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Xian E, Morrison T, Wong J. Hyperacute in-Stent Thrombosis Causing Large Vessel Occlusion after Stent-Assisted Aneurysm Coiling Secondary to Complete Clopidogrel and Prasugrel Resistance: a Case Report. J Neurol Surg A Cent Eur Neurosurg 2024; 85:531-533. [PMID: 35705178 DOI: 10.1055/a-1877-0421] [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: 10/18/2022]
Abstract
Dual antiplatelet therapy (DAPT) is standard treatment for endoluminal stent insertion, and complete resistance to DAPT is rare. A case of in-stent thrombosis occurring 3 hours after stent-assisted coiling of internal carotid artery aneurysm is presented despite compliance with DAPT. Platelet function tests (PFTs) revealed complete clopidogrel and prasugrel resistance.
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Affiliation(s)
- Elissa Xian
- Royal Prince Alfred Hospital, Camperdown, NSW, Sydney, Australia
| | - Thomas Morrison
- Royal Prince Alfred Hospital, Camperdown, NSW, Sydney, Australia
| | - Johnny Wong
- Royal Prince Alfred Hospital, Camperdown, NSW, Sydney, Australia
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2
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Nickelsen PM, Neyens R, Al Kasab S. Clopidogrel Hyperresponsiveness and Hemorrhagic Complications Using On-Label Clopidogrel Dosing after Pipeline Embolization. J Pharm Pract 2024:8971900241273311. [PMID: 39133207 DOI: 10.1177/08971900241273311] [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: 08/13/2024]
Abstract
Introduction: Clopidogrel hyperresponsiveness is a timely topic, with wide ranging reports of hemorrhagic complications, using various clopidogrel dosing strategies following neuroendovascular procedures. This study serves to investigate hemorrhagic complications using standard clopidogrel doses and timing of these complications in relation to the procedure. Materials and Methods: Retrospective cohort of consecutive adult patients undergoing flow diversion with Pipeline Embolization Device (PED) at an academic medical center, receiving on-label clopidogrel doses. Patients with clopidogrel hyperresponsiveness (VerifyNowTM P2Y12 reaction unit (PRU) ≤ 70) were compared to those who were normoresponsive. The primary outcome is the rate of hemorrhagic complications between groups. Results: Of 148 included patients, 54 (36.5%) were identified as clopidogrel hyperresponsive (PRU ≤ 70) and 94 (63.5%) as clopidogrel normoresponsive (PRU 71 - 194). There were no hemorrhagic complications observed in patients who were clopidogrel hyperresponsive, with 5 occurring in patients who were normoresponsive (P = 0.09). Three (60%) of the hemorrhages were intracranial with most occurring intra-procedure or within the first week of the procedure. Age > 60 years was the only candidate predictor for hemorrhagic complications (P = 0.004). Conclusion: Our findings are contradictory, with lower hemorrhagic complications in clopidogrel hyperresponders than prior literature, and most occurring intra-op or in the immediate acute post-op phase.
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Affiliation(s)
| | - Ron Neyens
- Department of Pharmacy, Medical University of South Carolina, San Diego, CA, USA
- College of Pharmacy, Medical University of South Carolina, San Diego, CA, USA
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, San Diego, CA, USA
- Department of Neurology, Medical University of South Carolina, San Diego, CA, USA
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Ramirez-Velandia F, Enriquez-Marulanda A, Filo J, Young M, Fodor TB, Sconzo D, Muram S, Granstein JH, Shutran M, Taussky P, Ogilvy CS. Thromboembolic Events in the Posterior Circulation After Flow Diversion-A Closer Look at Coverage of the Posterior Cerebral Artery. World Neurosurg 2024; 187:e920-e928. [PMID: 38734173 DOI: 10.1016/j.wneu.2024.05.011] [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: 12/20/2023] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Flow diversion for bifurcation aneurysms requires excluding one of the branches from the parent artery, raising concern for ischemic events. We evaluated thromboembolic events and their relationship with covering the origin of the posterior cerebral artery (PCA). METHODS This retrospective analysis included patients with confirmed basilar and proximal PCA aneurysms treated with flow diversion between 2013 and 2023. Procedures were classified according to the coverage of the origin of the PCA. Thromboembolic events associated with the excluded PCA were evaluated. RESULTS Of the total 28 aneurysms included, 7 were at the basilar tip, 16 in the basilar trunk, and 5 in the first segment of the PCA; 15 were treated by excluding one of the PCAs. Dual antiplatelet therapy included aspirin and ticagrelor (57.1%), aspirin and clopidogrel (35.7%), or aspirin and prasugrel (3.57%). Complete and near-complete aneurysm occlusion was achieved in 80.8% of the aneurysms treated at a median follow-up of 12.31 months. Thromboembolic complications occurred in 3 patients (2 with basilar perforator stroke and 1 with basilar in-stent thrombosis). However, the difference in these events was not statistically significant between patients with PCA coverage and those without (P = 0.46). Diminished flow and a lack of flow was seen in 8 and 7 of the covered vessels, respectively. A modified Rankin scale score of ≤2 was reported for 89.3% of patients at a median clinical follow-up of 5.5 months. CONCLUSIONS The incidence of thromboembolic events is high in distal basilar and proximal PCA aneurysms; however, PCA coverage was not associated with their occurrence. There was no difference in postprocedural disability between patients whose aneurysms were treated by excluding one of the PCAs and those who were not.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jean Filo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas B Fodor
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Sconzo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sandeep Muram
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin H Granstein
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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Cagnazzo F, Radu RA, Derraz I, Lefevre PH, Dargazanli C, Machi P, Morganti R, Gascou G, Fendeleur J, Rapido F, Costalat V. Efficacy and safety of low dose intravenous cangrelor in a consecutive cohort of patients undergoing neuroendovascular procedures. J Neurointerv Surg 2023; 16:88-93. [PMID: 36922032 DOI: 10.1136/jnis-2023-020094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/25/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Cangrelor is an intravenous P2Y12 inhibitor with rapid onset and fast offset of antiplatelet action. Dose adjusted cangrelor based on platelet function testing is suggested to be advantageous for use during neuroendovascular procedures. In this study, we aimed to assess the efficacy and safety of this strategy. METHODS This retrospective study included consecutive patients who received low dose intravenous cangrelor (5 µg/kg; infusion 1 µg/kg/min) for ruptured (RIA) and unruptured (UIA) intracranial aneurysms, and acute ischemic stroke (AIS). Indications were acute stenting or intraluminal thrombus. Outcomes were assessed at 24 hours by brain CT and CT angiography. The primary efficacy outcome was the rate of stent occlusion or persistent intraluminal thrombus. The primary safety outcome was the rate of major hemorrhages. RESULTS 101 patients (56 men; median age (IQR) 59 (51-70) years) received low dose cangrelor for acute stenting (79/101 (78%)) and intraprocedural thrombus (22/101 (22%)). Overall, 5 (4.9%) patients experienced stent occlusion within 24 hours (RIA 3/28; AIS 2/52). There were no cases of failure among UIA patients. Stent mis-opening (fish mouthing or stenosis >50%) was significantly associated with stent occlusion (P<0.001). The overall rate of major hemorrhage was 2% (2/101), which occurred in AIS patients. Platelet reactivity unit (PRU) values were lower in those presenting with major hemorrhage (PRU 4 (SD 1.4) vs PRU 60 (SD 63); P=0.043). Mortality rate after cangrelor related hemorrhage was 1%. CONCLUSIONS Low dose cangrelor appears to be effective in preventing stent thrombosis and arterial patency with a low hemorrhagic risk.
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Affiliation(s)
- Federico Cagnazzo
- Neuroradiology Department, Hôpital Gui de Chauliac, Montpellier, France
| | | | - Imad Derraz
- Neuroradiology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Pierre Henri Lefevre
- Neuroradiology, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, France
| | - Cyril Dargazanli
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, France
| | - Paolo Machi
- Department of Neuroradiology, University of Geneva, Geneve, Switzerland
| | | | - Gregory Gascou
- Neuroradiology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Julien Fendeleur
- Anaesthesiology and Critical Care Medicine, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Francesca Rapido
- Anaesthesiology and Critical Care Medicine, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
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5
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Gegri M, Cheves TA, Anderson MN, McTaggart R, Sweeney JD. Discordance in tests used to detect inhibition of the P2Y12 receptor in patients undergoing interventional neuroradiology procedures. Interv Neuroradiol 2023; 29:655-664. [PMID: 36039509 PMCID: PMC10680952 DOI: 10.1177/15910199221122858] [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: 05/25/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Clopidogrel is an inhibitor of the P2Y12 platelet receptor but testing to demonstrate a drug effect is controversial since there are often discordant results between different tests methods. METHODS Samples from patients taking clopidogrel prior to intracranial flow-diversion procedures were tested using light transmission aggregometry (LTA), whole blood impedance aggregometry (WBIA) and the VerifyNow device (VND). Samples were classified as concordant if all test results were either responsive (inhibition) or resistant. Discordant results were separated using the VND into those with a responsive versus a resistant test result. RESULTS Samples from 96 patients were studied. Concordance for all three tests was seen in 53/96 (55%) of samples, of which 41 (43%) were responsive and 12 (12%) were resistant. Discordance was observed in 43 samples (45%), 37 (28%) of which were caused by responsive VND and either a resistant WBIA or LTA and 6 (7%) of which were caused by a resistant VND but a responsive test result using either WBIA or LTA. These two discordant groups differed in both platelet count and hematocrit, but no such difference was present between the two concordant groups. CONCLUSION Discordance in P2Y12 inhibition testing may be partly explained by sample platelet count and hematocrit.
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Affiliation(s)
- Mansour Gegri
- Departments of Coagulation and Transfusion Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Tracey A Cheves
- Departments of Coagulation and Transfusion Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Matthew N Anderson
- Departments of Neurosurgery, Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Ryan McTaggart
- Departments of Diagnostic Imaging, Rhode Island Hospital, Providence, RI, USA
- Departments of Neurology, Rhode Island Hospital, Providence, RI, USA
- Departments of Neurosurgery, Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, Providence, RI, USA
- The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI, USA
| | - Joseph D Sweeney
- Departments of Coagulation and Transfusion Medicine, Rhode Island Hospital, Providence, RI, USA
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Tsui BCH, Gupta RK. Role of neuromodulation in acute pain settings. Reg Anesth Pain Med 2023; 48:338-342. [PMID: 37080583 DOI: 10.1136/rapm-2022-103837] [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: 06/01/2022] [Accepted: 11/15/2022] [Indexed: 04/22/2023]
Abstract
Peripheral nerve stimulation (PNS), a type of neuromodulatory technique, is increasingly used to treat chronic pain syndromes. PNS has also recently gained popularity as a viable adjunct analgesic modality in acute pain settings, where the practice primarily relies on using boluses or infusion of local anesthetics for nerve blockade, followed by stimulation to extend the analgesia. There is some early promise in PNS for perioperative analgesic control, but considerable obstacles must be addressed before it can be implemented into standard practice. In this daring discourse, we explore the possibilities and constraints of using the PNS paradigm in acute pain.
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Affiliation(s)
- Ban C H Tsui
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA
| | - Rajnish K Gupta
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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7
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Sukun A, Tekeli F. Comparison of Clopidogrel, Prasugrel and Ticagrelor Response of Patients by PFA-100-Innovance Test Results. Indian J Hematol Blood Transfus 2023; 39:294-299. [PMID: 37006988 PMCID: PMC10064378 DOI: 10.1007/s12288-022-01600-7] [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: 10/02/2021] [Accepted: 10/18/2022] [Indexed: 11/07/2022] Open
Abstract
Devices such as stents and flow diverters require the use of safe and fast antiplatelet therapy. We aimed to compare the responses to clopidogrel, prasugrel, and ticagrelor by assessing the Platelet Function Analysis (PFA-100)-Innovance test results of patients undergoing endovascular stenting to determine their resistance rates. Sixty-one women and 55 men, aged 18-87 years, were included in this study. Patients were divided into three groups: clopidogrel treatment, prasugrel treatment, and ticagrelor treatment. The systemic diseases of the patients, especially hypertension and diabetes, were recorded. The test results were evaluated according to the results for the collagen/epinephrine (COL-EPI), collagen/adenosine (COL-ADP), and P2Y results. The PFA-100-Innovance results for COL-EPI and P2Y were significantly higher for patients treated with prasugrel and ticagrelor compared with patients treated with clopidogrel (COL-EPI, p = 0.001; P2Y, p = 0.001). Clopidogrel resistance was identified in 31 patients (26.7%), and prasugrel resistance was identified in 4 patients (3.4%). Ticagrelor resistance was not detected. Therefore, 30.1% of patients were classified as drug-resistant. Perioperative bleeding was not detected in any patient. Hypertension was the most common disease recorded for patients being treated for cerebral aneurysm, and diabetes was the most common disease recorded for patients who underwent peripheral artery stenting (p = 0.002). Potent antiplatelet agents, such as prasugrel and ticagrelor, have a low rate of resistance but are associated with an increased bleeding risk. Thus, the choice of a suitable drug during the treatment window remains a critical factor when determining treatment strategies.
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Affiliation(s)
- Abdullah Sukun
- Department of Radiology, Baskent University Alanya Application and Research Center, Antalya, Turkey
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Rostock, Germany
- Exchange Programme for Fellowships, European School of Radiology (ESOR), Vienna, Austria
| | - Feyza Tekeli
- Department of Biochemistry, Antalya Training and Research Hospital, Antalya, Turkey
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8
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Simgen A, Roth C, Kulikovski J, Papanagiotou P, Roumia S, Dietrich P, Mühl-Benninghaus R, Kettner M, Reith W, Yilmaz U. Endovascular treatment of unruptured intracranial aneurysms with flow diverters: A retrospective long-term single center analysis. Neuroradiol J 2023; 36:76-85. [PMID: 35695038 PMCID: PMC9893170 DOI: 10.1177/19714009221108678] [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] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The introduction of flow diverters (FDs) in 2007 greatly enhanced the treatment of intracranial aneurysms. Here, we present our long-term clinical experience in treating unruptured intracranial aneurysms with FDs. METHODS 107 patients with unruptured aneurysms and treated with an FD between 2010 and 2019 were retrospectively reviewed. Aneurysm occlusion, procedural complications, and clinical outcome were evaluated. RESULTS Angiographic follow-up was available for 93 patients with a mean long-term follow-up time of 28.4 ± 21.6 months. Additional coiling was performed in 15.1% of patients (n = 14). Adequate aneurysm occlusion (Kamran grades 3 and 4) at long-term follow-up was achieved in 94.6% of patients (n = 88). 3.2% (n = 3) required endovascular retreatment since the last follow-up showed a lack of aneurysm occlusion (Kamran grade 0) due to a foreshortening of the FD. Incomplete opening of the FD and parent vessel occlusion was seen in 1.1% (n = 1) and 3.2% (n = 3) of patients, respectively. In-stent stenosis was observed in 57% (n = 53) of cases at short-term follow-up and 22.6% (n = 21) at long-term, which were moderate and asymptomatic overall. In-stent stenosis decreased significantly between short- and long-term follow-ups (31.4 ± 17.0% vs 9.7 ± 13.6%, respectively; p ≤ 0.001). Thromboembolic and hemorrhagic events occurred in 7.5% (n = 7) and 1.1% (n = 1) of patients, respectively. Good clinical outcome (modified Rankin scale: 0-2) was obtained in 97.8% (n = 91) leading to an overall treatment-related morbidity of 2.2% (n = 2). There was no procedural mortality. CONCLUSION Our study shows that FD treatment of unruptured intracranial aneurysms is effective and safe with high occlusion rates and low rates of permanent morbidity at long-term follow-up.
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Affiliation(s)
- Andreas Simgen
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Christian Roth
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Johann Kulikovski
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | | | - Safwan Roumia
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Philipp Dietrich
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | | | - Michael Kettner
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Umut Yilmaz
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
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Nakahara H, Sarker T, Dean CL, Skukalek SL, Sniecinski RM, Cawley CM, Guarner J, Duncan A, Maier CL. A Sticky Situation: Variable Agreement Between Platelet Function Tests Used to Assess Anti-platelet Therapy Response. Front Cardiovasc Med 2022; 9:899594. [PMID: 35845048 PMCID: PMC9283921 DOI: 10.3389/fcvm.2022.899594] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/13/2022] [Indexed: 11/15/2022] Open
Abstract
Background Platelet function testing to monitor antiplatelet therapy is important for reducing thromboembolic complications, yet variability across testing methods remains challenging. Here we evaluated the agreement of four different testing platforms used to monitor antiplatelet effects of aspirin (ASA) or P2Y12 inhibitors (P2Y12-I). Methods Blood and urine specimens from 20 patients receiving dual antiplatelet therapy were analyzed by light transmission aggregometry (LTA), whole blood aggregometry (WBA), VerifyNow PRUTest and AspirinWorks. Result interpretation based on pre-defined cutoff values was used to calculate raw agreement indices, and Pearson's correlation coefficient determined using individual units of measure. Results Agreement between LTA and WBA for P2Y12-I-response was 60% (r = 0.65, high-dose ADP; r = 0.75, low-dose ADP). VerifyNow agreed with LTA in 75% (r = 0.86, high-dose ADP; r = 0.75, low-dose ADP) and WBA in 55% (r = 0.57) of cases. Agreement between LTA and WBA for ASA-response was 45% (r = 0.09, high-dose collagen WBA; r = 0.19, low-dose collagen WBA). AspirinWorks agreed with LTA in 60% (r = 0.32) and WBA in 35% (r = 0.02, high-dose collagen WBA; r = 0.08, low-dose collagen WBA) of cases. Conclusions Overall agreement varied from 35 to 75%. LTA and VerifyNow demonstrated the highest agreement for P2Y12-I-response, followed by moderate agreement between LTA and WBA. LTA and AspirinWorks showed moderate agreement for aspirin response, while WBA showed the weakest agreement with both LTA and AspirinWorks. The results from this study support the continued use of LTA for monitoring dual antiplatelet therapy, with VerifyNow as an appropriate alternative for P2Y12-I-response. Integration of results obtained from these varied testing platforms with patient outcomes remains paramount for future studies.
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Affiliation(s)
- Hirotomo Nakahara
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Tania Sarker
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Christina L. Dean
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Susana L. Skukalek
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Roman M. Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, United States
| | - C. Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Jeannette Guarner
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Alexander Duncan
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Cheryl L. Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, United States
- *Correspondence: Cheryl L. Maier
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Giorgianni A, Agosti E, Molinaro S, Terrana AV, Vizzari FA, Nativo L, Garg K, Craparo G, Conti V, Locatelli D, Baruzzi F, Valvassori L, Lanzino G. Flow diversion for acutely ruptured intracranial aneurysms treatment: A retrospective study and literature review. J Stroke Cerebrovasc Dis 2022; 31:106284. [PMID: 35007933 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106284] [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: 11/06/2021] [Accepted: 12/19/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Flow diversion is becoming an increasingly established practice for the treatment of acutely ruptured intracranial aneurysms. In this study the authors present a literature review and meta-analysis, adding a retrospective review of institutional registry on emergency treatment of aRIA with flow diverter stent. MATERIALS AND METHODS A systematic search of PubMed, SCOPUS, Ovid MEDLINE, and Ovid EMBASE was performed on April 20th, 2021, extrapolating 35 articles. R language 'meta' and 'metafor' packages were used for data pooling. The DerSimonian-Laird model was used to calculate the pooled effect. The I2 value and Q statistic evaluated study heterogeneity. Additionally, the authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured intracranial aneurysms treated with flow diverter stent placement from May 2010 to November 2020 was performed. RESULTS From the systematic literature review and meta-analysis, the pooled proportion of complete aneurysm occlusion was 78%, with a pooled rate of 79%, 71%, 80%, and 50% for dissecting, saccular, fusiform, and mycotic aneurysms, respectively. The pooled proportion of aneurysm rebleeding and intrastent stenosis was 12% and 15% respectively, for a total of 27% rate. The analysis of authors retrospective register showed an overall mortality rate of 16.7% (3/18), with a low but not negligible postprocedural rebleeding and intrastent thrombosis rates (5.6% and 11.1% respectively). CONCLUSION Although increasingly utilized in the management of selected patients with acutely ruptured intracranial aneurysms, flow diversion for acutely ruptured intracranial aneurysms treatment presents rebleeding and intrastent stenosis rates not negligible.
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Affiliation(s)
- Andrea Giorgianni
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Brescia, Italy.
| | - Stefano Molinaro
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Alberto Vito Terrana
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | | | - Luca Nativo
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Kanwaljeet Garg
- Associate Professor, Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Giuseppe Craparo
- Department of Department of Neuroradiology, ARNAS Civico di Palermo, Palermo, Italy
| | - Vinicio Conti
- Department of Anesthesiology and Resuscitation, ASST Sette Laghi, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Fabio Baruzzi
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | | | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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Winters H, Schüngel MS, Scherlach C, Mucha D, Thalwitzer J, Härtig W, Donitza A, Bailis N, Maybaum J, Hoffmann KT, Quäschling U, Schob S. First Experience of Three Neurovascular Centers With the p64MW-HPC, a Low-Profile Flow Diverter Designed for Proximal Cerebral Vessels With Antithrombotic Coating. Front Neurol 2021; 12:724705. [PMID: 34594297 PMCID: PMC8476967 DOI: 10.3389/fneur.2021.724705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/12/2021] [Indexed: 12/23/2022] Open
Abstract
Background: In the last decade, flow diversion (FD) has been established as hemodynamic treatment for cerebral aneurysms arising from proximal and distal cerebral arteries. However, two significant limitations remain—the need for 0.027” microcatheters required for delivery of most flow diverting stents (FDS), and long-term dual anti-platelet therapy (DAPT) in order to prevent FDS-associated thromboembolism, at the cost of increasing the risk for hemorrhage. This study reports the experience of three neurovascular centers with the p64MW-HPC, a FDS with anti-thrombotic coating that is implantable via a 0.021” microcatheter. Materials and methods: Three neurovascular centers contributed to this retrospective analysis of patients that had been treated with the p64MW-HPC between March 2020 and March 2021. Clinical data, aneurysm characteristics, and follow-up results, including procedural and post-procedural complications, were recorded. The hemodynamic effect was assessed using the O'Kelly–Marotta Scale (OKM). Results: Thirty-two patients (22 female, mean age 57.1 years) with 33 aneurysms (27 anterior circulation and six posterior circulation) were successfully treated with the p64MW-HPC. In 30/32 patients (93.75%), aneurysmal perfusion was significantly reduced immediately post implantation. Follow-up imaging was available for 23 aneurysms. Delayed aneurysm perfusion (OKM A3: 8.7%), reduction in aneurysm size (OKM B1-3: 26.1%), or sufficient separation from the parent vessel (OKM C1-3 and D1: 65.2%) was demonstrated at the last available follow-up after a mean of 5.9 months. In two cases, device thrombosis after early discontinuation of DAPT occurred. One delayed rupture caused a caroticocavernous fistula. The complications were treated sufficiently and all patients recovered without permanent significant morbidity. Conclusion: Treatment with the p64MW-HPC is safe and feasible and achieves good early aneurysm occlusion rates in the proximal intracranial circulation, which are comparable to those of well-established FDS. Sudden interruption of DAPT in the early post-interventional phase can cause in-stent thrombosis despite the HPC surface modification. Deliverability via the 0.021” microcatheter facilitates treatment in challenging vascular anatomies.
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Affiliation(s)
- Helge Winters
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany.,Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Germany
| | | | - Cordula Scherlach
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Dirk Mucha
- Institut für Radiologie und Neuroradiologie, Heinrich-Braun- Klinikum, Zwickau, Germany
| | - Jörg Thalwitzer
- Institut für Radiologie und Neuroradiologie, Klinikum Chemnitz gGmbH, Chemnitz, Germany
| | - Wolfgang Härtig
- Paul-Flechsig-Institut für Hirnforschung, Universität Leipzig, Leipzig, Germany
| | - Aneta Donitza
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle, Halle (Saale), Germany
| | - Nikolaos Bailis
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Jens Maybaum
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Karl Titus Hoffmann
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Ulf Quäschling
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Stefan Schob
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle, Halle (Saale), Germany
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Park KY, Ozaki T, Kostynskyy A, Kortman H, Hilario A, Nicholson P, Agid R, Krings T, Pereira VM. Ticagrelor versus Clopidogrel in the Dual Antiplatelet Regimen for Intracranial Stenting or Flow-Diverter Treatment for Unruptured Cerebral Aneurysms: A Single-Center Cohort Study. AJNR Am J Neuroradiol 2021; 42:1638-1644. [PMID: 34244132 DOI: 10.3174/ajnr.a7216] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/25/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE Ticagrelor is a novel P2Y12 antagonist, and little is known about its efficacy and safety in the endovascular treatment of aneurysms. This study evaluated the efficacy and safety of ticagrelor versus clopidogrel for stent-assisted coiling or flow-diversion treatment in patients with unruptured cerebral aneurysms. MATERIALS AND METHODS From November 2003 to February 2019, two hundred one patients (mean age, 57.5 years; 156 women) with 233 unruptured aneurysms underwent stent-assisted coiling or flow-diversion treatment. All patients received antiplatelet therapy of aspirin plus clopidogrel (clopidogrel group, 121 patients with 140 aneurysms) or aspirin plus ticagrelor (ticagrelor group, 80 patients with 93 aneurysms). The clinical and radiologic data in each group were retrospectively reviewed and compared. RESULTS Two hundred thirty-six procedures were performed, including stent-assisted coiling (n = 101) and flow diversion (n = 135). At 90 days, the primary outcome-a composite of any stroke and death-occurred in 9.9% of the clopidogrel group and 8.6% of the ticagrelor group (P = .822). Ischemic stroke occurred in 10 (7.0%) of the clopidogrel group and 7 (7.5%) of the ticagrelor group (P > .999). Disabling stroke occurred in 4 (2.8%) in the clopidogrel group and in 4 (4.3%) in the ticagrelor group (P = .716). Ninety-day death occurred in 3 (2.1%) in the clopidogrel group and 1 (1.1%) in the ticagrelor group (P > .999). Any bleeding at 90 days occurred in 13 (9.2%) in the clopidogrel group and 6 (6.5%) in the ticagrelor group (P = .479). CONCLUSIONS Ticagrelor appears to be as effective and safe as clopidogrel in stent-assisted coiling or flow-diversion treatment for unruptured cerebral aneurysms.
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Affiliation(s)
- K Y Park
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Neurosurgery (K.Y.P.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - T Ozaki
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - A Kostynskyy
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - H Kortman
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Radiology (H.K.), Elisabeth-TweeSteden Ziekenhuis St. Elisabeth Hospital, Tilburg, the Netherlands
| | - A Hilario
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - P Nicholson
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - R Agid
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - T Krings
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - V M Pereira
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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13
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Simgen A, Mayer C, Kettner M, Mühl-Benninghaus R, Reith W, Yilmaz U. Retrospective analysis of intracranial aneurysms after flow diverter treatment including color-coded imaging (syngo iFlow) as a predictor of aneurysm occlusion. Interv Neuroradiol 2021; 28:190-200. [PMID: 34107790 DOI: 10.1177/15910199211024056] [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] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Flow Diverters (FD) have immensely extended the treatment of cerebral aneurysms in the past years. Complete aneurysm occlusion is a process that often takes a certain amount of time and is usually difficult to predict. Our aim was to investigate different syngo iFlow parameters in order to predict aneurysm occlusion. METHODS Between 2014 and 2018 patients with unruptured cerebral aneurysms treated with a FD were reviewed. Aneurysm occlusion and complication rates have been assessed.In addition, various quantitative criteria were assessed using syngo iFlow before, after the intervention, and after short and long-term digital subtraction angiography (DSA). RESULTS A total of 66 patients hosting 66 cerebral aneurysms were included in this study. 87.9% (n = 58) aneurysms in the anterior and 12.1% (n = 8) in the posterior circulation were treated. Adequate aneurysm occlusion at long-term follow-up (19.05 ± 15.1 months) was achieved in 90.9% (n = 60). Adequately occluded aneurysm revealed a significantly greater peak intensity delay (PI-D, p = 0.008) and intensity decrease ratio (ID-R, p < 0.001) compared to insufficiently occluded aneurysms. Increased intra-aneurysmal contrast agent intensity (>100%) after FD implantation resulted in an ID-R < 1, which was associated with aneurysm growth during follow-up DSA. Retreatment with another FD due to foreshortening and/or aneurysm growth was performed in 10.6% (n = 7). Overall morbidity and mortality rates were 1.5% (n = 1) and 0%. CONCLUSION The applied syngo iFlow parameters were found to be useful in predicting adequate aneurysm occlusion and foresee aneurysm growth, which might indicate the implantation of another FD.
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Affiliation(s)
- Andreas Simgen
- Departments of Neuroradiology, Saarland University Hospital, Homburg/Saar, Germany
| | - Christine Mayer
- Departments of Neuroradiology, Saarland University Hospital, Homburg/Saar, Germany
| | - Michael Kettner
- Departments of Neuroradiology, Saarland University Hospital, Homburg/Saar, Germany
| | | | - Wolfgang Reith
- Departments of Neuroradiology, Saarland University Hospital, Homburg/Saar, Germany
| | - Umut Yilmaz
- Departments of Neuroradiology, Saarland University Hospital, Homburg/Saar, Germany
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14
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Aguilar Perez M, Hellstern V, Serna Candel C, Wendl C, Bäzner H, Gansladt O, Henkes H. Use of pCONUS HPC for the treatment of unruptured wide-necked bifurcation aneurysms: early clinical experience using single antiplatelet therapy. Stroke Vasc Neurol 2020; 6:57-64. [PMID: 32920538 PMCID: PMC8005901 DOI: 10.1136/svn-2020-000399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/13/2020] [Accepted: 07/30/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In recent years, a growing number of stents and stent-like devices have become available to facilitate the treatment of challenging aneurysms. However, the need for dual antiplatelet therapy can limit their use, especially in ruptured aneurysms. The hydrophilic polymer coating (pHPC, phenox) is a novel glycan-based multilayer polymer that reduces platelet adhesion. This study aims to report our initial experience using the pCONUS HPC device for the treatment of unruptured wide-necked bifurcation aneurysms (WNBA) using acetylsalicylic acid (ASA) as single antiplatelet therapy (SAPT). METHODS We retrospectively identified all patients who were treated with the pCONUS HPC for unruptured WNBA in a multi-staged procedure using ASA as SAPT. Records were made of periprocedural complications, clinical outcome and angiographic and clinical follow-up. RESULTS We identified 15 patients with 15 WNBA. The average age was 69 years old (range, 41-76). Seven aneurysms were located in the middle cerebral artery, five in the anterior communicating artery, two at the basilar tip and one in the posterior communicating artery. Immediate post-treatment angiography showed five aneurysms with modified Raymond-Roy classification (mRRC) grade I and four aneurysms with mRRC grade II. There were no haemorrhagic complications. Four patients developed thrombus formation during the second treatment session, all of them completely resolving after administration of glycoprotein IIb/IIIa antagonists. Angiographic follow-up data were available for 10 patients and showed adequate occlusion (mRRC I or II) in eight aneurysms (80%). In-stent stenosis was observed in one patient whereas two patients showed de novo stenosis in one of the efferent branches. CONCLUSIONS This early experience on the use of the pCONUS HPC device suggests that it can be useful for treating unruptured WNBA under ASA as SAPT. Further investigation with a randomised treatment registry and larger cohort is needed.
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Affiliation(s)
- Marta Aguilar Perez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Victoria Hellstern
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Carmen Serna Candel
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Christina Wendl
- Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Fakultät für Medizin der Universität Regensburg, Regensburg, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Gansladt
- Neurochirurgische, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.,Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
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15
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Entezami P, Holden DN, Boulos AS, Paul AR, Field NC, Nourollahzadeh E, Yamamoto J, Dalfino JC. Cangrelor dose titration using platelet function testing during cerebrovascular stent placement. Interv Neuroradiol 2020; 27:88-98. [PMID: 32611215 DOI: 10.1177/1591019920936923] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Optimal antiplatelet inhibition is vital during cerebrovascular stenting procedures, yet no standardized recommendation exists for antithrombotic therapy in these scenarios. Cangrelor is an intravenous P2Y12 inhibitor with a favorable pharmacokinetic profile for use during neuroendovascular stenting. METHODS A retrospective review of all neuroendovascular patients who underwent stenting between 1 January 2019 and 22 March 2020 and were treated with cangrelor was conducted. Thirty-seven patients met inclusion criteria. RESULTS All patients were administered a bolus of 5 mcg/kg of cangrelor followed by a maintenance infusion. Antiplatelet effects of cangrelor were monitored using platelet reactivity units (PRU). Based on the initial PRU, seven patients' doses were adjusted with subsequent PRUs in or near the goal range of 50-150. One patient experienced an acute intraprocedural occlusion likely related to a subtherapeutic PRU which subsequently resolved with cangrelor dose adjustment and intra-arterial tirofiban administration, and one patient experienced a post-procedure stent occlusion which required a thrombectomy and intra-arterial tirofiban administration. No hemorrhagic complications occurred. DISCUSSION Cangrelor utilization during neuroendovascular stenting with maintenance doses of <2 mcg/kg/min with dose adjustments based on platelet function testing has not been previously described. Cangrelor presents many advantages compared to standard therapy in patients undergoing stent placement related to its pharmacokinetic profile, rapid onset of action, ease of transition to oral P2Y12 antiplatelet agents, and measurability. CONCLUSION Cangrelor is a promising alternative to currently available therapies, especially in patients with a high hemorrhagic risk.
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Affiliation(s)
- Pouya Entezami
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Devin N Holden
- Department of Pharmacy, Albany Medical Center, Albany, NY, USA
| | - Alan S Boulos
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Alexandra R Paul
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Nicholas C Field
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Emad Nourollahzadeh
- Department of Neurosurgery, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Junichi Yamamoto
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - John C Dalfino
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
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16
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Kim MJ, Patel P, Vyas N, Leveque C, Diaz O, Salazar E. A 70-Year-Old Female with Unexpected Platelet Function Testing Results. Lab Med 2020; 51:310-314. [PMID: 31665395 DOI: 10.1093/labmed/lmz070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A 70-year-old female with a history of hypertension and left A2 segment aneurysm was scheduled for pipeline embolization device (PED) placement. Preinterventional antiplatelet prophylaxis included aspirin and ticagrelor. Unexpectedly, after 13 days of treatment, VerifyNow showed a P2Y12 reaction unit (PRU) value of 216, approximately >5 times the mean PRU of other patients on aspirin and ticagrelor. We confirmed platelet reactivity and ticagrelor resistance with light transmission aggregometry. Antiplatelet therapy was switched to prasugrel, and aspirin was continued. Eight days later, the P2Y12 reaction value (PRU) was 164. PED was placed without complications. Unlike clopidogrel, ticagrelor is a direct P2Y12 inhibitor that does not require metabolism to an active metabolite. Ticagrelor resistance is very rarely reported. To the best of our knowledge, there has been no case of ticagrelor resistance reported in the context of pre-PED placement prophylaxis.
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Affiliation(s)
- Moon Joo Kim
- Houston Methodist Hospital, Department of Pathology and Genomic Medicine, Houston, Texas
| | - Pragna Patel
- Houston Methodist Hospital, Department of Neurointerventional Radiology, Houston, Texas
| | - Niti Vyas
- Houston Methodist Hospital, Department of Pathology and Genomic Medicine, Houston, Texas
| | - Christopher Leveque
- Houston Methodist Hospital, Department of Pathology and Genomic Medicine, Houston, Texas
| | - Orlando Diaz
- Houston Methodist Hospital, Department of Neurointerventional Radiology, Houston, Texas
| | - Eric Salazar
- Houston Methodist Hospital, Department of Pathology and Genomic Medicine, Houston, Texas
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17
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Kan I, Ishibashi T, Sakuta K, Fujimura S, Yuki I, Kaku S, Kodama T, Kato N, Nishimura K, Aoki K, Sasaki Y, Karagiozov K, Murayama Y. Preoperative Light Transmission Aggregometry Values Predict for Thromboembolic Complications After Stent-Assisted Coil Embolization. World Neurosurg 2020; 134:e731-e738. [DOI: 10.1016/j.wneu.2019.10.179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 12/18/2022]
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18
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Mohanty A, Srivatsan A, Kan P. Commentary: Antiplatelet Therapy in Flow Diversion. Neurosurgery 2020; 86:E229-E230. [PMID: 31844903 DOI: 10.1093/neuros/nyz458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 08/23/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Alina Mohanty
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Aditya Srivatsan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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19
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Wipplinger C, Griessenauer CJ. Commentary: Antiplatelet Therapy in Flow Diversion. Neurosurgery 2020; 86:E231-E233. [PMID: 31844900 DOI: 10.1093/neuros/nyz462] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 08/23/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Christoph J Griessenauer
- Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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20
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Tonetti DA, Jankowitz BT, Gross BA. Antiplatelet Therapy in Flow Diversion. Neurosurgery 2019; 86:S47-S52. [DOI: 10.1093/neuros/nyz391] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 07/25/2019] [Indexed: 01/03/2023] Open
Abstract
Abstract
Dual antiplatelet therapy is typically employed as a means to mitigate thromboembolic complications after deployment of flow diverters, most commonly consisting of aspirin with either clopidogrel, prasugrel, or ticagrelor. Recent studies have demonstrated at least similar efficacy for ticagrelor as compared to clopidogrel in the form of periprocedural complications and angiographic results. Though controversial, systematic reviews of platelet function assay usage have demonstrated greater rates of thrombotic complications in antiplatelet hyporesponders and greater rates of hemorrhagic complications in hyperresponders. Though in its infancy, the management of antiplatelet therapy for acutely ruptured aneurysms treated with flow diversion is not yet standardized, with approaches including intravenous glycoprotein IIb-IIIa inhibitors and subsequent antiplatelet loading vs antiplatelet loading, response assessment, and subsequent treatment.
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Affiliation(s)
- Daniel A Tonetti
- UPMC Stroke Institute and Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian T Jankowitz
- UPMC Stroke Institute and Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bradley A Gross
- UPMC Stroke Institute and Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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21
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Podlasek A, Al Sultan AA, Assis Z, Kashani N, Goyal M, Almekhlafi MA. Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis. J Neurointerv Surg 2019; 12:148-155. [DOI: 10.1136/neurintsurg-2019-014996] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/30/2019] [Accepted: 06/02/2019] [Indexed: 01/15/2023]
Abstract
BackgroundThromboembolic complications are not uncommon in patients undergoing neurointerventional procedures. The use of flow diverting stents is associated with higher risks of these complications despite current dual antiplatelet regimens.ObjectiveTo explore contemporary evidence on the safety of emerging dual antiplatelet regimens in flow diverting stenting procedures.MethodsWe performed a systematic review and meta-analysis to identify relevant articles in electronic databases, and relevant references. Studies reporting the complications and mortality of flow diverting stenting procedures using acetyl salicylic acid (ASA) + ticagrelor or ASA + prasugrel compared with ASA + clopidogrel were included.ResultsOf 452 potentially relevant studies, we identified 49 studies (2526 patients) which reported the safety of ticagrelor or prasugrel for pooled analysis, and five studies (1005 patients) for meta-analysis. The pooled overall mortality in all studies was 2.14%, ischemic complications 6.89%, and hemorrhagic complications 3.68%. The use of ticagrelor or prasugrel was associated with a lower risk of mortality compared with clopidogrel (RR=4.57, 95% CI 1.23 to 16.99; p=0.02). Considering ischemic events, ASA + clopidogrel was as safe as ASA + prasugrel (RR=0.55, 95% CI 0.11 to 2.74; p=0.47) and ASA + ticagrelor (RR=0.74, 95% CI 0.32 to 1.74; p=0.49). ASA +ticagrelor was not associated with a higher risk of hemorrhagic complications (RR=0.92, 95% CI 0.27 to 3.16; p=0.89).ConclusionsEvidence suggests that dual antiplatelet regimens including ticagrelor or prasugrel are safe for patients undergoing flow diversion procedures. Regimens using ticagrelor were associated with better survival than those using clopidogrel in the included studies.
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22
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Griffin A, Reese V, Hüseyinoglu Z, Niedzwiecki D, Yang L, Cutler A, Gonzalez LF, Zomorodi A, Smith T, Hauck EF. Predictors of Clinical Outcome After Treatment of Intracranial Aneurysms with the Pipeline Embolization Device. World Neurosurg 2019; 130:e666-e671. [PMID: 31276854 DOI: 10.1016/j.wneu.2019.06.185] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/22/2019] [Accepted: 06/24/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Flow-diverting stents have revolutionized the endovascular treatment of intracranial aneurysms. The purpose of this study is to identify predictors of adverse outcomes associated with the pipeline embolization device (PED). METHODS A retrospective analysis of all patients treated with PED at a single high-volume center from January 2014 to September 2018. Patient outcomes, neurologic morbidity/mortality, and other clinical variables were analyzed. RESULTS We treated 204 aneurysms in 170 patients with PED. Mean length of follow-up was 11 months. Most (181) aneurysms (89%) were located in the anterior circulation, and 23 (11%) were found in the posterior circulation. Most aneurysms were saccular (82%), followed by fusiform (11%), blister (4%), and dissecting pseudoaneurysms (3%). Mean aneurysm size was 8.2 + 5.7 mm with 145 (71%) small aneurysms (≤10 mm), 53 (26%) large aneurysms (between 10 and 25 mm), and 6 (3%) giant aneurysms (≥25 mm). Ninety-two percent of aneurysms were unruptured, and 8% were ruptured. The overall major neurologic morbidity/mortality was 4.7% and 1.8%, respectively. The all-cause mortality was 2.9%. Predictors of neurologic morbidity/mortality included the baseline modified Rankin Scale (P = 0.001), aneurysm neck size (P = 0.003), aneurysm size (P = 0.006), anterior versus posterior location (P = 0.02), and rupture at presentation (0.006). The P2Y12 Reactivity Unit, parent vessel diameter, and patient age did not correlate with adverse events. CONCLUSIONS The PED has a satisfactory safety profile in both on- and off-label indications. A poor clinical patient baseline, wider aneurysm neck or larger size, and rupture predict an increased risk of an unfavorable outcome.
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Affiliation(s)
- Andrew Griffin
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
| | - Vanessa Reese
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Zeynep Hüseyinoglu
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Donna Niedzwiecki
- Department of Biostatistics, Duke University Medical Center, Durham, North Carolina, USA
| | - Lexie Yang
- Department of Biostatistics, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrew Cutler
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Ali Zomorodi
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Tony Smith
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Erik F Hauck
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
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23
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Henkes H, Bhogal P, Aguilar Pérez M, Lenz-Habijan T, Bannewitz C, Peters M, Sengstock C, Ganslandt O, Lylyk P, Monstadt H. Anti-thrombogenic coatings for devices in neurointerventional surgery: Case report and review of the literature. Interv Neuroradiol 2019; 25:619-627. [PMID: 31248313 PMCID: PMC6820329 DOI: 10.1177/1591019919858000] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Stent-assisted coiling and extra-saccular flow diversion require dual anti-platelet therapy due to the thrombogenic properties of the implants. While both methods are widely accepted, thromboembolic complications and the detrimental effects of dual anti-platelet therapy remain a concern. Anti-thrombogenic surface coatings aim to solve both of these issues. Current developments are discussed within the framework of an actual clinical case. CASE DESCRIPTION A 33-year-old male patient lost consciousness while doing sport and was administered 500 mg acetylsalicylic acid on site. Computed tomography revealed a massive subarachnoid haemorrhage, and digital subtraction angiography showed an aneurysm of the right middle cerebral artery. Stent-assisted coiling using a neck bridging device with a hydrophilic coating (pCONUS_HPC) was considered as an appropriate approach. Another 500 mg acetylsalicylic acid IV was given. After the single anti-platelet therapy was seen to be effective, a pCONUS_HPC was implanted, and the aneurysm sac subsequently fully occluded using coils. No thrombus formation was encountered. During the following days, 2 × 500 mg acetylsalicylic acid IV daily were required to maintain single anti-platelet therapy, monitored by frequent response testing. Follow-up digital subtraction angiography after 13 days confirmed the occlusion of the aneurysm and the patency of the middle cerebral artery. CONCLUSION A variety of ways to reduce the thrombogenicity of neurovascular stents is discussed. Hydrophilic surface coatings are a valid concept to improve the haemocompatibility of neurovascular implants while avoiding the use of dual anti-platelet therapy. Phosphorylcholine and phenox hydrophilic polymer coating are currently the most promising candidates. This concept is supported by anecdotal experience. However, formalised registries and randomised trials are currently being established.
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Affiliation(s)
- Hans Henkes
- Neuroradiological Clinic, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | | | | | | | - Marcus Peters
- Experimental Pneumology, Medical Faculty, Ruhr University, Bochum, Germany
| | - Christina Sengstock
- Surgical Research, BG University Hospital Bergmannsheil Bochum, Ruhr University, Bochum, Germany
| | | | - Pedro Lylyk
- Clinica La Sagrada Familia, ENERI, Buenos Aires, Argentina
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24
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Chen JA, Garrett MC, Mlikotic A, Ausman JI. Treatment of intracranial vertebral artery dissecting aneurysms involving the posterior inferior cerebellar artery origin. Surg Neurol Int 2019; 10:116. [PMID: 31528452 PMCID: PMC6744774 DOI: 10.25259/sni-281-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 05/02/2019] [Indexed: 02/07/2023] Open
Abstract
Background Vertebral artery dissecting aneurysm (VADA) involving the origin of the posterior inferior cerebellar artery (PICA) is a complex disease entity in which the dual goals of preventing future rebleeding and maintaining perfusion of the lateral medulla must be considered. We present an illustrative case and review the literature surrounding treatment strategies. Case Description We report a patient presenting with extensive subarachnoid hemorrhage due to rupture of an intracranial VADA involving the PICA origin. After consideration of the patient's cerebral vasculature and robustness of collaterals, a flow-diverting stent was placed with angiographic resolution of the lesion and maintenance of antegrade PICA flow. Ultimately, the patient experienced a contralateral intraparenchymal hemorrhage leading to death. Review of the literature identified 124 cases of VADA involving the PICA origin described over the past decade. The methods of surgical and endovascular treatment of these cases were reviewed, with particular focus on the rationale of treatment, outcomes, and complications. Conclusion Numerous treatment options for VADA involving PICA have been reported with different risk and benefit profiles. Flow-diverting stents appear to offer the most favorable balance of securing the aneurysm and avoiding medullary infarction, but the risks and optimal anti-thrombotic treatment strategy are incompletely understood. In select cases, in which the surgical risk is low or in which the anatomy is favorable (e.g., nondominant parent vessel or robust collateral circulation in the involved territories), parent artery trapping with or without microsurgical revascularization can be considered.
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Affiliation(s)
- Jason A Chen
- Department of Neurosurgery, University of California, Los Angeles
| | | | - Anton Mlikotic
- Department of Radiology, Harbor-UCLA Medical Center, Torrance, California, USA
| | - James I Ausman
- Department of Neurosurgery, University of California, Los Angeles
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25
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Sarrami-Foroushani A, Lassila T, Hejazi SM, Nagaraja S, Bacon A, Frangi AF. A computational model for prediction of clot platelet content in flow-diverted intracranial aneurysms. J Biomech 2019; 91:7-13. [PMID: 31104921 DOI: 10.1016/j.jbiomech.2019.04.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 03/14/2019] [Accepted: 04/30/2019] [Indexed: 01/30/2023]
Abstract
Treatment of intracranial aneurysms with flow-diverting stents is a safe and minimally invasive technique. The goal is stable embolisation that facilitates stent endothelialisation, and elimination of the aneurysm. However, it is not fully understood why some aneurysms fail to develop a stable clot even with sufficient levels of flow reduction. Computational prediction of thrombus formation dynamics can help predict the post-operative response in such challenging cases. In this work, we propose a new model of thrombus formation and platelet dynamics inside intracranial aneurysms. Our novel contribution combines platelet activation and transport with fibrin generation, which is key to characterising stable and unstable thrombus. The model is based on two types of thrombus inside aneurysms: red thrombus (fibrin- and erythrocyte-rich) can be found in unstable clots, while white thrombus (fibrin- and platelet-rich) can be found in stable clots. The thrombus generation model is coupled to a CFD model and the flow-induced platelet index (FiPi) is defined as a quantitative measure of clot stability. Our model is validated against an in vitro phantom study of two flow-diverting stents with different sizing. We demonstrate that our model accurately predicts the lower thrombus stability in the oversized stent scenario. This opens possibilities for using computational simulations to improve endovascular treatment planning and reduce adverse events, such as delayed haemorrhage of flow-diverted aneurysms.
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Affiliation(s)
- Ali Sarrami-Foroushani
- Centre for Computational Imaging and Simulation Technologies in Biomedicine (CISTIB), School of Computing, University of Leeds, Leeds, UK
| | - Toni Lassila
- Centre for Computational Imaging and Simulation Technologies in Biomedicine (CISTIB), School of Computing, University of Leeds, Leeds, UK
| | - Seyed Mostafa Hejazi
- Department of Electronic and Electrical Engineering, The University of Sheffield, Sheffield, UK
| | | | - Andrew Bacon
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, UK
| | - Alejandro F Frangi
- Centre for Computational Imaging and Simulation Technologies in Biomedicine (CISTIB), School of Computing, University of Leeds, Leeds, UK; Biomedical Imaging Department, Leeds Institute for Cardiovascular and Metabolic Medicine (LICAMM), School of Medicine, University of Leeds, Leeds, UK.
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26
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Ajadi E, Kabir S, Cook A, Grupke S, Alhajeri A, Fraser JF. Predictive value of platelet reactivity unit (PRU) value for thrombotic and hemorrhagic events during flow diversion procedures: a meta-analysis. J Neurointerv Surg 2019; 11:1123-1128. [PMID: 31005859 DOI: 10.1136/neurintsurg-2019-014765] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/26/2019] [Accepted: 03/28/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Platelet function testing prior to flow diversion procedures, although initially heavily debated, has seen a substantial increase in its adoption to assess the risk of operative and perioperative thrombotic and hemorrhagic events. This meta-analysis was conducted to assess platelet function testing, particularly the VerifyNow Platelet Reactivity Unit (PRU) assay, for a relationship between the reported assay PRU value and thrombotic and hemorrhagic events. MATERIALS AND METHODS The currently available literature (2013-2018) was surveyed with PubMed and Google Scholar searches. Included studies were those for which there were at least 30 cases during the study period, for which VerifyNow platelet reactivity unit values were obtained prior to the procedures and for which intraoperative and perioperative adverse events were noted. PRU value cut-offs ranging from >200 to >240 comprised the hyporesponse group while values ranging from <60 to <70 comprised the hyper-response group. The data were subject to statistical analysis to assess the relationship between PRU values and thrombotic and hemorrhagic events. The collected data were subsequently statistically analyzed to assess for publication bias. RESULTS The searches yielded 27 studies, of which 12 met the inclusion criteria for the meta-analysis. The meta-analysis included data from 1464 reported Pipeline cases. The study included 273 men and 1177 women with a mean age across the analyzed procedures of 58 years (range 25-85). After loading with antiplatelet medications, preprocedural platelet hyper-responsiveness was associated with a greater incidence of hemorrhagic events with an increased absolute risk of 12%, but showed no relationship with thrombotic events. Preprocedural platelet hyporesponsiveness was associated with a greater incidence of thrombotic events with an absolute risk of 15%, but showed no relationship with hemorrhagic events. CONCLUSIONS VerifyNow PRU values that correspond to platelet hyporesponse or hyper-response to dual antiplatelet therapy are associated with a higher risk of thrombotic and hemorrhagic events, respectively. Thus, the PRU value may offer some predictive value for these events.
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Affiliation(s)
- Ebunoluwa Ajadi
- University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Shaowli Kabir
- Department of Statistics, College of Arts and Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Aaron Cook
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Stephen Grupke
- Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Abdulnasser Alhajeri
- Department of Neurology, University of Kentucky, Lexington, KY, USA.,Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Justin F Fraser
- Department of Neurology, University of Kentucky, Lexington, KY, USA.,Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA.,Department of Radiology, University of Kentucky, Lexington, KY, USA.,Department of Neuroscience, University of Kentucky, Lexington, KY, USA
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27
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Treatment of ruptured blood blister-like aneurysms of the internal carotid artery with flow-diverting stents: Case report and review of pharmacological management. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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28
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Colby GP, Jiang B, Bender MT, Beaty NB, Westbroek EM, Xu R, Lin LM, Campos JK, Tamargo RJ, Huang J, Cohen AR, Coon AL. Pipeline-assisted coil embolization of a large middle cerebral artery pseudoaneurysm in a 9-month-old infant: experience from the youngest flow diversion case. J Neurosurg Pediatr 2018; 22:532-540. [PMID: 30141750 DOI: 10.3171/2018.6.peds18165] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/04/2018] [Indexed: 11/06/2022]
Abstract
Intracranial aneurysms in the pediatric population are rare entities. The authors recently treated a 9-month-old infant with a 19-mm recurrent, previously ruptured, and coil-embolized left middle cerebral artery (MCA) pseudoaneurysm, which was treated definitively with single-stage Pipeline-assisted coil embolization. The patient was 5 months old when she underwent resection of a left temporal Grade 1 desmoplastic infantile ganglioglioma at an outside institution, which was complicated by left MCA injury with a resultant 9-mm left M1 pseudoaneurysm. Within a month, the patient had two aneurysmal rupture events and underwent emergency craniectomy for decompression and evacuation of subdural hematoma. The pseudoaneurysm initially underwent coil embolization; however, follow-up MR angiography (MRA) revealed aneurysm recanalization with saccular enlargement to 19 mm. The patient underwent successful flow diversion-assisted coil embolization at 9 months of age. At 7 months after the procedure, follow-up MRA showed complete aneurysm occlusion without evidence of in-stent thrombosis or stenosis. Experience with flow diverters in the pediatric population is still in its early phases, with the youngest reported patient being 22 months old. In this paper the authors report the first case of such a technique in an infant, whom they believe to be the youngest patient to undergo cerebral flow diversion treatment.
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Affiliation(s)
- Geoffrey P Colby
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
- 2Department of Neurosurgery, UCLA Medical Center, Los Angeles, California; and
| | - Bowen Jiang
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Matthew T Bender
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Narlin B Beaty
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Erick M Westbroek
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Risheng Xu
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Li-Mei Lin
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
- 3Department of Neurosurgery, UC Irvine Medical Center, Orange, California
| | - Jessica K Campos
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Judy Huang
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alan R Cohen
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alexander L Coon
- 1Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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29
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Saber H, Kherallah RY, Hadied MO, Kazemlou S, Chamiraju P, Narayanan S. Antiplatelet therapy and the risk of ischemic and hemorrhagic complications associated with Pipeline embolization of cerebral aneurysms: a systematic review and pooled analysis. J Neurointerv Surg 2018; 11:362-366. [PMID: 30201813 DOI: 10.1136/neurintsurg-2018-014082] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pipeline embolization devices (PEDs) are increasingly used in the treatment of cerebral aneurysms. Yet, major ischemic or hemorrhagic complications after PED treatment associated with antiplatelet regimens are not well-established. OBJECTIVE To investigate the risk of ischemic and hemorrhagic complications associated with common antiplatelet regimens following PED treatment, and to examine whether platelet function testing (PFT) is associated with a lower risk of these complications. METHODS We searched Medline, Embase, and Cochrane from 2009 to 2017. Twenty-nine studies were included that had reported a uniform antiplatelet regimen protocol and had provided data on major ischemic and hemorrhagic complications following PED treatment. Random-effect meta-analysis was used to pool overall ischemic and hemorrhagic event rates across studies. The rate of these complications with respect to the antithrombotic regimen and PFT was assessed by χ2 proportional tests. RESULTS Overall, 2002 patients (age 55.9 years, 76% female) were included. A low-dose acetylsalicylic acid (ASA) regimen before and after PED treatment was associated with a higher rate of late ischemic complications than with high-dose ASA therapy (2.62 (95% CI 1.46 to 4.69) and 2.56 (1.41 to 4.64), respectively). Duration of post-procedure clopidogrel therapy <6 months was associated with greater rates of ischemic complications (1.56, 95% CI 1.11 to 2.20) than a clopidogrel regimen of ≥6 months. Performing PFT before PED treatment was not associated with the risk of ischemic complications (1.27, 95% CI 0.77 to 2.10). CONCLUSION High-dose ASA therapy and clopidogrel treatment for at least 6 months were associated with a reduced incidence of ischemic events, without affecting the risk of hemorrhagic events.
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Affiliation(s)
- Hamidreza Saber
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Riyad Y Kherallah
- Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Mohamad O Hadied
- Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | - Parthasarathi Chamiraju
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sandra Narayanan
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
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30
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Essbaiheen F, AlQahtani H, Almansoori TM, Cora EA, Patro S, Tsehmaister-Abitbul V, Drake B, Lesiuk H, Finitsis SN, Iancu D. Transient in-stent stenosis at mid-term angiographic follow-up in patients treated with SILK flow diverter stents: incidence, clinical significance and long-term follow-up. J Neurointerv Surg 2018; 11:166-170. [PMID: 30194108 DOI: 10.1136/neurintsurg-2018-013928] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Little is known about in-stent stenosis (ISS) in patients with aneurysms treated with flow diverter (FD) stents. The reported incidence in the literature varies significantly. OBJECTIVE The aim of this study was to assess the incidence, severity, distribution, clinical significance, and possible predictors for ISS. METHODS Between July 2012 and June 2016 we retrospectively reviewed all patients treated with SILK FDs in our center. Only cases with short-term (4±2 months) and long-term (>1 year) follow-ups with digital subtraction angiograms were included. ISS was graded as mild (<25%), moderate (25-50%) or severe (>50%). The following predictors for ISS were assessed: gender, age, the presence of subarachnoid hemorrhage, aneurysm size, location, occlusion status, and post-stenting angioplasty. RESULTS Thirty-six patients met the inclusion criteria. At mid-term follow-up, ISS was observed in 16/36 patients (44%). Eleven patients (69%) had mild ISS, three (19%) moderate, and two (12%) severe ISS. ISS was diffuse in 11 patients (69%) and focal in five patients (31%). All patients were asymptomatic. Thirteen patients were maintained on dual antiplatelet therapy and three on aspirin alone. At long-term follow-up, complete ISS resolution was seen in 11 patients, improvement in three and worsening in two patients. No de novo ISS occurrence was observed. On univariate analysis there was no significant predictor for ISS. CONCLUSIONS Transient ISS after FD deployment is a common asymptomatic finding on mid-term angiographic follow-up. Complete resolution or improvement at long-term follow-up is seen in most patients who are maintained on dual antiplatelet therapy.
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Affiliation(s)
- Fahad Essbaiheen
- Division of Interventional Neuroradiology, Department of Diagnostic Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Medical Imaging, King Saud University, Riyadh, Riyadh Province, Saudi Arabia
| | - Hanan AlQahtani
- Division of Interventional Neuroradiology, Department of Diagnostic Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Elena Adela Cora
- Division of Interventional Neuroradiology, Department of Diagnostic Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Satya Patro
- Division of Interventional Neuroradiology, Department of Diagnostic Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Vered Tsehmaister-Abitbul
- Division of Interventional Neuroradiology, Department of Diagnostic Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Brian Drake
- Department of Neurosurgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Howard Lesiuk
- Department of Neurosurgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stephanos Nikolaos Finitsis
- Division of Interventional Neuroradiology, Department of Diagnostic Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Daniela Iancu
- Division of Interventional Neuroradiology, Department of Diagnostic Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada
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31
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Cohen JE, Gomori JM, Leker RR, Spektor S, Abu El Hassan H, Itshayek E. Stent and flow diverter assisted treatment of acutely ruptured brain aneurysms. J Neurointerv Surg 2018; 10:851-858. [PMID: 29778996 DOI: 10.1136/neurintsurg-2017-013742] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 02/26/2018] [Accepted: 03/02/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE We present our experience with stent techniques in the management of acutely ruptured aneurysms, focusing on aneurysm occlusion rates, intraprocedural complications, and late outcomes. METHODS We retrospectively reviewed the clinical records of patients treated by stent techniques during the early acute phase of aneurysmal rupture, from June 2011 to June 2016. Patients who underwent stenting for the management of unruptured aneurysms, or in a delayed fashion for a ruptured lesion, were excluded. RESULTS 47 patients met inclusion criteria, including 46 with subarachnoid hemorrhage (SAH). There were 27 men and 20 women, mean age 38 years (range 23-73). They harbored 71 aneurysms, including 56 treated in the acute phase. Aneurysmal dome and neck width averaged 4.7 mm (range 1.7-12.1) and 3.2 mm (range 1.5-7.1), respectively. Single stent techniques were used in 39 patients and dual stent techniques in 17. External ventricular drains (EVDs) were placed before embolization in 35 patients (92%) and after in 3. Intraprocedure thromboembolic complications due to a hyporesponse to antiplatlets in 4 patients (8.5%) were successfully managed with intra-arterial antiplatelet agents. In 45 surviving patients (96%), there was complete aneurysm occlusion at the 9-12 month follow-up in 26/29 aneurysms treated by stent-assisted coiling (90%), in 2/3 aneurysms treated by flow diverter-assisted coiling (66%), and in 19/22 aneurysms treated by flow diverter alone (86%); 42/45 patients (93%) presented with a modified Rankin Scale score of 0-2. CONCLUSION Stenting techniques in ruptured aneurysms can be performed with good technical success; however, procedural thromboembolic complications related to the antiplatelet strategy merit investigation. EVD placement before stenting must be considered.
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Affiliation(s)
- José E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J Moshe Gomori
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Sergey Spektor
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hosni Abu El Hassan
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Eyal Itshayek
- Department of Neurosurgery, Rabin Medical Center, Petah Tikva, Israel
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32
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Adeeb N, Gupta R, Schneider AM, Leadon M, Enriquez A, Griessenauer CJ, Salem M, Alturki A, Schmalz P, Ogilvy CS, Thomas AJ, Moore JM. Defining a Clopidogrel Response Cut-Off Value Using Light Transmission Aggregometry Before Pipeline Embolization of Unruptured Intracranial Aneurysms. World Neurosurg 2018; 113:e146-e152. [DOI: 10.1016/j.wneu.2018.01.198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 01/29/2018] [Indexed: 10/18/2022]
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33
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Jiang B, Bender MT, Westbroek EM, Campos JK, Lin LM, Xu R, Tamargo RJ, Huang J, Colby GP, Coon AL. Procedural complexity independent of P2Y12 reaction unit (PRU) values is associated with acute in situ thrombosis in Pipeline flow diversion of cerebral aneurysms. Stroke Vasc Neurol 2018; 3:169-175. [PMID: 30294473 PMCID: PMC6169609 DOI: 10.1136/svn-2018-000150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/24/2018] [Indexed: 12/03/2022] Open
Abstract
Background Acute in situ thrombosis is an ischaemic phenomenon during Pipeline embolisation device (PED) procedures with potentially high morbidity and mortality. There is controversy regarding the role of platelet function testing with P2Y12 assay as a predictor of intraprocedural thromboembolic events. There is limited knowledge on whether procedural complexity influences these events. Methods Data were collected retrospectively on 742 consecutive PED cases at a single institution. Patients with intraprocedural acute thrombosis were compared with patients without these events. Results A cohort of 37 PED cases with acute in situ thrombosis (mean age 53.8 years, mean aneurysm size 8.4 mm) was matched with a cohort of 705 PED cases without intraprocedural thromboembolic events (mean age 56.4 years, mean aneurysm size 6.9 mm). All patients with in situ thrombosis received intra-arterial and/or intravenous abciximab. The two groups were evenly matched in patient demographics, previous treatment/subarachnoid hemorrhage (SAH) and aneurysm location. There was no statistical difference in postprocedural P2Y12 reaction unit (PRU) values between the two groups, with a mean of 156 in the in situ thrombosis group vs 148 in the control group (p=0.5894). Presence of cervical carotid tortuosity, high cavernous internal carotid artery grade, need for multiple PED and vasospasm were not significantly different between the two groups. The in situ thrombosis group had statistically significant longer fluoroscopy time (60.4 vs 38.4 min, p<0.0001), higher radiation exposure (3476 vs 2160 mGy, p<0.0001), higher rates of adjunctive coiling (24.3% vs 8.37%, p=0.0010) and higher utilisation of balloon angioplasty (37.8% vs 12.2%, p<0.0001). Clinically, the in situ thrombosis cohort had higher incidence of major and minor stroke, intracerebral haemorrhage and length of stay. Conclusions Predictors of procedural complexity (higher radiation exposure, longer fluoroscopy time, adjunctive coiling and need for balloon angioplasty) are associated with acute thrombotic events during PED placement, independent of PRU values.
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Affiliation(s)
- Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica K Campos
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Li-Mei Lin
- Department of Neurosurgery, University of California, Irvine School of Medicine, Orange, California, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 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, Baltimore, Maryland, USA
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Al-Mufti F, Amuluru K, Cohen ER, Patel V, El-Ghanem M, Wajswol E, Dodson V, Al-Marsoummi S, Majmundar N, Dangayach NS, Nuoman R, Gandhi CD. Rescue Therapy for Procedural Complications Associated With Deployment of Flow-Diverting Devices in Cerebral Aneurysms. Oper Neurosurg (Hagerstown) 2018; 15:624-633. [DOI: 10.1093/ons/opy020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 03/15/2018] [Indexed: 12/12/2022] Open
Abstract
Abstract
Flow diverting devices (FDDs) have revolutionized the treatment of morphologically complex intracranial aneurysms such as wide-necked, giant, or fusiform aneurysms. Although FDDs are extremely effective, they carry a small yet significant risk of intraprocedural complications. As the implementation of these devices increases, the ability to predict and rapidly treat complications, especially those that are iatrogenic or intraprocedural in nature, is becoming increasingly more necessary.
Our objective in this paper is to provide a descriptive summary of the various types of intraprocedural complications that may occur during FDDs deployment and how they may best be treated. A systematic and qualitative review of the literature was conducted using electronic databases MEDLINE and Google Scholar. Searches consisted of Boolean operators “AND” and “OR” for the following terms in different combinations: “aneurysm,” “endovascular,” “flow diverter,” “intracranial,” and “pipeline.”
A total of 94 papers were included in our analysis; approximately 87 of these papers dealt with periprocedural endovascular (mainly related to FDDs) complications and their treatment; 7 studies concerned background material. The main categories of periprocedural complications encountered during deployment of FDDs are failure of occlusion, parent vessel injury and/or rupture, spontaneous intraparenchymal hemorrhage, migration or malposition of the FDDs, thromboembolic or ischemic events, and side branch occlusion
Periprocedural complications occur mainly due to thromboembolic events or mechanical issues related to device deployment and placement. With increasing use and expanding versatility of FDDs, the understanding of these complications is vital in order to effectively manage such situations in a timely manner.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Neuro-surgery, and Radiology, Robert Wood Johnson Medical School, Rutgers Uni-versity, New Brunswick, New Jersey
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh Medical Center Hamot, Erie, Pennsylvania
| | - Eric R Cohen
- Department of Radiology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Vikas Patel
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
- Department of Neurology, New Jersey Medical School, Rutgers University, Newark, New Jersey
| | - Mohammad El-Ghanem
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Ethan Wajswol
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Vincent Dodson
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Sarmad Al-Marsoummi
- Department of Neuroscience, University of North Dakota, Grand Forks, North Dakota
| | - Neil Majmundar
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Neha S Dangayach
- Department of Neurology and Neurosurgery, Ichan School of Medicine at Mount Sinai, New York, New York
| | - Rolla Nuoman
- Department of Neurology, New Jersey Medical School, Rutgers University, Newark, New Jersey
| | - Chirag D Gandhi
- Department of Neurosurgery, New York Medical College, Westchester Medical Center, New York, New York
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35
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Narata AP, Amelot A, Bibi R, Herbreteau D, Angoulvant D, Gruel Y, Janot K. Dual Antiplatelet Therapy Combining Aspirin and Ticagrelor for Intracranial Stenting Procedures: A Retrospective Single Center Study of 154 Consecutive Patients With Unruptured Aneurysms. Neurosurgery 2018; 84:77-83. [DOI: 10.1093/neuros/nyy002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/05/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Ana Paula Narata
- Department of Radiology and Neu-roradiology, University Hospital of Tours, Tours, France
| | - Aymeric Amelot
- Department of Neurosurgery, University Hospital of Tours, Tours, France
| | - Richard Bibi
- Department of Radiology and Neu-roradiology, University Hospital of Tours, Tours, France
| | - Denis Herbreteau
- Department of Radiology and Neu-roradiology, University Hospital of Tours, Tours, France
| | - Denis Angoulvant
- Department of Cardiology, University Hospital of Tours, Tours, France
| | - Yves Gruel
- Department of Hematology, University Hospital of Tours, Tours, France
| | - Kevin Janot
- Department of Radiology and Neu-roradiology, University Hospital of Tours, Tours, France
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