULTS Seventy-six patients with ICAS-ELVO involving the microcatheter "first-pass effect" during EVT were enrolled. Compared with patients in the PMT group, those in the PBA group were associated with (i) a higher rate of first-pass recanalization (54.0% vs. 28.9%, p = .010) and complete reperfusion (expanded thrombolysis in cerebral ischemia ≥ 2c; 76.0% vs. 53.8%, p = .049), (ii) shorter puncture-to-recanalization time (49.5 min vs. 89.0 min, p < .001), (iii) lower operation costs (¥48,499.5 vs. ¥ 99,086.0, p < .001), and (iv) better 90-day functional outcomes (modified Rankin scale:0-1; 44.0% vs. 19.2%, p = .032). Logistic regression analysis revealed that balloon angioplasty as the first-choice recanalization strategy was an independent predictor of 90-day excellent functional outcomes for ICAS-ELVO patients with microcatheter "first-pass effect" (adjusted odds ratio = 6.01, 95% confidence interval: 1.15-31.51, p = .034). CONCLUSION Direct balloon angioplasty potentially improves 90-day functional outcomes for ICAS-ELVO patients with small clot burden, and may be a more appropriate first-choice recanalization strategy than mechanical thrombectomy for these patients.
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Affiliation(s)
- Liang Zhang
- Department of Neurology, First Affiliated Hospital of Jinan University, NO 613 West Huangpu Rd, Tianhe Dt, Guangzhou, 510630, China
| | - Xiong'jun He
- Department of Neurology, Shenzhen Hospital of Southern Medical University, NO 1333 Xinhu Rd, Baoan Dt, Shenzhen, 518101, China
| | - Kai'feng Li
- Department of Neurology, Shenzhen Hospital of Southern Medical University, NO 1333 Xinhu Rd, Baoan Dt, Shenzhen, 518101, China
| | - Li Ling
- Department of Neurology, Shenzhen Hospital of Southern Medical University, NO 1333 Xinhu Rd, Baoan Dt, Shenzhen, 518101, China
| | - Min Peng
- Department of Neurology, First Affiliated Hospital of Jinan University, NO 613 West Huangpu Rd, Tianhe Dt, Guangzhou, 510630, China
| | - Li'an Huang
- Department of Neurology, First Affiliated Hospital of Jinan University, NO 613 West Huangpu Rd, Tianhe Dt, Guangzhou, 510630, China.
| | - Ya'jie Liu
- Department of Neurology, Shenzhen Hospital of Southern Medical University, NO 1333 Xinhu Rd, Baoan Dt, Shenzhen, 518101, China.
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Bu Z, Sun D, Ma G, Jia B, Tong X, Huo X, Wang A, Ma N, Gao F, Mo D, Song L, Sun X, Deng Y, Li X, Wang B, Luo G, Su D, Miao Z. The impact of intraarterial, intravenous, and combined tirofiban on endovascular treatment for acute intracranial atherosclerotic occlusion. Front Neurol 2024; 15:1336098. [PMID: 38414555 PMCID: PMC10896834 DOI: 10.3389/fneur.2024.1336098] [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: 11/10/2023] [Accepted: 01/29/2024] [Indexed: 02/29/2024] Open
Abstract
Background and purpose Adjunctive tirofiban administration in patients undergoing endovascular treatment (EVT) for acute large vessel occlusion (LVO) has been investigated in several studies. However, the findings are conflict. This study aimed to compare the effect of different administration pathways of tirofiban on patients undergoing EVT for acute LVO with intracranial atherosclerotic disease (ICAD). Methods Patients were selected from the ANGEL-ACT Registry (Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke: A Prospective Multicenter Registry Study) and divided into four groups: intra-arterial (IA), intravenous (IV), and intra-arterial plus intravenous (IA+IV) and non-tirofiban. The primary outcome was 90-day ordinal modified Rankin Scale (mRS) score, and the secondary outcomes included the rates of mRS 0-1, 0-2, and 0-3 at 90-day, successful recanalization. The safety outcomes were symptomatic intracranial hemorrhage (sICH) and other safety endpoints. The multivariable logistic regression models adjusting for potential baseline confounders were performed to compare the outcomes. A propensity score matching (PSM) with a 1:1:1:1 ratio was conducted among four groups, and the outcomes were then compared in the post-matched population. Results A total of 502 patients were included, 80 of which were in the IA-tirofiban group, 73 in IV-tirofiban, 181 in (IA+IV)-tirofiban group, and 168 in the non-tirofiban group. The median (IQR) 90-day mRS score in the four groups of IA, IV, IA+IV, and non-tirofiban was, respectively 3(0-5) vs. 1(0-4) vs. 1(0-4) vs. 3(0-5). The adjusted common odds ratio (OR) for 90-day ordinal modified Rankin Scale distribution with IA-tirofiban vs. non-tirofiban was 0.77 (95% CI, 0.45-1.30, P = 0.330), with IV-tirofiban vs. non-tirofiban was 1.36 (95% CI, 0.78-2.36, P = 0.276), and with (IA+IV)-tirofiban vs. non-tirofiban was 1.03 (95% CI, 0.64-1.64, P = 0.912). The adjusted OR for mRS 0-1 and mRS 0-2 at 90-day with IA-tirofiban vs. non-tirofiban was, respectively 0.51 (95% CI, 0.27-0.98, P = 0.042) and 0.50 (95% CI, 0.26-0.94, P = 0.033). The other outcomes of each group were similar with non-tirofiban group, all P was >0.05. After PSM, the common odds ratio (OR) for 90-day ordinal modified Rankin Scale distribution with IA-tirofiban vs. non-tirofiban was 0.41 (95% CI, 0.18-0.94, P = 0.036), and the OR for mRS 0-1 and mRS 0-2 at 90-day with IA-tirofiban vs. non-tirofiban was, respectively 0.28 (95% CI, 0.11-0.74, P = 0.011) and 0.25 (95% CI, 0.09-0.67, P = 0.006). Conclusions Intra-arterial administration of tirofiban was associated with worse outcome than non-tirofiban, which suggested that intra-arterial tirofiban had a harmful effect on patients undergoing EVT for ICAD-LVO. Clinical trial registration http://www.clinicaltrials.gov, Unique identifier: NCT03370939.
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Affiliation(s)
- Zhiping Bu
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ligang Song
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuan Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yiming Deng
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoqing Li
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bo Wang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gang Luo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Deguo Su
- Department of Neurology, Liangxiang Hospital of Beijing Fangshan District, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Brake A, Heskett C, Alam N, Fry L, Le K, Mahnken JD, Abraham M. Glycoprotein inhibitors as a first line rescue treatment after unsuccessful recanalization of endovascular thrombectomy: A systematic review and meta-analysis. Interv Neuroradiol 2024:15910199241226470. [PMID: 38204180 DOI: 10.1177/15910199241226470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Intracranial atherosclerotic disease (ICAD) is a major cause of stroke with a high rate of re-occlusion following mechanical thrombectomy (MT). Among the available rescue options, glycoprotein IIb/IIIa inhibitors (GPI) have shown promise as a potential therapeutic strategy. This systematic review and meta-analysis examine studies exploring the use of glycoprotein inhibitors as a first-line treatment for refractory occlusion or high-grade stenosis following EVT in the setting of ICAD. METHODS A systematic review and meta-analysis were performed. Studies using GPI as the first-line rescue treatment (GPI-rt) after failed thrombectomy or in the setting with high-grade stenosis (>50%) were included. The primary outcome of interest was good clinical outcomes (defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days). Secondary outcomes of interest were successful recanalization (TICI 2b-3), symptomatic intracranial hemorrhage (sICH), and mortality by 90 days. RESULTS Our study processed 2111 articles, which yielded eight relevant studies for review, four single and four double arm. These studies comprised 763 patients, divided into GPI-rt (535 patients) and non-GPI-rt (228 patients) cohorts. The GPI-rt group had higher rates of mRS ≤ 2 at 90 days (58.5% vs 38.9%, p = 0.002) and lower mortality rates (7.8% vs 17.5%, p = 0.04) compared to the non-GPI-rt cohort. mTICI 2b-3 rates and rates of sICH were not significantly different between the cohorts. CONCLUSIONS First line GPI-rt demonstrates significant clinical benefit and significantly lower mortality without a rise in rates of sICH. GPI are a potential first line rescue treatment of ICAD.
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Affiliation(s)
- Aaron Brake
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Cody Heskett
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Naima Alam
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Lane Fry
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Kevin Le
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Jonathan D Mahnken
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, USA
| | - Michael Abraham
- Department of Neurology, University of Kansas Health System, Kansas City, KS, USA
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Han B, Man X, Ding J, Li Y, Tian X, Zhu X, Yu J, Sun J. Subtyping treatment response of tirofiban in acute ischemic stroke based on neuroimaging features. Clin Transl Sci 2024; 17:e13686. [PMID: 37974520 PMCID: PMC10772471 DOI: 10.1111/cts.13686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/24/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023] Open
Abstract
In a previously published clinical trial, we demonstrated that tirofiban was effective and safe in acute ischemic stroke (AIS) patients who did not undergo early recanalization treatments. We aimed to evaluate neuroimaging characteristics and their clinical significance to guide tirofiban treatment. In this post hoc analysis, location of infarcts (anterior circulation stroke [ACS] vs. posterior circulation stroke [PCS]), degree of cerebral artery stenosis (≤69% vs. ≥70% or occlusion), total infarct volume, and ASPECTS were used to predict the treatment effects of tirofiban, defined as the proportions of excellent and favorable functional outcome (modified Rankin Scale [mRS] score of 0-1, 0-2) at 90 days. ACS patients were more likely to achieve excellent (OR 2.08; 95% CI 1.25-3.45; p = 0.004) and favorable functional outcome (OR 2.28; 95% CI 1.24-4.22; p = 0.008) when treated with tirofiban. However, there was no significant difference in PCS patients between tirofiban and the control group. For patients with severe stenosis (≥70% or occlusion), tirofiban treatment improved the proportion of good outcomes (OR 2.84; 95% CI 1.44-5.60; p = 0.002 for mRS 0-1; OR 2.42; 95% CI 1.22-4.77; p = 0.011 for mRS 0-2). Meanwhile, we found that tirofiban improved outcome in patients with ASPECTS 8-10 and was independent of total infarct volume. These findings support the hypothesis that patients with ACS and severe stenosis may be recommended for tirofiban treatment, which can be predicted independent of total infarct volume.
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Affiliation(s)
- Bin Han
- Department of NeurologyThe Affiliated Hospital of Qingdao UniversityQingdaoChina
| | - Xu Man
- Institute of Integrative Medicine, Qingdao Medical CollegeQingdao UniversityQingdaoChina
| | - Jian Ding
- Department of NeurologyThe Affiliated Hospital of Qingdao UniversityQingdaoChina
| | - Yuzhu Li
- Department of Intensive Care UnitQingdao Singde Jialang Geriatric HospitalQingdaoChina
| | - Xintao Tian
- Department of Emergency Internal MedicineThe Affiliated Hospital of Qingdao UniversityQingdaoChina
| | - Xuelian Zhu
- Department of NeurologyThe Fourth Division Cocodala City General Hospital of Xinjiang Production and Construction CorpsXinjiangChina
| | - Jiang Yu
- Department of NeurologyThe Fourth Division Cocodala City General Hospital of Xinjiang Production and Construction CorpsXinjiangChina
| | - Jinping Sun
- Department of Emergency Internal MedicineThe Affiliated Hospital of Qingdao UniversityQingdaoChina
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8
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Liang K, Zhang J, Zhao L, Cao Y, Jiang L, Liu Q, Liu S, Shi H, Jia Z. Acute Vertebrobasilar Artery Occlusion with Underlying Atherosclerosis: Balloon Angioplasty Combined with Tirofiban as Initial Salvage Therapy. World Neurosurg 2023; 179:e321-e327. [PMID: 37634670 DOI: 10.1016/j.wneu.2023.08.084] [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: 08/09/2023] [Accepted: 08/19/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE The optimal rescue endovascular treatment for patients with intracranial atherosclerotic stenosis in acute vertebrobasilar artery occlusion is not well established. We investigated the safety and efficacy of balloon angioplasty combined with tirofiban as the initial rescue strategy in these patients. METHODS We retrospectively analyzed the records of 41 patients admitted between January 2014 and September 2022, with vertebrobasilar artery atherosclerotic occlusion. Balloon angioplasty in combination with tirofiban was used as the first-line salvage therapy after the failure of mechanical thrombectomy. The technical success rate, recanalization outcome, procedure-related complications, symptomatic intracranial hemorrhage, and functional outcome at 90 days were reviewed. RESULTS Recanalization with a modified Thrombolysis in Cerebral Infarction grade of 2b-3 was achieved in 38 of the 41 patients (92.7%). Acute stents were deployed in 5 patients who did not achieve successful reperfusion after balloon angioplasty. Six patients (14.6%, 6/41) underwent stent angioplasty in the stable stage for severe residual stenosis detected on follow-up imaging. There was no procedure-related complication. Hemorrhagic transformation was detected on follow-up imaging in 11 patients (26.8%), while no symptomatic intracranial hemorrhage was recorded. Good functional outcome rate was 31.7% (13/41). CONCLUSIONS Balloon angioplasty combined with intravenous tirofiban administration is a safe and effective salvage therapy in patients with acute atherosclerotic occlusion of the vertebrobasilar artery.
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Affiliation(s)
- Kun Liang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiulou Zhang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Linbo Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuezhou Cao
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Jiang
- Department of Emergency, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qianghui Liu
- Department of Emergency, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Haibin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhenyu Jia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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9
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Khachatryan T, Shafie M, Abcede H, Shah J, Nagamine M, Granstein J, Yuki I, Golshani K, Suzuki S, Yu W. Rescue therapy after thrombectomy for large vessel occlusion due to underlying atherosclerosis: review of literature. Front Neurol 2023; 14:1181295. [PMID: 37396754 PMCID: PMC10313123 DOI: 10.3389/fneur.2023.1181295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/24/2023] [Indexed: 07/04/2023] Open
Abstract
In this review article, we summarized the current advances in rescue management for reperfusion therapy of acute ischemic stroke from large vessel occlusion due to underlying intracranial atherosclerotic stenosis (ICAS). It is estimated that 24-47% of patients with acute vertebrobasilar artery occlusion have underlying ICAS and superimposed in situ thrombosis. These patients have been found to have longer procedure times, lower recanalization rates, higher rates of reocclusion and lower rates of favorable outcomes than patients with embolic occlusion. Here, we discuss the most recent literature regarding the use of glycoprotein IIb/IIIa inhibitors, angioplasty alone, or angioplasty with stenting for rescue therapy in the setting of failed recanalization or instant/imminent reocclusion during thrombectomy. We also present a case of rescue therapy post intravenous tPA and thrombectomy with intra-arterial tirofiban and balloon angioplasty followed by oral dual antiplatelet therapy in a patient with dominant vertebral artery occlusion due to ICAS. Based on the available literature data, we conclude that glycoprotein IIb/IIIa is a reasonably safe and effective rescue therapy for patients who have had a failed thrombectomy or have residual severe intracranial stenosis. Balloon angioplasty and/or stenting may be helpful as a rescue treatment for patients who have had a failed thrombectomy or are at risk of reocclusion. The effectiveness of immediate stenting for residual stenosis after successful thrombectomy is still uncertain. Rescue therapy does not appear to increase the risk of sICH. Randomized controlled trials are warranted to prove the efficacy of rescue therapy.
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Affiliation(s)
- Tigran Khachatryan
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Mohammad Shafie
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Hermelinda Abcede
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Jay Shah
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Masaki Nagamine
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Justin Granstein
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Ichiro Yuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Kiarash Golshani
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Shuichi Suzuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Wengui Yu
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
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10
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Huo X, Sun D, Chen W, Han H, Abdalkader M, Puetz V, Yi T, Wang H, Liu R, Tong X, Jia B, Ma N, Gao F, Mo D, Yan B, Mitchell PJ, Leung TW, Yavagal DR, Albers GW, Costalat V, Fiehler J, Zaidat OO, Jovin TG, Liebeskind DS, Nguyen TN, Miao Z. Endovascular Treatment for Acute Large Vessel Occlusion Due to Underlying Intracranial Atherosclerotic Disease. Semin Neurol 2023; 43:337-344. [PMID: 37549690 DOI: 10.1055/s-0043-1771207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Intracranial atherosclerotic disease (ICAD) is one of the most common causes of acute ischemic stroke worldwide. Patients with acute large vessel occlusion due to underlying ICAD (ICAD-LVO) often do not achieve successful recanalization when undergoing mechanical thrombectomy (MT) alone, requiring rescue treatment, including intra-arterial thrombolysis, balloon angioplasty, and stenting. Therefore, early detection of ICAD-LVO before the procedure is important to enable physicians to select the optimal treatment strategy for ICAD-LVO to improve clinical outcomes. Early diagnosis of ICAD-LVO is challenging in the absence of consensus diagnostic criteria on noninvasive imaging and early digital subtraction angiography. In this review, we summarize the clinical and diagnostic criteria, prediction of ICAD-LVO prior to the procedure, and EVT strategy of ICAD-LVO and provide recommendations according to the current literature.
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Affiliation(s)
- Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | | | - Volker Puetz
- Department of Neurology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hao Wang
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Raynald Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre, Melbourne, Australia
| | - Peter J Mitchell
- Department of Radiology, Melbourne Brain Centre, Melbourne, Australia
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Dileep R Yavagal
- Departments of Neurology and Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Güi-de-Chauliac, CHU de Montpellier, Montpellier, France
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Osama O Zaidat
- Department of Neuroscience, Mercy Saint Vincent Medical Center, Toledo, Ohio
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Camden, New Jersey
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, California
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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11
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Ma A, Detaram HD, Steinfort B, Harrington T, Nguyen TN, Abdalkader M, Siopis G, Bath PM, Dhillon PS, Podlasek A, Qureshi AI, Qiu Z, Krishnan K. Antiplatelet Therapy in Neurointervention. Semin Neurol 2023; 43:466-479. [PMID: 37562452 DOI: 10.1055/s-0043-1771383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.
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Affiliation(s)
- Alice Ma
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | | | - Brendan Steinfort
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Tim Harrington
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Centre, Boston, Massachusetts
| | | | - George Siopis
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Permesh Singh Dhillon
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom
| | - Anna Podlasek
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People's Republic of China
| | - Kailash Krishnan
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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12
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Sang H, Xie D, Tian Y, Nguyen TN, Saver JL, Nogueira RG, Wu J, Long C, Tian Z, Hu Z, Wang T, Li R, Ke Y, Zhu X, Peng D, Chang M, Li L, Ruan J, Wu D, Zi W, Yang Q, Li F, Qiu Z. Association of Tirofiban With Functional Outcomes After Thrombectomy in Acute Ischemic Stroke Due to Intracranial Atherosclerotic Disease. Neurology 2023; 100:e1996-e2006. [PMID: 36941074 PMCID: PMC10186214 DOI: 10.1212/wnl.0000000000207194] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/01/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVE To investigate the efficacy and safety of IV infusion of tirofiban before endovascular thrombectomy for patients with large vessel occlusion due to intracranial atherosclerotic disease. The secondary objective was to identify potential mediators for the clinical effect of tirofiban. METHODS Post hoc exploratory analysis of the Endovascular Treatment With versus Without Tirofiban for Patients with Large Vessel Occlusion Stroke (RESCUE BT) trial, which was a randomized, double-blinded, placebo-controlled trial at 55 centers in China from October 2018 to October 2021. Patients with occlusion of the internal carotid artery or middle cerebral artery due to intracranial atherosclerosis were included. The primary efficacy outcome was the proportion of patients achieving functional independence (defined as modified Rankin scale 0-2) at 90 days. Binary logistic regression and causal mediation analyses were used to estimate the treatment effect of tirofiban and the potential mediators. RESULTS This study included 435 patients, of whom 71.5% were men. The median age was 65 (interquartile range [IQR] 56-72) years, with a median NIH Stroke Scale of 14 (IQR 10-19). Patients in the tirofiban group had higher rates of functional independence at 90 days than patients in the placebo group (adjusted odds ratio 1.68; 95% CI 1.11-2.56, p = 0.02) without an increased risk of mortality or symptomatic intracranial hemorrhage. Tirofiban was associated with fewer thrombectomy passes (median [IQR] 1 [1-2] vs 1 [1-2], p = 0.004), which was an independent predictor of functional independence. Mediation analysis showed tirofiban-reduced thrombectomy passes explained 20.0% (95% CI 4.1%-76.0%) of the effect of tirofiban on functional independence. DISCUSSION In this post hoc analysis of the RESCUE BT trial, tirofiban was an effective and well-tolerated adjuvant medication of endovascular thrombectomy for patients with large vessel occlusion due to intracranial atherosclerosis. These findings need to be confirmed in future trials. TRIAL REGISTRATION INFORMATION The RESCUE BT trial was registered on the Chinese Clinical Trial Registry: chictr.org.cn, ChiCTR-INR-17014167. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that tirofiban plus endovascular therapy improves 90-day outcome for patients with large vessel occlusion due to intracranial atherosclerosis.
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Affiliation(s)
- Hongfei Sang
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Dongjing Xie
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Yan Tian
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Thanh N Nguyen
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Jeffrey L Saver
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Raul G Nogueira
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Junxiong Wu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Chen Long
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Zhenxuan Tian
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Zhizhou Hu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Tao Wang
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Rongzong Li
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Yingbing Ke
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Xiurong Zhu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Daizhou Peng
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Mingze Chang
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Lingfei Li
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Jie Ruan
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Deping Wu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Wenjie Zi
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Qingwu Yang
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Fengli Li
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Zhongming Qiu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China.
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Caroff J, Aubert L, Lavenu-Bombled C, Figueiredo S, Habchi K, Cortese J, Eugene F, Ognard J, Tahon F, Forestier G, Ifergan H, Zhu F, Hak JF, Reyre A, Laubacher M, Traore A, Desilles JP, Derraz I, Moreno R, Bintner M, Charbonnier G, Le Bras A, Veunac L, Gariel F, Redjem H, Sedat J, Tessier G, Dumas V, Gauberti M, Chivot C, Consoli A, Bricout N, Tuilier T, Guedon A, Pop R, Thouant P, Bellanger G, Zannoni R, Soize S, Richter JS, Heck O, Mihalea C, Burel J, Girot JB, Shotar E, Gazzola S, Boulouis G, Kerleroux B. Antithrombotic therapies for neurointerventional surgery: a 2021 French comprehensive national survey. J Neurointerv Surg 2023; 15:402-407. [PMID: 35347058 DOI: 10.1136/neurintsurg-2021-018601] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/15/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND Neurointerventionists lack guidelines for the use of antithrombotic therapies in their clinical practice; consequently, there is likely to be significant heterogeneity in antithrombotic use between centers. Through a nationwide survey, we aimed to obtain an exhaustive cross-sectional overview of antithrombotic use in neurointerventional procedures in France. METHODS In April 2021, French neurointerventional surgery centers were invited to participate in a nationwide 51-question survey disseminated through an active trainee-led research collaborative network (the JENI-RC). RESULTS All 40 centers answered the survey. Fifty-one percent of centers reported using ticagrelor and 43% used clopidogrel as premedication before intracranial stenting. For flow diversion treatment, dual antiplatelet therapy was maintained for 3 or 6 months in 39% and 53% of centers, respectively, and aspirin was prescribed for 12 months or more than 12 months in 63% and 26% of centers, respectively. For unruptured aneurysms, the most common heparin bolus dose was 50 IU/kg (59%), and only 35% of centers monitored heparin activity for dose adjustment. Tirofiban was used in 64% of centers to treat thromboembolic complications. Fifteen percent of these comprehensive stroke centers reported using tenecteplase to treat acute ischemic strokes. Cangrelor appeared as an emergent drug in specific indications. CONCLUSION This nationwide survey highlights the important heterogeneity in clinical practices across centers. There is a pressing need for trials and guidelines to further evaluate and harmonize antithrombotic regimens in the neurointerventional field.
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Affiliation(s)
- Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Laurent Aubert
- Department of Anesthesia and Surgical Resuscitation Department, Bicetre Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Paris Saclay, Le Kremlin-Bicetre, France
| | - Cécile Lavenu-Bombled
- Department of Biological Hematology, Assistance Publique-Hôpitaux de Paris, Faculté de médecine Paris Saclay, Hospital Bicetre, Le Kremlin-Bicetre, France
| | - Samy Figueiredo
- Department of Anesthesia and Surgical Resuscitation Department, Bicetre Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Paris Saclay, Le Kremlin-Bicetre, France
| | - Kamelia Habchi
- Department of Anesthesia and Surgical Resuscitation Department, Bicetre Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Paris Saclay, Le Kremlin-Bicetre, France
| | - Jonathan Cortese
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | | | - Julien Ognard
- Department of Neuroradiology, CHU Brest, Brest, France
| | - Florence Tahon
- Department of Neuroradiology, Hôpital Privé Clairval, Marseille, France
| | | | - Heloise Ifergan
- Diagnostic and Interventional Neuroradiology, CHU Tours, Tours, France
| | - François Zhu
- Department of Diagnostic and Interventional Neuroradiology, CHU Nancy, Nancy, France.,Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | | | - Anthony Reyre
- Department of Neuroradiology, Hospital Timone, Marseille, France
| | | | - Abdoulaye Traore
- Department of Neuroradiology, Hôpital Louis Pasteur, Colmar, France
| | | | - Imad Derraz
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Ricardo Moreno
- Department of Neuroradiology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Marc Bintner
- Department of Neuroradiology, CHU de la Réunion, Saint-Denis, France
| | | | - Anthony Le Bras
- Department of Radiology, CH Bretagne Atlantique Site Chubert, Vannes, France
| | - Louis Veunac
- Department of Radiology, CH de la Cote Basque, Bayonne, France
| | - Florent Gariel
- Department of Interventional Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, France
| | - Hocine Redjem
- Department of Interventional Neuroradiology, Clinique des Cèdres, Toulouse, France
| | - Jacques Sedat
- Department of Interventional Neuroradiology, CHU Nice, Nice, France
| | | | - Victor Dumas
- Department of Radiology, CHU Poitiers, Poitiers, France
| | | | - Cyril Chivot
- Department of Neuroradiology, CHU Amiens-Picardie, Amiens, Hauts-de-France, France
| | - Arturo Consoli
- Department of Neuroradiology, Hospital Foch, Suresnes, France
| | - Nicolas Bricout
- Department of Interventional Neuroradiology, CHU Lille, Lille, France
| | - Titien Tuilier
- Department of Neuroradiology, CHU Henri Mondor, Créteil, France
| | - Alexis Guedon
- Department of Neuroradiology, CHU Lariboisiere Fernand-Widal, Paris, France
| | - Raoul Pop
- Department of Neuroradiology, CHU Strasbourg, Strasbourg, France
| | | | | | - Riccardo Zannoni
- Department of Neuroradiology, CHU Saint-Etienne, Saint-Etienne, France
| | | | | | - Olivier Heck
- Department of Neuroradiology, CHU Grenoble, Grenoble, France
| | - Cristian Mihalea
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Julien Burel
- Department of Radiology, CHU Rouen, Rouen, France
| | | | - Eimad Shotar
- Department of Neuroradiology, CHU Pitié Salpêtrière, Paris, France
| | - Sebastian Gazzola
- Department of Neuroradiology, Saint Anne Military Hospital, Toulon, France
| | | | - Basile Kerleroux
- Department of Neuroradiologie, Saint Anne Hospital, Paris, France
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Shang X, He C, Yang K, Guo Y, Zhou Z, Zi W. Effects of Antecedent Intravenous Thrombolysis on Endovascular Treatment of Acute Stroke Using Tirofiban. J Vasc Interv Radiol 2023; 34:420-426. [PMID: 36509235 DOI: 10.1016/j.jvir.2022.12.007] [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: 06/03/2022] [Revised: 11/18/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To investigate whether preceding intravenous thrombolysis combined with tirofiban in patients with acute ischemic stroke undergoing endovascular treatment is safe and effective. MATERIALS AND METHODS Consecutive data were identified for patients who experienced acute ischemic stroke and were admitted to 2 comprehensive stroke centers from January 2015 to August 2021. All patients were divided into 2 groups-a thrombolytic with tirofiban group and a tirofiban-alone group-on the basis of whether intravenous thrombolysis before emergency endovascular angioplasty was used. Multivariate regression and propensity adjustment analyses were performed to characterize differences in safety and clinical outcomes between the 2 groups. RESULTS Of 373 eligible patients, 111 (29.7%) were treated with thrombolysis with tirofiban. There was a significant difference in the rate of any intracerebral hemorrhage (35.1% vs 24.8%; P = .04) but not in the rates of symptomatic intracerebral hemorrhage (16.2% vs 11.5%; P = .23) and reocclusion at 24 hours (5.4% vs 7.6%; P = .51) between the 2 groups. Multivariate regression analysis revealed that intravenous thrombolysis was not associated with any or symptomatic intracerebral hemorrhage, artery occlusion, functional outcome, or death at the 3-month follow-up (all adjusted P > .05). After propensity adjustment, the thrombolytic with tirofiban group showed nonsignificant rates of clinical and safety outcomes compared with those of the tirofiban-alone group (all P > .05). CONCLUSIONS Tirofiban may be used without increasing the risk of adverse events in selected patients who experienced ischemic stroke and were treated with intravenous thrombolysis and endovascular therapy.
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Affiliation(s)
- Xianjin Shang
- Department of Neurology, the First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu City, Anhui Province, China
| | - Caifeng He
- Department of Dermatology, the First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu City, Anhui Province, China
| | - Ke Yang
- Department of Neurology, the First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu City, Anhui Province, China
| | - Yapeng Guo
- Department of Neurology, the First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu City, Anhui Province, China
| | - Zhiming Zhou
- Department of Neurology, the First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu City, Anhui Province, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China.
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15
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Anaesthetic and peri-operative management for thrombectomy procedures in stroke patients. Anaesth Crit Care Pain Med 2023; 42:101188. [PMID: 36599377 DOI: 10.1016/j.accpm.2022.101188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/15/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE To provide recommendations for the anaesthetic and peri-operative management for thrombectomy procedure in stroke patients DESIGN: A consensus committee of 15 experts issued from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation, SFAR), the Association of French-language Neuro-Anaesthetists (Association des Neuro-Anesthésistes Réanimateurs de Langue Francaise, ANARLF), the French Neuro-Vascular Society (Société Francaise de Neuro-Vasculaire, SFNV), the French Neuro-Radiology Society (Société Francaise de Neuro-Radiologie, SFNR) and the French Study Group on Haemostasis and Thrombosis (Groupe Français d'Études sur l'Hémostase et la Thrombose, GFHT) was convened, under the supervision of two expert coordinators from the SFAR and the ANARLF. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were required to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence. METHODS Four fields were defined prior to the literature search: (1) Peri-procedural management, (2) Prevention and management of secondary brain injuries, (3) Management of antiplatelet and anticoagulant treatments, (4) Post-procedural management and orientation of the patient. Questions were formulated using the PICO format (Population, Intervention, Comparison, and Outcomes) and updated as needed. Analysis of the literature was then conducted and the recommendations were formulated according to the GRADE methodology. RESULTS The SFAR/ANARLF/SFNV/SFNR/GFHT guideline panel drew up 18 recommendations regarding anaesthetic management of mechanical thrombectomy procedures. Due to a lack of data in the literature allowing to conclude with high certainty on relevant clinical outcomes, the experts decided to formulate these guidelines as "Professional Practice Recommendations" (PPR) rather than "Formalized Expert Recommendations". After two rounds of rating and several amendments, a strong agreement was reached on 100% of the recommendations. No recommendation could be formulated for two questions. CONCLUSIONS Strong agreement among experts was reached to provide a sizable number of recommendations aimed at optimising anaesthetic management for thrombectomy in patients suffering from stroke.
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Li W, Sui X, Li C, Zhao W, Yuan S, Dou S, Han G, Ji K, Ma Q, Ji X. Emergency Angioplasty or Stenting for Stroke Patients with Intracranial Atherosclerotic Large Vessel Occlusion. J Atheroscler Thromb 2023; 30:160-169. [PMID: 35466122 PMCID: PMC9925205 DOI: 10.5551/jat.63381] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
AIM Mechanical thrombectomy (MT) has become the gold standard for the treatment of large vessel occlusion (LVO) in acute ischemic stroke. However, it remains controversial whether emergency angioplasty or stenting in patients with intracranial atherosclerotic stenosis (ICAS) should be adopted. Thus, we performed a retrospective analysis of clinical data to determine whether emergency angioplasty or stenting is necessary. METHODS We retrospectively analyzed data from patients undergoing MT with ICAS-related LVO of the acute anterior circulation between 2017 and 2019. Eligible patients were divided into two treatment groups: those who received rescue angioplasty or stenting [Patients treated with rescue angioplasty or stenting (PTAS) group] and those who received thrombectomy alone (non-PTAS group). The primary outcomes were good prognosis at 90 days (mRS: 0-2). Mortality, symptomatic intracranial hemorrhage, and reocclusion rate were evaluated as secondary outcomes. RESULTS A total of 184 patients with severe stenosis after MT were enrolled, including 64 patients receiving rescue angioplasty or stenting and 120 patients without rescue angioplasty or stenting. Compared with the non-PTAS group, a better functional outcome (mRS0-2) (51.6% vs. 35.0%, adjusted odds ratio: 2.11, 95% confidence interval [CI]: 1.22-4.29; P=0.02), lower 7-day National Institutes of Health Stroke Scale [6 (3-12.75) vs. 10 (4-16); P=0.04], lower 24-h neurological deterioration rate (7.8% vs. 21.7%, P=0.02), and lower 24-h reocclusion rate were observed in the PTAS group (6.3% vs. 17.5%, P=0.03). There were no significant differences in mortality or incidence of symptomatic intracerebral hemorrhage. CONCLUSION Emergency angioplasty or stenting could be a safe and feasible therapeutic option with better outcomes for stroke patients with ICAS-related LVO.
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Affiliation(s)
- Weili Li
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China,Cerebrovascular Diseases Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China,Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xueqin Sui
- Department of General Medicine, Affiliated Hospital of Weifang Medical University, Shandong province, China
| | - Cong Li
- Department of Neurology, Weifang People’s Hospital, Shandong province, China
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Shuhua Yuan
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China,Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Shoutan Dou
- Department of Neurology, Affiliated Hospital of Weifang Medical University, Shandong province, China
| | - Guosheng Han
- Department of Neurology, Affiliated Hospital of Weifang Medical University, Shandong province, China
| | - Kangxiang Ji
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China,Cerebrovascular Diseases Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China,Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
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17
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Ni H, Hang Y, Wang CD, Liu S, Jia ZY, Shi HB, Zhao LB. Balloon Angioplasty Combined with Tirofiban as a First-Line Rescue Treatment After Failed Mechanical Thrombectomy for Middle Cerebral Artery Occlusion with Underlying Atherosclerosis. World Neurosurg 2022; 166:e306-e312. [PMID: 35809841 DOI: 10.1016/j.wneu.2022.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The standard rescue modality for patients with intracranial atherosclerotic stenosis after failed mechanical thrombectomy (MT) is not well established. We evaluated the safety and efficacy of balloon dilation in combination with tirofiban as the first-line salvage therapy when MT failed in these patients. METHODS We retrospectively analyzed the records of 47 patients admitted between January 2018 and June 2021, with middle cerebral artery atherosclerotic occlusion, who underwent balloon angioplasty in combination with tirofiban as the first-line salvage therapy after the failure of MT. The recanalization outcome, procedure-related complications, symptomatic intracranial hemorrhage, and functional outcome at 90 days were reviewed. RESULTS Recanalization with a modified Thrombolysis in Cerebral Infarction grade of 2b-3 was achieved in 41 (87.2%) of the 47 patients. Acute stents were deployed in another 6 patients who did not achieve successful re-perfusion after balloon angioplasty. Successful recanalization was achieved in 3 of them. One patient (2.1%, 1/47) experienced re-occlusion several days later due to the withdrawal of antiplatelet therapy for parenchymal hematoma. Seven patients (14.9%, 7/47) underwent stent angioplasty in the stable stage (range: 1-2 months) because severe residual stenosis was detected on follow-up imaging. There was only one event of periprocedural complication, namely ectopic migration of emboli. The good functional outcome rate was 55.3% (26/47), without the events of symptomatic intracranial hemorrhage and mortality. CONCLUSIONS Balloon angioplasty in combination with tirofiban is safe and effective for middle cerebral artery atherosclerotic occlusion after the failure of MT.
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Affiliation(s)
- Heng Ni
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yu Hang
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Chen-Dong Wang
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Sheng Liu
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Zhen-Yu Jia
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China.
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18
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Zhang Y, Zhang L, Zhang Y, Li Z, Zhang Y, Xing P, Chen W, Wang S, Li T, Yang P, Liu J. Endovascular Recanalization for Acute Internal Carotid Artery Terminus Occlusion: A Subgroup Analysis From the Direct-MT Trial. Neurosurgery 2022; 91:596-603. [PMID: 35856942 PMCID: PMC9447436 DOI: 10.1227/neu.0000000000002085] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/23/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The efficacy of endovascular recanalization for internal carotid artery (ICA) terminus occlusion has not been completely evaluated. OBJECTIVE To investigate the efficacy of endovascular recanalization for ICA terminus occlusion. METHODS Data from Direct-MT, a randomized controlled trial, were applied. ICA terminus occlusions were diagnosed with preprocedure computed tomography angiography by the core laboratory. We dichotomized the ICA terminus occlusions into 2 groups (non-T and T) and analyzed the differences between them. Single-factor analysis and multiple logistic regression were applied to detect independent factors for clinical outcomes and futile recanalization. RESULTS The rates of first-pass effect, successful recanalization, good clinical outcome, mortality, and futile recanalization were 22.3% (50 of 224), 83.0% (181 of 224), 24.6% (55 of 224), 26.7% (60 of 224), and 69.6% (126 of 181), respectively. Baseline National Institutes of Health Stroke Scale (negative factor; odds ratio [OR] 0.89; 95% CI 0.84-0.95; P < .001), hypertension (negative factor; OR 0.38; 95% CI 0.18-0.80; P = .010), Alberta Stroke Program Early CT Score ≥ 6 (OR 3.68; 95% CI 1.29-10.5; P = .014), tirofiban use (OR 2.46; 95% CI 1.16-5.19; P = .018), first-pass effect (OR 2.87; 95% CI 1.28-6.41; P = .010), and final extended thrombolysis in cerebral infarction ≥ 2b (OR, 3.50; 95% CI 1.17-10.4; P = .024) were independent factors for good clinical outcome. Baseline National Institutes of Health Stroke Scale (OR 1.12; 95% CI 1.05-1.20; P = .004), Alberta Stroke Program Early CT Score < 6 (OR 4.68; 95% CI 1.51-14.5; P = .007), tirofiban use (negative factor; OR 0.39; 95% CI 0.18-0.86; P = .020), and first-pass effect (negative factor; OR 0.44; 95% CI 0.19-0.99; P = .047) were independent factors for futile recanalization. CONCLUSION More efforts in modifiable factors should be made to improve the efficacy of endovascular recanalization for better clinical outcomes and less futile recanalization in ICA terminus occlusions.
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Affiliation(s)
- Yingying Zhang
- Department of Neurology, Fudan University Huadong Hospital, Shanghai, China
| | - Lei Zhang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Department of Neurology, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zifu Li
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongxin Zhang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Pengfei Xing
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Wenhuo Chen
- Department of Neurology, Fujian Medical University Zhangzhou Hospital, Zhangzhou, China
| | - Shouchun Wang
- Department of Neurology, Jilin University First affiliated Hospital, Changchun, China
| | - Tianxiao Li
- Department of Radiology, Zhenzhou University Henan Provincial People's Hospital, Zhenzhou, China
| | - Pengfei Yang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Jianmin Liu
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
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Psychogios M, Brehm A, López-Cancio E, Marco De Marchis G, Meseguer E, Katsanos AH, Kremer C, Sporns P, Zedde M, Kobayashi A, Caroff J, Bos D, Lémeret S, Lal A, Arenillas JF. European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease. Eur Stroke J 2022; 7:III-IV. [PMID: 36082254 PMCID: PMC9446330 DOI: 10.1177/23969873221099715] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/22/2022] [Indexed: 07/22/2023] Open
Abstract
The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of patients with intracranial atherosclerotic disease (ICAD). The guidelines were prepared following the Standard Operational Procedure of the European Stroke Organisation guidelines and according to GRADE methodology. ICAD represents a major cause of ischemic stroke worldwide, and patients affected by this condition are exposed to a high risk for future strokes and other major cardiovascular events, despite best medical therapy available. We identified 11 relevant clinical problems affecting ICAD patients and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions. The first two questions refer to the asymptomatic stage of the disease, which is being increasingly detected thanks to the routine use of noninvasive vascular imaging. We were not able to provide evidence-based recommendations regarding the optimal detection strategy and management of asymptomatic ICAD, and further research in the field is encouraged as subclinical ICAD may represent a big opportunity to improve primary stroke prevention. The second block of PICOs (3-5) is dedicated to the management of acute large vessel occlusion (LVO) ischemic stroke caused by ICAD, a clinical presentation of this disease that is becoming increasingly relevant and problematic, since it is associated with more refractory endovascular reperfusion procedures. An operational definition of probable ICAD-related LVO is proposed in the guideline. Despite the challenging context, no dedicated randomized clinical trials (RCTs) were identified, and therefore the guideline can only provide with suggestions derived from observational studies and our expert consensus, such as the escalated use of glycoprotein IIb-IIIa inhibitors and angioplasty/stenting in cases of refractory thrombectomies due to underlying ICAD. The last block of PICOs is devoted to the secondary prevention of patients with symptomatic ICAD. Moderate-level evidence was found to recommend against the use of oral anticoagulation as preferred antithrombotic drug, in favor of antiplatelets. Low-level evidence based our recommendation in favor of double antiplatelet as the antithrombotic treatment of choice in symptomatic ICAD patients, which we suggest to maintain during 90 days as per our expert consensus. Endovascular therapy with intracranial angioplasty and or stenting is not recommended as a treatment of first choice in high-grade symptomatic ICAD (moderate-level evidence). Regarding neurosurgical interventions, the available evidence does not support their use as front line therapies in patients with high-grade ICAD. There is not enough evidence as to provide any specific recommendation regarding the use of remote ischemic conditioning in ICAD patients, and further RCTs are needed to shed light on the utility of this promising therapy. Finally, we dedicate the last PICO to the importance of aggressive vascular risk factor management in ICAD, although the evidence derived from RCTs specifically addressing this question is still scarce.
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Affiliation(s)
- Marios Psychogios
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
| | - Alex Brehm
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
| | - Elena López-Cancio
- Department of Neurology, Hospital
Universitario Central de Asturias, Oviedo, Spain
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Elena Meseguer
- Department of Neurology and Stroke
Center, Assistance Publique Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster
University and Population Health Research Institute, Hamilton, ON, Canada
| | - Christine Kremer
- Department of Neurology, Skåne
University Hospital, Malmö, Department of Clinical Sciences Lund University, Lund,
Sweden
| | - Peter Sporns
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
- Department of Neuroradiology,
University Clinic Hamburg Eppendorf, Hamburg, Germany
| | - Marialuisa Zedde
- Neurology Unit, Department of
Neuromotor Physiology, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio
Emilia, Italy
- Neurology Unit, Stroke Unit, Azienda
Unità Sanitaria Locale-IRCCS di Reggio Emilia, Italy
| | - Adam Kobayashi
- Department of Pharmacology and
Clinical Pharmacology, Institute of Medical Sciences, Faculty of Medicine –
Collegium Medicum Cardinal Stefan Wyszynski University in Warsaw, Poland
- Department of Neurology and Stroke
Unit, Mazovian Voivodeship Hospital in Siedlce, Poland
| | - Jildaz Caroff
- Department of Interventional
Neuroradiology – NEURI Brain Vascular Center, Bicêtre Hospital, Assistance Publique
Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Daniel Bos
- Department of Radiology and Nuclear
Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus
MC, Rotterdam, The Netherlands
| | | | - Avtar Lal
- European Stroke Organisation, Basel,
Switzerland
| | - Juan F Arenillas
- Stroke Program, Department of
Neurology, Hospital Clínico Universitario de Valladolid, Spain
- Clinical Neurosciences Research
Group, Department of Medicine, University of Valladolid, Spain
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20
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Long-Term Outcomes of Local Tirofiban Infusion for Intracranial Atherosclerosis-Related Occlusion. Brain Sci 2022; 12:brainsci12081089. [PMID: 36009153 PMCID: PMC9406202 DOI: 10.3390/brainsci12081089] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/12/2022] [Accepted: 08/13/2022] [Indexed: 11/17/2022] Open
Abstract
Local tirofiban infusion has been reported as a rescue strategy for intracranial atherosclerotic stenosis (ICAS)-related stroke. However, the long-term outcomes of local tirofiban infusion during endovascular reperfusion therapy (ERT) for ICAS-related stroke are still uncertain. This study aimed to investigate the long-term outcomes of local tirofiban infusion during ERT. We retrospectively analyzed acute patients with ICAS-related stroke who were treated with local tirofiban as a rescue strategy during ERT. The primary outcomes were ischemic stroke, transient ischemic stroke (TIA), and stroke-related death within 30 days. Secondary outcomes included ischemic stroke and TIA beyond 30 days and up to 2 years after ERT in the corresponding treated vessel, symptomatic brain hemorrhage, any stroke, and non-stroke-related death. During a median follow-up of 24.0 months, 12 patients developed an ischemic stroke and TIA (4 within 30 days and 8 afterward). The 1-year risk of stroke and TIA was 9.2% (95% confidence interval, 8.0–18.6%). This study demonstrates that 1-year outcomes of local tirofiban infusion were comparable to the results of intracranial stenting in patients with symptomatic ICAS. Local tirofiban infusion for ICAS-related stroke may be a feasible rescue strategy that can have a bridging role until the maximum effect of antiplatelet agents is achieved.
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21
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Han B, Ma T, Liu Z, Wu Y, Tan W, Sun S, Li X, Shao C, Tang D, Sun J. Efficacy and Safety of Tirofiban in Clinical Patients With Acute Ischemic Stroke. Front Neurol 2022; 12:785836. [PMID: 35211073 PMCID: PMC8860815 DOI: 10.3389/fneur.2021.785836] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/30/2021] [Indexed: 01/01/2023] Open
Abstract
Background Intravenous thrombolysis and endovascular thrombectomy have been approved for acute ischemic stroke (AIS). However, only a minority of patients received these treatments in China. We aimed to evaluate the efficacy and safety of tirofiban in patients with AIS who were not undergoing early recanalization treatments. Methods Patients with mild-to-moderate stroke [National Institutes of Health Stroke Scale (NIHSS) score, 4–15] were enrolled in this study. Patients due to cardiogenic embolism were excluded. Eligible patients within 12 h from symptom onset were randomly assigned (1:1) to receive tirofiban (a loading dose of 0.4 μg/kg/min over 30 min and a maintenance dose of 0.1 μg/kg/min up to 48 h) followed by regular treatment or to receive regular treatment (aspirin at a dose of 100 mg per day for 90 days) (control). The primary outcome was the proportion of favorable functional outcomes at 90 days [defined as the modified Rankin Scale (mRS) score of 0–2]. The secondary outcomes included a shift in the distribution of the mRS scores at 90 days and the NIHSS score at 24 h and 7 days. The primary safety outcome was symptomatic intracranial hemorrhage (sICH) within 7 days after tirofiban treatment. Results A total of 380 eligible patients were randomly assigned to the tirofiban group (n = 190) or the control group (n = 190). The proportion of favorable functional outcomes was higher in the tirofiban group (79.1%) than that in the control group (67.8%) at 90 days [odds ratio (OR), 1.80; 95% CI, 1.12–2.90; p = 0.0155]. An improvement was also observed in the overall distribution of the 90-day mRS scores (adjusted common OR, 2.31; 95% CI, 1.58–3.39; p < 0.0001). Additionally, the median NIHSS score was lower in the tirofiban group than in the control group at 7 days (3 vs. 5, p < 0.0001). Next, we observed that the occurrence of sICH did not differ between the two groups. Conclusion Our trial supports that tirofiban was safe and effective and might be a remedial treatment for patients with AIS who did not receive recanalization treatments. Clinical Trial Registration http://www.chictr.org.cn/, identifier: ChiCTR2000031297.
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Affiliation(s)
- Bin Han
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Teng Ma
- Department of Neurology, Qingdao Hospital of Traditional Chinese Medicine (Qingdao Hiser Hospital), Qingdao, China
| | - Zhendong Liu
- Department of Neurology, Laixi People's Hospital, Laixi, China
| | - Yiqun Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Weiwei Tan
- Department of Neurology, Pingdu People's Hospital, Pingdu, China
| | - Shaoyang Sun
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xuemei Li
- Department of Neurology, Qingdao West Coast New Area Central Hospital, Qingdao, China
| | - Changyan Shao
- Department of Pharmacology, Feixian People's Hospital, Linyi, China
| | - Duyong Tang
- Department of Neurology, Pingdu Third People's Hospital, Pingdu, China
| | - Jinping Sun
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China.,Department of Emergency Internal Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China.,National Engineering and Technology Research Center of Chirality Pharmaceutical, Linyi, China
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22
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Lee JS, Lee SJ, Hong JM, Alverne FJAM, Lima FO, Nogueira RG. Endovascular Treatment of Large Vessel Occlusion Strokes Due to Intracranial Atherosclerotic Disease. J Stroke 2022; 24:3-20. [PMID: 35135056 PMCID: PMC8829471 DOI: 10.5853/jos.2021.01375] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 12/08/2021] [Indexed: 11/23/2022] Open
Abstract
Mechanical thrombectomy (MT) has become the gold-standard for patients with acute large vessel occlusion strokes (LVOS). MT is highly effective in the treatment of embolic occlusions; however, underlying intracranial atherosclerotic disease (ICAD) represents a therapeutic challenge, often requiring pharmacological and/or mechanical rescue treatment. Glycoprotein IIb/IIIa inhibitors have been suggested as the best initial approach, if reperfusion can be achieved after thrombectomy, with angioplasty and/or stenting being reserved for the more refractory cases. In this review, we focus on the therapeutic considerations surrounding the endovascular treatment of ICAD-related acute LVOS.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Seong-Joon Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | | | | | - Raul G. Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, UPMC Stroke Institute, Pittsburg, PA, USA
- Correspondence: Raul G. Nogueira Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, UPMC Stroke Institute, C-400 PUH, 200 Lothrop Street, Pittsburgh, PA 15213, USA Tel: +1-412-647-8080 Fax: +1-412-647-8445 E-mail:
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23
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Park HK, Ko SB, Jung KH, Jang MU, Kim DH, Kim JT, Choi JC, Jeong HS, Kim C, Heo JH, Rha JH, Kwon SU, Kim JS, Lee BC, Bae HJ, Yoon BW, Hong KS. 2022 Update of the Korean Clinical Practice Guidelines for Stroke: Antithrombotic Therapy for Patients with Acute Ischemic Stroke or Transient Ischemic Attack. J Stroke 2022; 24:166-175. [PMID: 35135073 PMCID: PMC8829490 DOI: 10.5853/jos.2021.02628] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/04/2021] [Indexed: 11/11/2022] Open
Abstract
Antithrombotic therapy is a cornerstone of acute ischemic stroke (AIS) management and secondary stroke prevention. Since the first version of the Korean Clinical Practice Guideline (CPG) for stroke was issued in 2009, significant progress has been made in antithrombotic therapy for patients with AIS, including dual antiplatelet therapy in acute minor ischemic stroke or high-risk transient ischemic stroke and early oral anticoagulation in AIS with atrial fibrillation. The evidence is widely accepted by stroke experts and has changed clinical practice. Accordingly, the CPG Committee of the Korean Stroke Society (KSS) decided to update the Korean Stroke CPG for antithrombotic therapy for AIS. The writing members of the CPG committee of the KSS reviewed recent evidence, including clinical trials and relevant literature, and revised recommendations. A total of 35 experts were invited from the KSS to reach a consensus on the revised recommendations. The current guideline update aims to assist healthcare providers in making well-informed decisions and improving the quality of acute stroke care. However, the ultimate treatment decision should be made using a holistic approach, considering the specific medical conditions of individual patients.
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Affiliation(s)
- Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Min Uk Jang
- Department of Neurology, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - Hye Seon Jeong
- Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Chulho Kim
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Ji Hoe Heo
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joung-Ho Rha
- Department of Neurology, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
| | - Sun U. Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong S. Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Byung-Woo Yoon
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Korea
- Correspondence: Keun-Sik Hong Department of Neurology, Inje University Ilsan Paik Hospital, College of Medicine, Inje University, 170 Juhwa-ro, Ilsanseogu, Goyang 10380, Korea Tel: +82-31-910-7680 Fax: +82-31-913-7368 E-mail:
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Cai L, Yu X, Yu J, Xu J, Xu L, Ling C, Lou M, Yu C, Qian C. Can Tirofiban Improve the Outcome of Patients With Acute Ischemic Stroke: A Propensity Score Matching Analysis. Front Neurol 2021; 12:688019. [PMID: 34589044 PMCID: PMC8475187 DOI: 10.3389/fneur.2021.688019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/28/2021] [Indexed: 02/02/2023] Open
Abstract
Objective: To evaluate the efficacy and safety of tirofiban for patients with acute ischemic stroke (AIS), especially posterior circulation stroke (PCS). Methods: We enrolled consecutive patients with AIS who suffered large artery occlusion (LAO) and underwent mechanical thrombectomy (MT) between January 2016 and May 2020. Patients were divided into two groups according to whether tirofiban was used during MT. The primary efficacy outcome was a favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0–2 at 3 months. The safety outcomes were the rate of mortality at 3 months and the presence of intracranial hemorrhage (ICH) and symptomatic intracranial hemorrhage (sICH). Cohorts were balanced using 1:1 propensity score matching (PSM). Subgroup analysis was further performed to compare the efficacy and safety of tirofiban between the anterior circulation stroke (ACS) and PCS groups. Results: A total of 292 patients were eligible for this study and divided into the tirofiban group (n = 51) and the no-tirofiban group (n = 241). In the propensity-score-matched cohort, the tirofiban group had a higher rate of favorable outcomes than the no-tirofiban group (49.0 vs. 25.5%, p = 0.014), and the mortality at 3 months showed a greater downward trend in the tirofiban group than the no-tirofiban group (15.6 vs. 33.3% p = 0.064). The risk of sICH and ICH was the same between the tirofiban and control groups (17.6 vs. 27.4% p = 0.236, 31.3 vs. 45.1% p = 0.154, respectively). Tirofiban use was predictive of favorable outcomes [adjusted odds ratio (aOR) = 2.87, 95% confidence interval (CI) 1.52–6.44, p = 0.043] after multiple logistic regression analysis. Subgroup analysis revealed that tirofiban use was significantly associated with favorable outcomes in ACS (aOR = 3.66, 95% CI 1.24–5.22, p = 0.019) but not in PCS (aOR = 1.12, 95% CI 0.47–7.52, p = 0.570). Conclusion: We demonstrated that tirofiban may be associated with improving favorable outcome for the AIS patients who underwent MT, without increasing ICH or sICH. Furthermore, our results indicated that for PCS patients tirofiban may not be associated with favorable outcome, and more comprehensive randomized controlled trials are needed to confirm this finding.
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Affiliation(s)
- Lingxin Cai
- Department of Neurological Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaobo Yu
- Department of Neurological Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jun Yu
- Department of Neurological Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jing Xu
- Department of Neurological Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Liang Xu
- Department of Neurological Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Chenhan Ling
- Department of Neurological Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Cheng Yu
- Department of Neurosurgery, The Second People's Hospital, Quzhou, China
| | - Cong Qian
- Department of Neurological Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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25
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Jang SH, Sohn SI, Park H, Lee SJ, Kim YW, Hong JM, Kim CH, Choi JW, Kang DH, Kim YS, Hwang YH, Lee JS, Hong JH. The Safety of Intra-arterial Tirofiban during Endovascular Therapy after Intravenous Thrombolysis. AJNR Am J Neuroradiol 2021; 42:1633-1637. [PMID: 34301637 DOI: 10.3174/ajnr.a7203] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/07/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The safety and efficacy of tirofiban during endovascular therapy in patients undergoing intravenous thrombolysis with recombinant IV tPA remain unclear. This study aimed to investigate the safety and efficacy of intra-arterial tirofiban use during endovascular therapy in patients treated with IV tPA. MATERIALS AND METHODS Using a multicenter registry, we enrolled patients with acute ischemic stroke who underwent endovascular therapy. Safety outcomes included postprocedural parenchymal hematoma type 2 and/or thick subarachnoid hemorrhage, intraventricular hemorrhage, and 3-month mortality. Efficacy outcomes included the successful reperfusion rate, postprocedural reocclusion, and good outcomes at 3 months (mRS scores of 0-2). The tirofiban effect on the outcomes was evaluated using a multivariable analysis while adjusting for potential confounders. RESULTS Among enrolled patients, we identified 314 patients with stroke (279 and 35 patients in the no tirofiban and tirofiban groups, respectively) due to an intracranial artery occlusion who underwent endovascular therapy with intravenous thrombolysis. A multivariable analysis revealed no association of intra-arterial tirofiban with postprocedural parenchymal hematoma type and/or thick subarachnoid hemorrhage (adjusted OR, 1.07; 95% CI, 0.20-4.10; P = .918), intraventricular hemorrhage (adjusted OR, 0.43; 95% CI, 0.02-2.85; P = .467), and 3-month mortality (adjusted OR, 0.38; 95% CI, 0.04-1.87; P = .299). Intra-arterial tirofiban was not associated with good outcome (adjusted OR, 2.22; 95% CI, 0.89 -6.12; P = .099). CONCLUSIONS Using intra-arterial tirofiban during endovascular therapy after IV tPA could be safe.
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Affiliation(s)
- S H Jang
- From the Departments of Neurology (S.H.J., S.-I.S., H.P., J.-H.H.)
| | - S-I Sohn
- From the Departments of Neurology (S.H.J., S.-I.S., H.P., J.-H.H.)
| | - H Park
- From the Departments of Neurology (S.H.J., S.-I.S., H.P., J.-H.H.)
| | - S-J Lee
- Department of Neurology (S.-J.L., J.M.H., J.S.L.)
| | - Y-W Kim
- Department of Neurology (Y.-W.K., Y.-H.H.)
| | - J M Hong
- Department of Neurology (S.-J.L., J.M.H., J.S.L.)
| | - C-H Kim
- Neurosurgery (C.-H.K.), School of Medicine Keimyung University, Daegu, South Korea
| | - J W Choi
- Radiology (J.W.C.), School of Medicine, Ajou University, Suwon, South Korea
| | | | - Y-S Kim
- Radiology (Y.-S.K.), School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Y-H Hwang
- Department of Neurology (Y.-W.K., Y.-H.H.)
| | - J S Lee
- Department of Neurology (S.-J.L., J.M.H., J.S.L.)
| | - J-H Hong
- From the Departments of Neurology (S.H.J., S.-I.S., H.P., J.-H.H.)
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26
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Zhao W, Xu J, Li S, Liu G, Wu L, Li C, Wu C, Ren C, Chen J, Duan J, Wang R, Song H, Ma Q, Ji X. Low-dose tirofiban is associated with reduced in-hospital mortality in cardioembolic stroke patients treated with endovascular thrombectomy. J Neurol Sci 2021; 427:117539. [PMID: 34153842 DOI: 10.1016/j.jns.2021.117539] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/24/2021] [Accepted: 06/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Whether tirofiban is safe and effective in cardioembolic stroke patients treated with endovascular thrombectomy (EVT) remains unknown; this study evaluated the safety and efficacy of low-dose tirofiban in this patients population. METHODS This study was a prospective registry study. Patients with cardioembolic stroke undergoing EVT from January 2013 to December 2020 were treated with EVT alone or EVT plus low-dose tirofiban. The primary outcome was symptomatic intracerebral hemorrhage (sICH) prior to discharge. The secondary outcomes included reocclusion, in-hospital mortality, and 3-month functional outcomes. RESULTS Overall, 288 patients were recruited and 117 received low-dose tirofiban; 137 patients (47.6%) experienced ICH, 42 patients (14.6%) were sICH, and 23 patients (8%) were fatal ICH. Thirteen patients (11.1%) receiving tirofiban and 29 patients (17.0%) not receiving tirofiban experienced sICH (p = 0.167). Reocclusion occurred in nine patients (7.7%) receiving tirofiban and 15 patients (8.8%) not receiving tirofiban (p = 0.745). The rates of hernia (6.8% versus 20.5%) and decompressive craniectomy (2.6% versus 11.7%) were significantly lower in patients receiving tirofiban (p < 0.01). At 3-month follow-up, functional independence was achieved in 39 patients(33.3%) receiving tirofiban and 43 patients (25.1%) not receiving tirofiban (p = 0.131). Tirofiban was associated with lower odds of in-hospital mortality (3.4% versus 12.3%; adjusted odds ratio, 0.16; 95% confidence interval, 0.03-0.81; adjusted p = 0.027). CONCLUSIONS In patients with cardioembolic stroke undergoing EVT, tirofiban is not associated with higher sICH, it seems to lead to lower odds of in-hospital death. Further investigations are needed to confirm these results and to determine the optimal treatment protocols of tirofiban.
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Affiliation(s)
- Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China; Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Jiali Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Sijie Li
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guiyou Liu
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Longfei Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Clinical Stroke Research Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Changhong Ren
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiangang Duan
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ruixian Wang
- Department of Neurology, Tianjin Beichen Traditional Chinese Medicine Hospital, Tianjin, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China; Clinical Stroke Research Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China; Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Lee JS, Hwang YH, Sohn SI. Factors Contributing to an Efficacious Endovascular Treatment for Acute Ischemic Stroke in Asian Population. Neurointervention 2021; 16:91-110. [PMID: 33765729 PMCID: PMC8261106 DOI: 10.5469/neuroint.2020.00339] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 02/19/2021] [Indexed: 12/13/2022] Open
Abstract
Although randomized control trials about endovascular treatment (EVT) of emergent large vessel occlusion (LVO) have demonstrated the success of mechanical thrombectomy as the choice of treatment, a wide range of caveats remain unaddressed. Asian patients were rarely included in the trials, thereby raising the question of whether the treatment could be generalized. In addition, there remains a concern on the feasibility of the method with respect to its application against intracranial atherosclerosis (ICAS)-related LVO, frequently observed in the Asian population. It is important to include evidence on ICAS LVO from Asian countries in the future for a comprehensive understanding of LVO etiology. Besides the issues with EVT, prognostic concerns in diabetes patients, acute kidney injury following EVT, neuroprotective management against reperfusion injury, and other peri-EVT issues should be considered in clinical practice. In the current article, we present an in-depth review of the literature that revises information pertaining to such concerns.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Kyemyung University School of Medicine, Daegu, Korea
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28
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Lee SJ, Park SY, Hong JM, Choi JW, Kang DH, Kim YW, Kim YS, Hong JH, Kim CH, Yoo J, Nogueira RG, Hwang YH, Sohn SI, Lee JS. Etiological Approach to Understanding Recanalization Failure in Intracranial Large Vessel Occlusion and Thrombectomy: Close to Embolism but Distant From Atherosclerosis. Front Neurol 2021; 11:598216. [PMID: 33536994 PMCID: PMC7848124 DOI: 10.3389/fneur.2020.598216] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/10/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction: In patients with intracranial large vessel occlusion (LVO) who undergo endovascular treatment (EVT), recanalization failure may be related to intracranial atherosclerotic stenosis (ICAS). We evaluated whether the risk factors of recanalization failure could possibly be a marker of ICAS among various types of LVO. Methods: From a multicenter registry, patients with middle cerebral artery M1 segment occlusions who underwent thrombectomy within 24 h were included. Based on the on-procedure and post-procedure angiographic findings, patients were classified into embolic, ICAS-related, tandem occlusion, and recanalization failure groups. Recanalization failure was defined if the occluded vessel could not be recanalized by stent retrieval, contact aspiration, or local lytics treatment. Risk factors, imaging markers, and EVT methods were compared between groups. Results: Among 326 patients, 214 were classified as embolism, 76 as ICAS, 16 as tandem, and 20 as recanalization failure. The group with recanalization failure showed higher scores on the National Institutes of Health Stroke Scale (NIHSS) (median, 16.0 vs. 14.5 vs. 14.0 vs. 17.0, p = 0.097), frequent atrial fibrillation (59.3 vs. 18.4 vs. 0 vs. 40.0% p < 0.001), and elevation in erythrocyte sedimentation rate (ESR) (14.5 ± 15.7 vs. 15.0 ± 14.1 vs. 21.2 ± 19.5 vs. 36.0 ± 32.9, p < 0.001) among the groups. The rate of computed tomography angiography-based truncal-type occlusion in recanalization failure group was not as high as that in the ICAS group (8.1 vs. 37.5 vs. 0 vs. 16.7%, p < 0.001). Balloon guide catheters (BGC) were less frequently utilized in the recanalization failure group as compared to their use in the other groups (72.0 vs. 72.4 vs. 62.5 vs. 30.0%, p = 0.001). In the multivariable analysis, initial higher NIHSS [odds ratio (OR), 1.11 95% confidence interval (CI), 1.01–1.22 p = 0.027], higher ESR (OR, 1.03 CI, 1.01–1.05 p = 0.006), and non-use of BGCs (OR, 3.41 CI, 1.14–10.17 p = 0.028) were associated with recanalization failure. In M1 occlusions, the predominant mechanism of recanalization failure was presumed to be embolic in 80% and due to ICAS in 20%. Conclusion: The analysis of recanalization failures does not suggest an underlying predominant ICAS mechanism. Sufficient utilization of thrombectomy devices and procedures may improve the rates of recanalization.
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Affiliation(s)
- Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - So Young Park
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Jin Wook Choi
- Department of Radiology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Dong-Hun Kang
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, South Korea.,Department of Radiology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Won Kim
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, South Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Sun Kim
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Joonsang Yoo
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea.,Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Raul G Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, United States
| | - Yang-Ha Hwang
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
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Prediction of Infarct Growth and Neurological Deterioration in Patients with Vertebrobasilar Artery Occlusions. J Clin Med 2020; 9:jcm9113759. [PMID: 33266388 PMCID: PMC7700123 DOI: 10.3390/jcm9113759] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/18/2020] [Accepted: 11/21/2020] [Indexed: 12/28/2022] Open
Abstract
We aimed to identify predictors of infarct growth and neurological deterioration (ND) in vertebrobasilar occlusions (VBOs) with a focus on clinical-core mismatch. From 2010 to 2018, VBO patients were selected from a university hospital registry. In total, 138 VBO patients were included. In these patients, a posterior circulation Alberta Stroke Program Early CT score (PC-ASPECTS) less than 6 was associated with futile outcome. Within patients with feasible cores, a decrease in PC-ASPECTS score of 2 or more on follow-up imaging was classified as infarct growth and could be predicted by a National Institutes of Health Stroke Scale (NIHSS) mental status subset of 1 or higher (odds ratio (OR): 3.34, 95% confidence interval (CI) (1.19-9.38), p = 0.022). Among the 73 patients who did not undergo reperfusion therapy, 13 patients experienced ND (increase in discharge NIHSS score of 4 or more compared to the initial presentation). Incomplete occlusion (vs. complete occlusion, OR 6.17, 95% CI (1.11-34.25), p = 0.037), poorer collateral status (BATMAN score, OR: 1.91, 95% CI (1.17-3.48), p = 0.009), and larger infarct cores (PC-ASPECTS, OR: 1.96, 95% CI (1.11-3.48), p = 0.021) were predictive of ND. In patients with VBO, an initial PC-ASPECTS of 6 or more, but with a decrease in the mental status subset of 1 or more can predict infarct growth, and may be used as a criterion for clinical-core mismatch. ND in VBO patients presenting with milder symptoms can be predicted by incomplete occlusion, poor collaterals, and larger infarct cores.
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