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Qureshi AI, Huang W, Lobanova I, Ishfaq MF, French BR, Siddiq F, Gomez CR. Clopidogrel Bolus is Inferior to Sustained Clopidogrel Pretreatment in Patients Undergoing Carotid Artery Stent Placement. Neurosurgery 2022; 90:717-724. [PMID: 35271515 DOI: 10.1227/neu.0000000000001899] [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: 06/08/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Clopidogrel bolus is an option used before carotid artery stent (CAS) placement when sustained clopidogrel pretreatment is not used. OBJECTIVE To compare the effect of clopidogrel bolus (450 mg administered ≥4 hours) with sustained clopidogrel pretreatment (48 hours or greater) before CAS among patients recruited in the Carotid Revascularization Endarterectomy versus Stenting Trial. METHODS We compared the rates of primary end point (either any stroke, myocardial infarction, or death during the periprocedural period or any ipsilateral stroke within 4 years) between patients who received clopidogrel bolus and those who received sustained clopidogrel pretreatment using Cox proportional hazards analysis after adjusting for age, sex, symptomatic status, and initial severity of stenosis (≥70% vs <70%) over 4 years. RESULTS The rate of periprocedural stroke (7.3% vs 3.4%, P = .03) and primary end point (11.3% vs 5.9%, P = .02) was significantly higher among patients who received clopidogrel bolus. The risk of primary end point was significantly higher in patients who received clopidogrel bolus (hazards ratio 1.9, 95% CI 1.1-3.4, P = .02) after adjusting for potential confounders. The overall mean (±standard deviation) primary end point-free survival based on Kaplan-Meier analysis was 7.0 ± 0.2 years for patients who received clopidogrel bolus and 8.9 ± 0.1 years for those who received sustained clopidogrel pretreatment (log-rank test P = .011). CONCLUSION Clopidogrel bolus was associated with higher rates of adverse outcomes compared with sustained clopidogrel pretreatment in patients who underwent CAS. Therefore, clopidogrel bolus may not be equivalent to sustained clopidogrel pretreatment.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Wei Huang
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Iryna Lobanova
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - M Fawad Ishfaq
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Brandi R French
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Farhan Siddiq
- Division of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
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Horev A, Zlotnik Y, Borodetsky V, Biederko R, Star M, Zvenigorodsky V, Shelef I, Ifergane G. Adjunctive treatment with low dose intra-arterial eptifibatide and intravenous aspirin during carotid stenting: A case series. J Clin Neurosci 2020; 84:29-32. [PMID: 33485594 DOI: 10.1016/j.jocn.2020.11.048] [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: 09/11/2020] [Revised: 11/03/2020] [Accepted: 11/27/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE According to most guidelines, medical protocol for carotid stenting includes the administration of oral Aspirin and Clopidogrel at least four days before the procedure, with intraprocedural intravenous (IV) heparin. Some publications have also reported the safety of adding glycoprotein 2b/3a inhibitors to the protocol. In this retrospective study, we evaluate the safety of a new medication protocol that includes IV aspirin and intra-arterial Eptifibatide (glycoprotein 2b/3a inhibitor) during carotid stenting. All patients who underwent carotid stenting at Soroka University Medical Center between January 2015 and May 2020 were included (emergent cases were excluded). We divided patients into two groups-patients treated under the standard protocol, and patients treated under the new protocol. In the latter, patients received both the standard protocol regimen, as well as 150 mg IV aspirin immediately before stenting, and a slow intra-arterial injection of 2-3 mg Eptifibatide (glycoprotein 2b/3a antagonist) immediately after stenting. Forty-four patients were treated according to the standard protocol (group 1), and 41 patients were treated according to the new protocol (group 2). In group 1, six patients had complications, while in group 2, no complications of any kind were noted (p = 0.027). The safety and possible efficacy of this novel protocol was preliminarily demonstrated in the present study. Future studies are needed to prove the safety and efficacy of a specific drug regimen that will further reduce the complication rates of carotid stenting.
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Affiliation(s)
- Anat Horev
- Neurology Department, Soroka University Medical Center, Beer-Sheva, Israel.
| | - Yair Zlotnik
- Neurology Department, Soroka University Medical Center, Beer-Sheva, Israel
| | | | - Ron Biederko
- Research Institute, Soroka University Medical Center, Beer-Sheva, Israel
| | - Michael Star
- Neurology Department, Soroka University Medical Center, Beer-Sheva, Israel
| | | | - Ilan Shelef
- Radiology Institute, Soroka University Medical Center, Beer-Sheva, Israel
| | - Gal Ifergane
- Neurology Department, Soroka University Medical Center, Beer-Sheva, Israel
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Park HR, Kim JH, Park S, Chang JC, Park SQ. National Trends in the Treatment of Ruptured Cerebral Aneurysms in Korea Using an Age-adjusted Method. J Korean Med Sci 2020; 35:e323. [PMID: 33045768 PMCID: PMC7550236 DOI: 10.3346/jkms.2020.35.e323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/04/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Two primary treatment methods are used for ruptured cerebral aneurysms, surgical clipping and endovascular coiling. In recent decades, endovascular coiling has shown remarkable progress compared to surgical clipping, along with technological developments. The aim of this study was to investigate the recent trends in treatments for ruptured cerebral aneurysms in Korea. METHODS The data were obtained from the National Health Insurance database. We evaluated the trends in endovascular coiling and surgical clipping for ruptured aneurysms for the period 2000-2017. We obtained the number of prescriptions with International Classification of Diseases, 9th Revision, clinical modification codes related to nontraumatic subarachnoid hemorrhage and prescription codes S4641/4642 for surgical clipping and M1661/1662 for endovascular coiling. The medical expenses for each prescription were also obtained. The primary outcomes included the cumulative number of patients, patient rates per 100,000 people, and the correlation between patient rates and the percentage of the population in each age group. RESULTS In the case of surgical clipping, there were no increasing or decreasing trends in the cumulative number of patients when the population/age group was ignored. When examining the trends in patient rates per 100,000 population at each year in male, there was no increasing or decreasing trend in the number of surgical clippings between the age groups, in spite of a decreasing tendency in the number of surgical clipping in male in their 40s and older than 60. In females, the surgical clipping rates tended to decrease only in patients older than 60 years, but there was no tendency to increase or decrease in the other ages. In contrast, the cumulative number of patients who underwent endovascular coiling for ruptured cerebral aneurysms increased year by year regardless of the population/age group. In both male and female, there was no increasing or decreasing trend only in the group aged 40 or younger and there was an increasing tendency in the rest of the age groups. In the trend of medical expenses, both the cost of surgical clipping and endovascular coiling showed increases. Specifically, the medical expense trend in endovascular coiling increased more rapidly than that for surgical clipping. CONCLUSION There was a significant increase in the proportion of patients with ruptured aneurysms undergoing endovascular coiling between 2010 and 2017, whereas the use of surgical clipping decreased. The endovascular coiling was significantly increased in all age groups and surgical clipping was decreased in all age groups, especially in patients under 50 years of age.
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Affiliation(s)
- Hye Ran Park
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae Heon Kim
- Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Suyeon Park
- Department of Biostatistics, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae Chil Chang
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sukh Que Park
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea.
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Patel RAG. State of the art in carotid artery stenting: trial data, technical aspects, and limitations. J Cardiovasc Transl Res 2014; 7:446-57. [PMID: 24771314 DOI: 10.1007/s12265-014-9567-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 04/13/2014] [Indexed: 10/25/2022]
Abstract
The volume of carotid artery stenting (CAS) safety and efficacy data has grown exponentially over the last decade. Recent comparative data with carotid endarterectomy, the utility of embolic protection devices, peri-procedural medications, basic technical aspects of CAS, developments in carotid stent design, potential complications of CAS, and complication risk factors are discussed in this review.
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Affiliation(s)
- Rajan A G Patel
- John Ochsner Heart & Vascular Institute, Ochsner Medical Center, 1514 Jefferson Hwy., New Orleans, LA, 70121, USA,
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Hussein HM, Emiru T, Georgiadis AL, Qureshi AI. Assessment of platelet inhibition by point-of-care testing in neuroendovascular procedures. AJNR Am J Neuroradiol 2013; 34:700-6. [PMID: 22422188 DOI: 10.3174/ajnr.a2963] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Antiplatelet agents are an important component of the preventive strategies currently used in clinical practice to minimize the risk of thromboembolic events during and after endovascular procedures. Because of the variability in the response to antiplatelet agents, measuring the degree of platelet inhibition may help identify and properly treat poor responders. POC testing is defined as diagnostic testing at or near the site of patient care. Knowledge of the specifics of these devices among practicing neurointerventionalists is relatively limited. In this article, the different POC devices available are presented, and their clinical utility in relation to endovascular procedures is discussed.
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Affiliation(s)
- H M Hussein
- Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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Allam H, Vora N, Edgell RC, Callison RC, Al Khalili Y, Storkan M, Alshekhlee A. How Safe is Eptifibatide during Urgent Carotid Artery Stenting? Front Neurol 2013; 4:4. [PMID: 23408773 PMCID: PMC3569662 DOI: 10.3389/fneur.2013.00004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/18/2013] [Indexed: 11/25/2022] Open
Abstract
Background: Glycoprotein IIB/IIIA inhibitors are occasionally utilized during carotid artery stenting (CAS) in the presence or absence of a visualized intra-operative thrombus. Objective: We assess the hemorrhagic and clinical outcomes associated with the use of eptifibatide during CAS. Methods: A retrospective analysis of prospectively collected data on patients with the diagnosis of carotid artery stenosis underwent CAS in a single center. We identified those who received intravenous eptifibatide intra-operatively and compared to the rest of the cohort. Hemorrhagic outcomes included intracerebral hemorrhage (ICH) or groin hematoma that occurred during the hospital stay. Results: In this analysis, 81 patients had CAS during a 3-year span; 16 of those had received 15 mg of intravenous eptifibatide intra-operatively. The mean age of the treated and untreated patients was similar (65.6 ± 13.4 versus 65.4 ± 10.2; P = 0.13). One patient (1.2%) in this series had ICH in the perioperative period that occurred in the non-eptifibatide group. Five patients (6.2%) in this series had groin hematoma; only one in the non-eptifibatide group required surgical repair. No mortality was reported and clinical outcomes including discharge modified Rankin scale, NIH stroke scale, as well as discharge destination were similar in both groups. A stratified analysis among those who underwent an urgent CAS showed no significant differences in the risks of hemorrhages or any clinical outcome (P > 0.05). Conclusion: The use of eptifibatide during CAS is safe. The risk of any hemorrhagic complication is rare in this series; however, a prospective study to validate this observation will be helpful.
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Affiliation(s)
- Hesham Allam
- Department of Neurology and Psychiatry, Souers Stroke Institute, St. Louis University St. Louis, MO, USA
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Qureshi AI, Hussein HM, El-Gengaihy A, Abdelmoula M, K Suri MF. CONCURRENT COMPARISON OF OUTCOMES OF PRIMARY ANGIOPLASTY AND OF STENT PLACEMENT IN HIGH-RISK PATIENTS WITH SYMPTOMATIC INTRACRANIAL STENOSIS. Neurosurgery 2008; 62:1053-60; discussion 1060-2. [PMID: 18580803 DOI: 10.1227/01.neu.0000325867.06764.3a] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota, USA.
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Qureshi AI, Hussein HM, Janjua N, Harris-Lane P, Ezzeddine MA. Postprocedure Intravenous Eptifibatide Following Intra-Arterial Reteplase in Patients with Acute Ischemic Stroke. J Neuroimaging 2008; 18:50-5. [DOI: 10.1111/j.1552-6569.2007.00185.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Zahn R, Ischinger T, Hochadel M, Mark B, Zeymer U, Jung J, Schramm A, Hauptmann KE, Seggewiss H, Janicke I, Mudra H, Senges J. Glycoprotein IIb/IIIa antagonists during carotid artery stenting:. Clin Res Cardiol 2007; 96:730-7. [PMID: 17593309 DOI: 10.1007/s00392-007-0551-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2006] [Accepted: 05/07/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Glycoprotein II b/IIIa antagonists (GPII b/IIIa-A) lower the periprocedural rate of ischemic events during high risk percutaneous coronary interventions. Their clinical impact on carotid artery stenting (CAS) remains to be determined. METHODS We analyzed data from the Carotid Artery Stent (CAS) Registry. RESULTS From 01/ 2000 to 06/2005 1322 CAS interventions were registered. In 94 (7.1%) procedures a GPII b/IIIa-A was used: abciximab in 8 cases (8.6%), tirofiban in 53 cases (57%) and eptifibatide in 32 cases (34.4%). The use of a GPII b/IIIa-A during CAS decreased significantly over time: from 17.6% in 2000 to 3% in 2005, p for trend <0.0001. The mean use of a GPII b/IIIa-A at the hospitals was 5.2%. More than 50% of the hospitals never used a GPII b/IIIa-A. There were no significant differences in baseline characteristics and concomitant diseases in CAS patients treated with GPII b/IIIa-A compared to those without GPII b/IIIa-A. A bilateral intervention was performed more often in patients treated with GPII b/IIIa-A (2.1 vs 0.2%, p = 0.04), a thrombus was more often visible (27 vs 12.4%, p <0.001) and an ulcer more frequently diagnosed (50 vs 37.5%, p = 0.03). There was no significant difference in the combined death or stroke rate between the two groups (5.3 vs 3.0%, p = 0.22, OR = 1.81, 95% CI: 0.69-4.72), which was confirmed by logistic regression analysis after adjusting for possible confounders (OR = 1.67, 95% CI: 0.62-4.46, p = 0.31). CONCLUSIONS Our data neither demonstrate a significant benefit nor a significant risk with the use of GPIIb/IIIa-A during CAS. However, only an adequately sized randomized controlled clinical trial could establish the real value of GPII b/IIIa-A during CAS. Until then, considering the potential increase in cerebral hemorrhage, we should not use GPII b/ IIIa-A routinely during CAS.
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Affiliation(s)
- R Zahn
- Kardiologie/Angiologie/Internistische Intensivmedizin, Klinikum Nürnberg, Breslauer Strasse 201, 90471 Nürnberg, Germany.
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AlKawi A, Kirmani JF, Nazli JN, Ezzeddine MA, Hanley DF, Qureshi AI. Management of recurrent cerebral arterial occlusion in a patient with cardiac decompensation. Neurocrit Care 2007; 6:139-45. [PMID: 17522797 DOI: 10.1007/s12028-007-0004-1] [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: 10/23/2022]
Abstract
We describe a woman with congestive heart failure who presented with acute cardiac decompensation followed by ischemic stroke. The management of the patient posed unique challenges for thrombolytic treatment (due to existing coagulopathy) and subsequent optimization of hemodynamic status. Issues related to rethrombosis and use of platelet glycoprotein IIB/IIIA inhibitors are also discussed.
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Affiliation(s)
- Ammar AlKawi
- Zeenat Qureshi Stroke Research Center, Department of Neurology and Neurosciences, University of Medicine and Dentistry of New Jersey (UMDNJ), 90 Bergen Street, DOC - 8100, Newark, NJ 07103, USA.
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Geraghty PJ, Oak J, Choi ET. Cardiogenic embolism producing crescendo transient ischemic attacks. Ann Vasc Surg 2005; 19:728-30. [PMID: 16027994 DOI: 10.1007/s10016-005-5424-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Lateralizing, repetitive transient ischemic attacks are characteristic of symptomatic carotid bifurcation atherosclerotic plaques. We report a case in which a cardiogenic embolus, after lodging at the left carotid bifurcation, produced crescendo episodes of expressive aphasia and mild right upper extremity weakness. Complete neurological recovery was achieved following emergent carotid embolectomy and endarterectomy. This case demonstrates that the laminar nature of internal carotid blood flow may result in the localization of embolic events to a single region of the cerebral vasculature, regardless of the source lesion in the carotid artery. The role of endoluminal techniques in the diagnosis and management of such lesions is discussed.
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Affiliation(s)
- Patrick J Geraghty
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8109, St. Louis, MO, 63110-1094, USA.
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Fiorella D, Thiabolt L, Albuquerque FC, Deshmukh VR, McDougall CG, Rasmussen PA. Antiplatelet Therapy in Neuroendovascular Therapeutics. Neurosurg Clin N Am 2005; 16:517-40, vi. [PMID: 15990042 DOI: 10.1016/j.nec.2005.03.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Our understanding of the pharmacology of antiplatelet therapy continues to evolve rapidly. Although the existing data are primarily generated in the setting of interventional and preventative cardiology studies, these data may be extrapolated to guide the rational application of these agents in neuroendovascular procedures. Platelet function testing represents an increasingly available and practical method by which to verify the adequacy of therapy and guide clinical decision making. The optimal application of these agents will undoubtedly improve the risk profile of neuroendovascular procedures, increase the success rate of acute stroke intervention, and facilitate more effective secondary stroke prevention.
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Affiliation(s)
- David Fiorella
- Cleveland Clinic Foundation, 9500 Euclid Avenue, S80, Cleveland, OH 44195, USA.
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Pancioli AM, Brott TG. Therapeutic potential of platelet glycoprotein IIb/IIIa receptor antagonists in acute ischaemic stroke: scientific rationale and available evidence. CNS Drugs 2004; 18:981-8. [PMID: 15584768 DOI: 10.2165/00023210-200418140-00003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Acute ischaemic stroke is the result of an abrupt interruption of focal cerebral blood flow. In the majority of cases, this interruption is caused by an acute thromboembolism. Based on clinical experience in the treatment of acute coronary syndromes, platelet glycoprotein (GP) IIb/IIIa receptor antagonists alone, in combination with reduced doses of thrombolytic agents, or as complementary therapy for short-term mechanical interventions merit consideration as a class of agents with potential use in ischaemic stroke. Research to date and extrapolation from the cardiac literature suggest significant, but as yet unproven, potential for the use of GP IIb/IIIa receptor antagonists in the treatment of acute ischaemic stroke. This potential exists both at the site of the thromboembolic occlusion and at the distal microvascular level. This article reviews the scientific rationale and available evidence for the potential use of platelet GP IIb/IIIa receptor antagonists in acute ischaemic stroke.
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Affiliation(s)
- Arthur M Pancioli
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio 45267-0769, USA.
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