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Pearce S, Maingard JT, Kuan Kok H, Barras CD, Russell JH, Hirsch JA, Chandra RV, Jhamb A, Thijs V, Brooks M, Asadi H. Antiplatelet Drugs for Neurointerventions: Part 2 Clinical Applications. Clin Neuroradiol 2021; 31:545-558. [PMID: 33646319 DOI: 10.1007/s00062-021-00997-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Abstract
Endovascular techniques have expanded to include balloon and stent-assistance, flow diversion and individualized endovascular occlusion devices, to widen the treatment spectrum for more complex aneurysm morphologies. While usually well-tolerated by patients, endovascular treatment of intracranial aneurysms carries the risk of complications, with procedure-related ischemic complications being the most common. Several antiplatelet agents have been studied in a neurointerventional setting for both prophylaxis and in the setting of intraprocedural thrombotic complications. Knowledge of these antiplatelet agents, evidence for their use and common dosages is important for the practicing neurointerventionist to ensure the proper application of these agents.Part one of this two-part review focused on basic platelet physiology, pharmacology of common antiplatelet medications and future directions and therapies. Part two focuses on clinical applications and evidence based therapeutic regimens.
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Affiliation(s)
- Samuel Pearce
- Department of Radiology, Western Health, 160 Gordon St, 3011, Footscray, Victoria, Australia. .,Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.
| | - Julian T Maingard
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Hong Kuan Kok
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Interventional Radiology Service, Northern Health Radiology, Melbourne, Victoria, Australia
| | - Christen D Barras
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jeremy H Russell
- Department of Neurosurgery, Austin Health, Melbourne, Victoria, Australia
| | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Imaging, Monash University, Melbourne, Victoria, Australia
| | - Ash Jhamb
- Interventional Neuroradiology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Austin Health, Melbourne, Victoria, Australia
| | - Mark Brooks
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Interventional Neuroradiology service, Radiology Department, Austin Health, Melbourne, Victoria, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Interventional Neuroradiology service, Radiology Department, Austin Health, Melbourne, Victoria, Australia
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Dornbos D, Katz JS, Youssef P, Powers CJ, Nimjee SM. Glycoprotein IIb/IIIa Inhibitors in Prevention and Rescue Treatment of Thromboembolic Complications During Endovascular Embolization of Intracranial Aneurysms. Neurosurgery 2019; 82:268-277. [PMID: 28472526 DOI: 10.1093/neuros/nyx170] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 03/10/2017] [Indexed: 11/13/2022] Open
Abstract
Thromboembolic complications remain a major risk of endovascular neurosurgery during the treatment of intracranial aneurysms, despite the use of therapeutic heparinization and oral antiplatelet therapy when indicated. Glycoprotein (GP) IIb/IIIa inhibitors target a nonredundant pathway of platelet aggregation following adhesion and activation. Initially established and implemented in the cardiovascular arena, this drug class has provided a new tool in the neurovascular armamentarium as well. Numerous case reports, case series, and retrospective reviews have evaluated the safety and efficacy of abciximab, eptifibatide, and tirofiban in the treatment of acute thromboembolic complications during the endovascular treatment of intracranial aneurysms. The use of this drug class has also been found to be beneficial as a prophylactic agent, providing ischemia protection during the placement of intracranial stents, flow diverters, and thrombogenic coils in the setting of subarachnoid hemorrhage and during elective aneurysmal embolization. While the current published literature clearly establishes efficacy and safety of GP IIb/IIIa inhibitors in the prevention of thromboembolic complications, there does not yet exist an established protocol for their administration in endovascular neurosurgery. This review provides a comprehensive evaluation of the current published literature pertaining to the use of all available GP IIb/IIIa inhibitors for thromboembolic complications, providing recommendations for dosing and administration of abciximab, eptifibatide, and tirofiban based on previously published rates of efficacy and intracranial hemorrhage.
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Affiliation(s)
- David Dornbos
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joel S Katz
- Department of Neurological Surgery, OhioHealth Grant and Riverside Medical Center, Columbus, Ohio
| | - Patrick Youssef
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ciarán J Powers
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Shahid M Nimjee
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Lin LM, Jiang B, Campos JK, Beaty NB, Bender MT, Tamargo RJ, Huang J, Colby GP, Coon AL. Abciximab (ReoPro) Dosing Strategy for the Management of Acute Intraprocedural Thromboembolic Complications during Pipeline Flow Diversion Treatment of Intracranial Aneurysms. INTERVENTIONAL NEUROLOGY 2018; 7:218-232. [PMID: 29765391 DOI: 10.1159/000486458] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/19/2017] [Indexed: 11/19/2022]
Abstract
Background Flow diversion with the Pipeline embolization device (PED) is an effective neuro-endovascular method and increasingly accepted for the treatment of cerebral aneurysms. Acute in situ thrombosis is a known complication of PED procedures. There is limited experience in the flow diversion literature on the use of abciximab (ReoPro) for the management of acute thrombus formation in PED cases. Methods Data were collected retrospectively on patients who received intra-arterial (IA) ReoPro with or without subsequent intravenous (IV) infusion during PED flow diversion treatment of intracranial aneurysms. Results A total of 30 cases in patients with a mean age of 56.7 years (range 36-84) and a mean aneurysm size of 8.6 mm (range 2-25) were identified to have intraprocedural thromboembolic complications during PED treatment. IA ReoPro was administered in all cases, with 20 cases receiving increments of 5-mg boluses and 10 cases receiving a 0.125 mg/kg IA bolus (half cardiac dosing). Complete or partial recanalization was achieved in 100% of the cases. IV ReoPro infusion at 0.125 μg/kg/min for 12 h was administered postprocedurally in 22 cases with a residual thrombus. Postprocedurally, 18 patients were transitioned from clopidogrel (Plavix) to prasugrel (Effient). The majority of the cases (23/30; 77%) were discharged home. Periprocedural intracranial hemorrhage was noted in 2 cases (7%) and radiographic infarct was noted in 4 cases (13%), with an overall mortality of 0% at the time of initial discharge. Clinical follow-up was available for 28/30 patients. The average duration of follow-up was 11.7 months, at which time 23/28 (82%) of the patients had a modified Rankin Scale score of 0. Conclusions IA ReoPro administration is an effective and safe rescue strategy for the management of acute intraprocedural thromboembolic complications during PED treatment. Using a dosing strategy of either 5-mg increments or a 0.125 mg/kg IA bolus (half cardiac dosing) can provide high rates of recanalization with low rates of hemorrhagic complications and long-term morbidity.
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Affiliation(s)
- Li-Mei Lin
- Department of Neurosurgery, University of California, Irvine School of Medicine, UC Irvine Medical Center, Orange, California, USA
| | - Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jessica K Campos
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Narlin B Beaty
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Murchison AG, Young V, Djurdjevic T, Cellerini M, Corkill R, Küker W. Stent placement in patients with acute subarachnoid haemorrhage: when is it justified? Neuroradiology 2018; 60:735-744. [PMID: 29644398 PMCID: PMC5995994 DOI: 10.1007/s00234-018-2020-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 04/02/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Endovascular stents are widely used for the elective treatment of cerebral aneurysms. Acute stenting is performed in the management of dissections, pseudo-aneurysms, broad-based aneurysms or as a 'bail out' measure after coil migration. The purpose of this study is to review the safety of using stents in acute subarachnoid haemorrhage. METHODS The stent registry of our institution was reviewed for procedures in patients with acute subarachnoid haemorrhage. Imaging studies were reviewed on the hospital's PACS system and the patients' notes were retrieved to assess complications and clinical outcomes. Procedures were analysed according to the type of stent, treatment indication, antiplatelet regime, complications and outcomes. RESULTS Between 2008 and 2016, 51 stents were placed during 50 stenting procedures in 49 patients with acute subarachnoid haemorrhage. This included 24 patients with saccular aneurysms, 10 with blister aneurysms, 10 dissections and five fusiform aneurysms. Stents were deployed in 'bail out' situations on eight occasions. In six cases, flow-diverting stents were used. Eighteen patients (37%) in the cohort suffered a stroke. Nine patients (18%) suffered persistent clinical deficits as a result of the stenting procedure, all but one of which occurred within 24 h. Two patients had a transient ischaemic episode, and there was evidence of asymptomatic ischaemia on imaging in four cases (8%). Five patients died, three (6%) as a result of procedural complications. Twelve patients (25%) required a further embolisation procedure. CONCLUSION The use of stents in acute subarachnoid haemorrhage incurs a considerable complication risk and should be reserved for exceptional circumstances.
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Affiliation(s)
- Andrew G Murchison
- Department of Neuroradiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Victoria Young
- Department of Neuroradiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Tanja Djurdjevic
- Department of Neuroradiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Martino Cellerini
- Department of Neuroradiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rufus Corkill
- Department of Neuroradiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Wilhelm Küker
- Department of Neuroradiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
- Nuffield Department of Clinical Neurosciences, University of Oxford, Headley Way, Oxford, OX3 9DU, UK.
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Nomura M, Mori K, Tamase A, Kamide T, Seki S, Iida Y, Shirokane K, Baba E, Tsuchiya A, Shima H. Thromboembolic complications during endovascular treatment of ruptured cerebral aneurysms. Interv Neuroradiol 2017; 24:29-39. [PMID: 29125027 DOI: 10.1177/1591019917739448] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background In cases of subarachnoid hemorrhage due to aneurysm rupture, the administration of an anticoagulant or antiplatelet agent involves the risk of rebleeding from the aneurysm. There is a possibility of inducing thromboembolic events during the endovascular embolization of ruptured cerebral aneurysms. Patients and methods From April 2006 to March 2017, we treated a total of 70 patients with ruptured cerebral aneurysms with an endovascular technique. Among them, five patients (7.1%) showed intra-arterial thrombus formation. The aneurysms were located at the anterior communicating artery and basilar artery in two patients each, and on the internal carotid artery at the bifurcation of the anterior choroidal artery (AChoA) in one. In these patients, the clinical course, radiological findings, and management were retrospectively reviewed. Results Thrombus formation was observed in the posterior cerebral artery, anterior cerebral artery (A2), AChoA, and middle cerebral artery. The timing of thrombus formation was during coil delivery in four cases, and guiding catheter advancement in one. As for thrombus management, for all patients, administrations of heparin and antiplatelet agents were performed. For four patients, urokinase injection into the affected arteries was added after the completion of embolization. Cerebral infarction was postoperatively identified in two patients, but no hemorrhage was noted. Conclusion Administrations of heparin and antiplatelet drugs should be performed appropriately during procedures, and close observation of the arterial condition on angiography is necessary. Once thromboembolism occurs during the endovascular embolization of ruptured cerebral aneurysms, adequate heparinization, and antiplatelet therapy should first be performed.
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Affiliation(s)
- Motohiro Nomura
- 1 Department of Neurosurgery, Kanto Rosai Hospital, Kawasaki, Japan
| | - Kentaro Mori
- 2 Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
| | - Akira Tamase
- 2 Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
| | - Tomoya Kamide
- 2 Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
| | - Syunsuke Seki
- 2 Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
| | - Yu Iida
- 2 Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
| | | | - Eiichi Baba
- 1 Department of Neurosurgery, Kanto Rosai Hospital, Kawasaki, Japan
| | - Atsushi Tsuchiya
- 3 Department of Neurology, Kanto Rosai Hospital, Kawasaki, Japan
| | - Hiroshi Shima
- 4 Department of Neurosurgery, Shima Neurosurgical and Orthopedic Clinic, Kawasaki, Japan
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Kim S, Choi JH, Kang M, Cha JK, Huh JT. Safety and Efficacy of Intravenous Tirofiban as Antiplatelet Premedication for Stent-Assisted Coiling in Acutely Ruptured Intracranial Aneurysms. AJNR Am J Neuroradiol 2016; 37:508-14. [PMID: 26471748 DOI: 10.3174/ajnr.a4551] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/13/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Stent-assisted coiling of intracranial aneurysms requires antiplatelet therapy, typically aspirin and clopidogrel to prevent thromboembolic complications. There is a substantial concern that tirofiban may increase the risk of hemorrhage when used as an antiplatelet premedication in ruptured intracranial aneurysms. Our aim was to evaluate the safety and efficacy of intravenous tirofiban administration, instead of oral dual antiplatelet agents, as an antiplatelet premedication for stent-assisted coiling in patients with acutely ruptured intracranial aneurysms. MATERIALS AND METHODS We conducted a retrospective review of a data base containing a consecutive series of patients who underwent stent-assisted coiling for acutely ruptured intracranial aneurysms between March 2010 and January 2015. Intravenous tirofiban was administered to all patients before stent-assisted coiling, instead of premedication with loading doses of aspirin or clopidogrel. RESULTS Forty patients with 41 aneurysms received intravenous tirofiban and underwent stent-assisted coiling. None of the patients had a newly developed intracerebral hemorrhage, subarachnoid hemorrhage, or intraventricular hemorrhage. Intraprocedural aneurysmal rupture occurred in 2 patients (5%). Cerebral infarction developed in 2 patients (5%). Ventriculostomy-related hemorrhage was seen in 2 of 10 patients in whom ventriculostomy was performed before or after coiling. Thirty-four (85%) patients had a good outcome (Glasgow Outcome Score of 4 or 5) at the time of discharge, but 1 patient died of cardiac arrest. None of the patients developed thrombocytopenia, retroperitoneal, gastrointestinal, or genitourinary bleeding related to tirofiban administration. CONCLUSIONS In our study, tirofiban showed a low risk of symptomatic hemorrhagic or thromboembolic complications. Tirofiban may offer a safe and effective alternative as an antiplatelet premedication during stent-assisted coiling of acutely ruptured intracranial aneurysms.
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Affiliation(s)
- S Kim
- From the Departments of Radiology (S.K., M.K.)
| | | | - M Kang
- From the Departments of Radiology (S.K., M.K.)
| | - J-K Cha
- Neurology (J.-K.C.), Busan-Ulsan Regional Cardio-Cerebrovascular Disease Center, Dong-A University Hospital, Busan, Republic of Korea
| | - J-T Huh
- Neurosurgery (J.-H.C., J.-T.H.)
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Gentric JC, Brisson J, Batista AL, Ghostine J, Raymond J, Roy D, Weill A. Safety of Abciximab injection during endovascular treatment of ruptured aneurysms. Interv Neuroradiol 2015; 21:332-6. [PMID: 25964436 DOI: 10.1177/1591019915582001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE We aimed to determine the safety of intra-arterial Abciximab injection in the management of thromboembolic complications during endovascular treatment of ruptured cerebral aneurysms. METHODS In a monocentric consecutive series of endovascular treatment of 783 ruptured aneurysms, 42 (5.3%) patients received Abciximab after the aneurysm was secured. Bleeding complications were registered and dichotomized as follows: new intracranial hemorrhage and peripheral bleeding. For each patient, World Federation of Neurosurgery (WFNS) subarachnoid hemorrhage (SAH) grade, shunting, and clinical outcomes in the post-operative period and at 3-6 months were recorded. RESULTS SAH WFNS grades were as follows: grade I n = 14, grade II n = 10, grade III n = 11, grade IV n = 4, grade V n = 3. Ten patients had intracranial hematoma additionally to the SAH prior to embolization. Four patients (9.5%) presented more blood on the post-embolization CT but only one suffered a new clinically relevant intracranial hemorrhage. Two patients (4.8%) experienced significant peripheral bleeding but none were associated with long-term disabilities. Fourteen patients had a shunt installed less than 24 h prior to Abciximab injection and one less than 48 h later. At 3-6-month follow-up, 31 patients (74%) achieved a modified Rankin Scale score (mRS) of 2 or less, six patients (14%) had a mRS of 3-5, three were dead (7%), and two were lost at follow-up. CONCLUSION When the aneurysm is secured, intra-arterial Abciximab injection is a low complication rate treatment modality for thromboembolic events during embolization of cerebral ruptured aneurysm.
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Affiliation(s)
| | | | | | | | - Jean Raymond
- CHUM Montréal, Neuroradiology, Montréal, Québec, Canada
| | - Daniel Roy
- CHUM Montréal, Neuroradiology, Montréal, Québec, Canada
| | - Alain Weill
- CHUM Montréal, Neuroradiology, Montréal, Québec, Canada
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Bhogal P, Brouwer PA, Söderqvist ÅK, Ohlsson M, Andersson T, Holmin S, Söderman M. Patients with subarachnoid haemorrhage from vertebrobasilar dissection: treatment with stent-in-stent technique. Neuroradiology 2015; 57:605-14. [PMID: 25740790 DOI: 10.1007/s00234-015-1505-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 02/20/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Vertebrobasilar dissection is an uncommon cause of subarachnoid haemorrhage (SAH) that carries a high risk for early repeat haemorrhage. The need for rapid treatment of this disease entity is without question; however, the best method for treatment is still undetermined. Here, we present our results using the stent-in-stent technique, without coiling, for these patients and propose that it is a viable treatment strategy. METHODS We identified in our local database for neurointerventional therapy, between 1st October 2000 and 1st January 2014, 93 patients with potential subarachnoid haemorrhage secondary to vertebrobasilar pathology. After review of the clinical notes and imaging, 15 were found to have presented with subarachnoid haemorrhage and treated with stents alone. All dissections were spontaneous with no history of preceding trauma. The ages ranged between 46 and 71 years (mean 61 years). RESULTS All patients presented with Fischer grade 4 SAH and had a visible pseudoaneurysm. The pre-operative GCS varied with two patients scoring 3, one patient scoring 6 and the remaining 12 patients scoring 8 or above. All cases were subjected to stent-in-stent treatment alone. We did not experience any intra-procedural complications. In our series, eight patients had full recovery with a Glasgow Outcome Scale (GOS) of 5, three had moderate disability (GOS 4), one had severe disability (GOS 3), and three patents died, one patient from stent thrombosis or re-bleeding and two from their initial SAH. CONCLUSION The stent-in-stent technique represents a viable reconstructive endovascular surgical technique with a low risk of intra-procedural complication and post-operative repeat haemorrhage.
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Affiliation(s)
- Pervinder Bhogal
- Department of Neuroradiology, The Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden,
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Ramakrishnan P, Yoo AJ, Rabinov JD, Ogilvy CS, Hirsch JA, Nogueira RG. Intra-Arterial Eptifibatide in the Management of Thromboembolism during Endovascular Treatment of Intracranial Aneurysms: Case Series and a Review of the Literature. INTERVENTIONAL NEUROLOGY 2014; 2:19-29. [PMID: 25187782 DOI: 10.1159/000354982] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Thromboembolic complications are well recognized during the endovascular management of intracranial aneurysms. In this study, we present a case series of 40 patients with intraprocedural thrombotic complications who were treated with intra-arterial eptifibatide (IAE), and a review of the literature. METHODS Twenty-five patients with ruptured intracranial aneurysms (RIA), 10 with unruptured intracranial aneurysms (UIA) and 5 with aneurysmal subarachnoid hemorrhage-induced vasospasm (VSP) received IAE for intraprocedural thrombi during endovascular treatment. Rates of recanalization, strokes, and hemorrhagic complications were assessed. RESULTS Recanalization was achieved in 96% (24/25) of the RIA patients [72% (18/25) complete; 24% (6/25) partial], in 100% (10/10) of the UIA patients [90% (9/10) complete; 10% (1/10) partial], and in 100% (5/5) of the VSP patients [80% (4/5) complete; 20% (1/5) partial]. Strokes following intraprocedural thrombosis were coil-related (20%, 5/25) or stent-related (12%, 3/25) in RIA patients, stent-related (10%, 1/10) in UIA patients, and heparin-induced thrombocytopenia type II-related (60%, 3/5) or vasospasm-related (20%, 1/5) in VSP patients. There were no intracerebral hemorrhagic complications in UIA. Intracerebral hemorrhage was observed in 20% of the RIA patients (5/25), all of whom had received intra-arterial thrombolytics and/or high-dose heparin infusion in addition to IAE; in 12%, this was external ventricular drain-related (3/25), 4% had parenchymal hematoma type 1 (1/25), and 4% parenchymal hematoma type 2 (1/25). One of the 5 VSP patients, who had received argatroban in addition to IAE, had parenchymal hematoma type 1. No clinically significant systemic hemorrhage was observed in this study. CONCLUSION Treatment of thromboembolic complications with IAE during endovascular management of aneurysms was effective in achieving recanalization and overall well tolerated in this series.
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Affiliation(s)
- Pankajavalli Ramakrishnan
- Departments of Neurology, Neurosurgery, and Radiology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Ga., USA
| | - Albert J Yoo
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass., USA
| | - James D Rabinov
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass., USA
| | - Christopher S Ogilvy
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass., USA
| | - Joshua A Hirsch
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass., USA ; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass., USA
| | - Raul G Nogueira
- Departments of Neurology, Neurosurgery, and Radiology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Ga., USA ; Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass., USA
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Brinjikji W, Morales-Valero SF, Murad MH, Cloft HJ, Kallmes DF. Rescue treatment of thromboembolic complications during endovascular treatment of cerebral aneurysms: a meta-analysis. AJNR Am J Neuroradiol 2014; 36:121-5. [PMID: 25082819 DOI: 10.3174/ajnr.a4066] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intraprocedural thrombus formation during endovascular treatment of intracranial aneurysms is often treated with glycoprotein IIb/IIIa inhibitors and, in some instances, fibrinolytic therapy. We performed a meta-analysis evaluating the safety and efficacy of GP IIb/IIIa inhibitors compared with fibrinolysis. We also evaluated the safety and efficacy of abciximab, an irreversible inhibitor, compared with tirofiban and eptifibatide, reversible inhibitors of platelet function. MATERIALS AND METHODS We performed a comprehensive literature search for studies on rescue therapy for intraprocedural thromboembolic complications with glycoprotein IIb/IIIa inhibitors or fibrinolysis during endovascular treatment of intracranial aneurysms. We studied rates of periprocedural stroke/hemorrhage, procedure-related morbidity and mortality, immediate arterial recanalization, and long-term good clinical outcome. Event rates were pooled across studies by using random-effects meta-analysis. RESULTS Twenty-three studies with 516 patients were included. Patients receiving GP IIb/IIIa inhibitors had significantly lower perioperative morbidity from stroke/hemorrhage compared with those treated with fibrinolytics (11.0%; 95% CI, 7.0%-16.0% versus 29.0%; 95% CI, 13.0%-55.0%; P = .04) and were significantly less likely to have long-term morbidity (16.0%; 95% CI, 11.0%-21.0% versus 35.0%; 95% CI, 17.0%-58.0%; P = .04). There was a trend toward higher recanalization rates among patients treated with glycoprotein IIb/IIIa inhibitors compared with those treated with fibrinolytics (72.0%; 95% CI, 64.0%-78.0% versus 50.0%; 95% CI, 28.0%-73.0%; P = .08). Patients receiving tirofiban or eptifibatide had significantly higher recanalization rates compared with those treated with abciximab (83.0%; 95% CI, 68.0%-91.0% versus 66.0%; 95% CI, 58.0%-74.0%; P = .05). No difference in recanalization was seen in patients receiving intra-arterial (77.0%; 95% CI, 66.0%-85.0%) or intravenous GP IIb/IIIa inhibitors (70.0%; 95% CI, 57.0%-80.0%, P = .36). CONCLUSIONS Rescue therapy with thrombolytic agents resulted in significantly more morbidity than rescue therapy with glycoprotein IIb/IIIa inhibitors. Tirofiban/eptifibatide resulted in significantly higher recanalization rates compared with abciximab.
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Affiliation(s)
- W Brinjikji
- From the Departments of Radiology (W.B., H.J.C., D.F.K.)
| | | | - M H Murad
- Center for Science of Healthcare Delivery (M.H.M.), Mayo Clinic, Rochester, Minnesota
| | - H J Cloft
- From the Departments of Radiology (W.B., H.J.C., D.F.K.) Neurosurgery (S.F.M.-V., H.J.C., D.F.K.)
| | - D F Kallmes
- From the Departments of Radiology (W.B., H.J.C., D.F.K.) Neurosurgery (S.F.M.-V., H.J.C., D.F.K.)
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11
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Sedat J, Chau Y, Mondot L, Chemla R, Lonjon M, Padovani B. Is eptifibatide a safe and effective rescue therapy in thromboembolic events complicating cerebral aneurysm coil embolization? Single-center experience in 42 cases and review of the literature. Neuroradiology 2013; 56:145-53. [PMID: 24281387 DOI: 10.1007/s00234-013-1301-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 11/02/2013] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Thromboembolic complications are the most frequent perioperative complications of endovascular treatment of intracranial aneurysms. Even if the effectiveness of glycoprotein IIb/IIIa inhibitors has been reported, the outcomes in published clinic data are contradictory. This study aims to assess the effectiveness and the safety of eptifibatide in thromboembolic complications during intracranial aneurysm embolization procedure. METHODS Between 2006 and 2012, 650 patients with intracranial aneurysm were treated using endovascular coil embolization, and in 62 cases (9.5 %), an intra-arterial thrombus developed. Glycoprotein IIb/IIIa inhibitor was administrated in 45 of them who required a rescue treatment. These 45 patients were treated with an intra-arterial bolus (0.2 mg/kg) of eptifibatide. We respectively reviewed the angiographic and clinical outcomes, and the periprocedural complications of the rescue treatment. RESULTS No intra- or early postoperative (48 h) bleeding was observed after treatment. A total recovery of the entire arterial tree (TICI 3) was established in 28 cases (62.2 %), a partial revascularization in 13 cases (28.8 %) (5 TICI 2A and 8 TICI 2B), and no revascularization or reperfusion (TICI 0 or TICI 1) in 4 cases (9 %). Eptifibatide was more effective on proximal obstructions and in-stent occlusions than on peripheral distal thrombus, which were completely disintegrated one time out of three. CONCLUSION Intra-operative intra-arterial use of eptifibatide does not imply an increase of hemorrhagic events. Even if eptifibatide allows for a high rate of arterial recanalization, its effectiveness seems to be less important in cases of distal occlusions.
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Affiliation(s)
- Jacques Sedat
- Unité de Neurointerventionnelle, Hôpital Saint-Roch, 5 rue Pierre Devoluy, Nice, 06000, France,
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12
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Jeong HW, Jin SC. Intra-arterial infusion of a glycoprotein IIb/IIIa antagonist for the treatment of thromboembolism during coil embolization of intracranial aneurysm: a comparison of abciximab and tirofiban. AJNR Am J Neuroradiol 2013; 34:1621-5. [PMID: 23660289 DOI: 10.3174/ajnr.a3501] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Abciximab and tirofiban are commonly used for the treatment of thromboembolisms that form during coiling of intracranial aneurysms; however, it is not known which of these inhibitors is safer and more effective. We report the safety and the recanalization rates for intra-arterial abciximab and intra-arterial tirofiban infusion for the treatment of thromboembolisms that form during coiling. MATERIALS AND METHODS Between March 2004 and April 2011, 346 intracranial aneurysms were treated with coiling. Thromboembolisms developed in 22 of these patients and were treated by use of intra-arterial tirofiban (n = 11) or abciximab (n = 11) infusion. RESULTS In the abciximab group, the thromboembolisms were completely (n = 1) or partially (n = 7) resolved in 8 cases (72.7%) at the time of the final control angiography. Complete (n = 9) or partial (n = 2) resolution was achieved in all cases at the time of follow-up angiography (<3 days after the procedure). In the tirofiban group, thromboembolisms were completely (n = 4) or partially (n = 6) resolved in 10 cases (90.9%) at the time of the final control angiography. Complete (n = 9) or partial (n = 2) resolution was observed in all cases at the time of the follow-up angiography. There were no statistically significant differences between the 2 groups with respect to thrombus resolution (final angiography, P = .311; follow-up angiography, P = .707). No hemorrhagic complications developed in either group. CONCLUSIONS These results suggest that tirofiban is more effective than abciximab for the immediate resolution of thromboembolisms, with no statistical significance. Both intra-arterial tirofiban and abciximab exhibited similar safety and recanalization rates.
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Affiliation(s)
- H W Jeong
- Department of Diagnostic Radiology, Busan Paik Hospital, Inje University, Busan, Korea
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13
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Mahmoud M. Rescue stenting in endovascular treatment of acutely ruptured cerebral aneurysms. Interv Neuroradiol 2013; 19:21-6. [PMID: 23472719 DOI: 10.1177/159101991301900103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 10/13/2012] [Indexed: 11/15/2022] Open
Abstract
Thromboembolic events and major artery occlusion following cerebral aneurysm coiling may lead to serious complications and even death if not treated. The use of an intracranial stent in the setting of subarachnoid hemorrhage (SAH) is risky due to the need for antiplatelet therapy. However in some conditions it could be an effective solution for this major problem. This study describes a revascularization technique using a Solitaire stent for treatment of anterior cerebral artery (ACA) occlusion following coiling of anterior communicating artery (Acom) aneurysms. Three cases of ruptured Acom aneurysms treated during the course of SAH underwent unplanned deployment of an intracranial stent. Complete occlusion of the ACA at the origin of the A2 segment developed during or shortly after coiling. Emergent CT brain scan was done in two cases to exclude rebleeding. Follow-up CT or MRI scans were performed 24 hours after stenting. Technical success was achieved in all cases. Complete revascularization of the Acom was achieved post stent deployment (TIMI grade 3). Time from onset of symptoms to full revascularization in the three cases was 35 minutes, one hour 50 minutes and two hours 40 minutes respectively. No intracranial bleeding occurred in any case following the procedure. No neurological changes occurred in case 1; mild neurological and radiological changes occurred in cases 2 and 3. Deployment of an intracranial stent achieved complete revascularization of the occluded Acom. Its use in a context of SAH is relatively risky but the technique resulted in a significant improvement of symptoms following flow restoration and probably helped prevent symptoms worsening, major disability or even death. A study on a larger patient sample with long-term follow-up will be of value.
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Affiliation(s)
- M Mahmoud
- Radiology Department, Ain Shams University, Cairo, Egypt.
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14
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Coller BS. Translating from the rivers of Babylon to the coronary bloodstream. J Clin Invest 2012; 122:4293-9. [PMID: 23114610 DOI: 10.1172/jci66867] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Barry S Coller
- Laboratory of Blood and Vascular Biology, Rockefeller University, 1230 York Avenue, New York, New York 10065, USA.
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15
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Cho YD, Lee JY, Seo JH, Kang HS, Kim JE, Jung KH, Han MH. Intra-arterial tirofiban infusion for thromboembolic complication during coil embolization of ruptured intracranial aneurysms. Eur J Radiol 2012; 81:2833-8. [PMID: 22683194 DOI: 10.1016/j.ejrad.2011.11.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 11/16/2011] [Accepted: 11/21/2011] [Indexed: 10/28/2022]
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16
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Pierot L, Kadziolka K, Portefaix C, Litré F, Rousseaux P. [Treatment for intracranial aneurysms]. Presse Med 2012; 41:532-41. [PMID: 22364802 DOI: 10.1016/j.lpm.2011.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 11/30/2011] [Accepted: 12/01/2011] [Indexed: 11/25/2022] Open
Abstract
Aneurysm rupture is suspected in case of sudden, intense headache, sometimes associated with nausea or vomiting, focal neurologic deficit or loss of consciousness. Aneurysm rupture is a diagnostic and therapeutic emergency that has to be managed in highly specialized centers. Ruptured aneurysms have to be treated in emergency to avoid rebleeding. Endovascular approach is the first line treatment. The indications for treatment of unruptured have to be discussed according to several factors including patient's age, aneurysm size and location. Follow-up examinations are needed after aneurysm treatment (CTA, MRA, DSA). According to aneurysm risk factors, patients with aneurysms have to stop smoking and their blood pressure should be controlled on a regular basis and treated if needed.
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Affiliation(s)
- Laurent Pierot
- CHU de Reims, hôpital Maison-Blanche, service de radiologie, 51092 Reims cedex, France.
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