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Zhang Z, Liu JY, Xing HS, Ma JY, Li AJ. Microsurgical clipping and endovascular intervention for middle cerebral artery aneurysm: A meta-analysis. Medicine (Baltimore) 2023; 102:e34956. [PMID: 37653731 PMCID: PMC10470800 DOI: 10.1097/md.0000000000034956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/12/2023] [Accepted: 08/04/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The purpose of this study is to compare the prognosis and effective rate of interventional embolization and surgical clipping in the treatment of middle cerebral artery aneurysms, to provide evidence-based basis for the selection of clinical treatment. METHODS By searching PubMed, Cochrane library, Medline, Embase and other databases, we collected the related studies interventional embolization and surgical clipping in the treatment of middle cerebral artery aneurysms, whether it was a randomized controlled trial or not. According to the relevant inclusion and exclusion criteria, 2 researchers independently screened and extracted the relevant data. Quality of life, residual neck and recurrence rate, incidence of ischemic cerebral infarction, intracranial infection rate, incidence of vasospasm and rebleeding rate were measured. Revman5.4 software was used for Meta-analysis. RESULTS There were 3658 patients included in 30 literatures, including 1478 patients treated with interventional embolization and 2180 patients treated with surgical clipping. The rate of low quality of life (odds ratio [OR] = 1.68, 95% confidence interval [CI]: 1.36-2.07, P < .00001) and intracranial infection rate (OR = 8.79,95% CI: 4.47-17.27, P < .00001) in the interventional embolization group were lower than those in the surgical clipping group. The postoperative rebleeding rate (OR = 0.46, 95% CI: 0.29-0.73, P = .0009), residual neck and recurrence rate (OR = 0.32, 95% CI: 0.24-0.43, P < .00001) in the interventional embolization group were higher than those in the surgical clipping group. The heterogeneity of residual neck and recurrence rate were high, so subgroup analysis was performed. We divide them into short-term group (OR = 0.68, 95% CI: 0.40-1.13, P = .13) and long-term group (OR = 0.23, 95% CI: 0.16-0.33, P < .00001). The results showed that the residual neck and recurrence rate in the interventional embolization group were higher than those in the surgical clipping group. There was no significant difference in the incidence of cerebral vasospasm (OR = 1.09, 95% CI: 0.64-1.86, P = .74) and ischemic stroke (OR = 0.87, 95% CI: 0.63-1.19, P = .37) between the 2 treatments. CONCLUSION According to the current clinical research evidence, compared with interventional embolization in the treatment of middle cerebral artery aneurysms, the quality of life of patients after clipping is lower, the incidence of intracranial infection is higher, but the residual neck, and recurrence rate are reduced. The risk of rebleeding is also reduced. There was no significant difference in the incidence of vasospasm and ischemic stroke between the 2 groups.
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Affiliation(s)
- Zheng Zhang
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Jing Yi Liu
- Plastic Surgery Institute, Weifang Medical University, Weifang, Weifang City, Shandong Province, China
| | - Hong Shun Xing
- Department of Neurosurgery, Weifang People’s Hospital Affiliated to Weifang Medical University, Weifang, China
| | - Jin Yuan Ma
- Department of Neurosurgery, The Affiliated Hospital of Qing Dao Binhai University, Qingdao, China
| | - Ai Jun Li
- Department of Neurosurgery, The Affiliated Hospital of Qing Dao Binhai University, Qingdao, China
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2
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Gao HL, Shao QJ, Chang KT, Li L, Li TX, Gao B. Use of the Neuroform Atlas stent for wide-necked cerebral aneurysms. Sci Rep 2023; 13:13695. [PMID: 37607977 PMCID: PMC10444864 DOI: 10.1038/s41598-023-40725-1] [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: 04/14/2023] [Accepted: 08/16/2023] [Indexed: 08/24/2023] Open
Abstract
To investigate the effect and safety of the Neuroform Atlas (NFA) stent in stent-assisted coiling of wide-necked intracranial aneurysms, patients with wide-necked intracranial aneurysms were retrospectively enrolled and treated with the NFA stent-assisted coiling. The modified Rankin scale (mRS) grades and Raymond grades were used to assess the clinical outcomes and aneurysm occlusion degrees, respectively, after embolization and at follow-up. Totally, 122 patients were enrolled with 129 wide-necked aneurysms, and forty-nine (40.2%) patients experienced subarachnoid hemorrhage. A total of 134 NFA stents were deployed in all patients. Immediately after endovascular embolization, the Raymond grade was I in 112 (86.8%), II in 8 (6.2%), and III in 9 (7.0%). Complications occurred in 7 (5.7%) patients, including stent displacement in 2 (1.6%) patients, thrombosis and cerebral infarction in 4 (3.3%), and death in 1 (0.8%). Clinical follow-up was performed in 113 (92.6%) patients 6-30 (mean 21) months after embolization, with the mRS grade 0 in 99 (87.6%) patients, 1 in 7 (6.2%), 2 in 5 (4.4%), and 3 in 2 (1.8%). Good prognosis (mRS ≤ 2) was achieved in 111 (98.2%) patients while poor prognosis (mRS > 2) in two (1.8%). Digital subtraction angiography was conducted in 98 (80.3%) patients with 104 (80.6%) aneurysms 6-30 (mean 21) months after embolization. The Raymond grade was grade I in 94 (90.4%) aneurysms, II in 4 (3.8%), and III in 6 (5.8%). Compared with the Raymond grades immediately after embolization, 93 (89.4%) aneurysms disappeared, 9 (8.7%) remained unchanged in the occlusion status, and 2 (1.9%) were recurrent. In conclusion, the NFA stent may have a high aneurysm occlusion rate and a low complication rate in assisting coiling of wide-necked intracranial aneurysms even though further studies are necessary to prove this.
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Affiliation(s)
- Hui-Li Gao
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University, 7 Weiwu Road, Zhengzhou, Henan, China
| | - Qiu-Ji Shao
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University, 7 Weiwu Road, Zhengzhou, Henan, China
| | - Kai-Tao Chang
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University, 7 Weiwu Road, Zhengzhou, Henan, China
| | - Li Li
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University, 7 Weiwu Road, Zhengzhou, Henan, China
| | - Tian-Xiao Li
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University, 7 Weiwu Road, Zhengzhou, Henan, China.
| | - Bulang Gao
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University, 7 Weiwu Road, Zhengzhou, Henan, China
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Das KK, Shaikh Z, Ashutosh H, Chappity P, Parida PK, Pradhan P, Mishra A, Mittal Y. Outcomes in Managing Vascular Tinnitus: Institutional Experience and Review of 6-Year Literature. Indian J Otolaryngol Head Neck Surg 2023; 75:21-31. [PMID: 37007879 PMCID: PMC10050490 DOI: 10.1007/s12070-023-03510-0] [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: 10/12/2022] [Accepted: 01/13/2023] [Indexed: 01/31/2023] Open
Abstract
To evaluate the outcomes in patients of vascular tinnitus managed at our institute. The clinical data of all patients diagnosed with pulsatile tinnitus from January 2014 to April 2022 and managed at AIIMS, Bhubaneswar, was retrospectively reviewed. The diagnosis, treatment and outcomes were analyzed. A 6-year literature review was performed from March 2015 to April 2021. Our series discusses managing eleven cases of vascular tinnitus with varied aetiology and their outcomes. Out of the eleven cases, eight patients underwent surgical or radiological intervention, and seven had complete resolution of symptoms. Of the eleven patients, three had partial resolution. The 6-year literature review revealed sigmoid and transverse sinus as the most common causative anatomical sites for pulsatile tinnitus. Amongst those who received an intervention, 83.56% of the patients had complete resolution of symptoms. Vascular tinnitus can be cured if the exact vessel causing it is localized. Clinical suspicion is based on the character of tinnitus and patient history. A careful evaluation of the head and neck sites for any vascular anomaly that can cause pulsatile tinnitus must be done. Radiology demonstrates treatable causes of it. It delineates the aberrant anatomical variations that can lead to this disturbing aetiology. Treatable causes are best addressed, and pathology should be taken care of. A multidisciplinary team comprising ENT surgeons, audiologists and interventional radiologists must identify and treat the pathology.
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Affiliation(s)
- Krishna Kinkar Das
- Department of ENT and Head Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha 751019 India
| | - Zaid Shaikh
- Department of ENT and Head Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha 751019 India
| | - Hota Ashutosh
- Acharya Harihar Post Graduate Institute of Cancer, Cuttack, Odisha India
| | - Preetam Chappity
- Department of ENT and Head Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha 751019 India
| | - Pradipta K. Parida
- Department of ENT and Head Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha 751019 India
| | - Pradeep Pradhan
- Department of ENT and Head Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha 751019 India
| | - Abhijeet Mishra
- Department of ENT and Head Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha 751019 India
| | - Yash Mittal
- Department of ENT and Head Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha 751019 India
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4
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Bilgin C, Ghozy S, Shehata M, Ibrahim M, Jabal MS, Kobeissi H, Gerberi DJ, Kadirvel R, Kallmes DF. The Prophylactic Use of Glycoprotein 2b/3a Inhibitors in the Endovascular Treatment of Intracranial Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 168:e50-e66. [PMID: 36096391 PMCID: PMC9942935 DOI: 10.1016/j.wneu.2022.08.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND There has been a growing interest in the use of Glycoprotein 2b/3a (GP2B3A) inhibitors in neuroendovascular procedures. However, clinical evidence for their prophylactic use is still sparse. In this review, we aimed to assess the safety and efficacy of prophylactic GP2B3A inhibitor use and to compare the performance of GP2B3A inhibitors with oral dual antiplatelet (DAP) treatment in intracranial aneurysm patients treated with stent-assisted coil embolization or flow diversion. METHODS A systematic literature search was conducted in Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, and Cochrane Central Register of Clinical Trials databases. Data collected included hemorrhagic and thromboembolic complication rates, mortality, good functional outcome, and rupture status. A random-effects model was fit for each outcome measure. RESULTS Thirteen studies comprising 1429 patients were included. The overall hemorrhagic complication rate of the GP2B3A cohort was 3.98% (95% confidence interval [CI] = 1.58-7.42). The subgroup analysis comparing ruptured versus unruptured aneurysms in which GP2B3A antagonists were used did not show a significant difference in hemorrhagic complication rates (P-value = 0.504). Compared with the DAP group, the GP2B3A inhibitor cohort had significantly lower hemorrhagic complication rates (odds ratio = 0.33; 95% CI = 0.13-0.85; P-value = 0.022). The thromboembolic complication rates were 6.63% (95% CI = 3.44-10.75) for the GP2B3A inhibitor group and 10.4% (95% CI = 7-13.8) for the DAP group. However, the difference was not statistically significant (odds ratio = 0.52; 95% CI = 0.22-1.24; P-value = 0.142). CONCLUSIONS Our results support that GP2B3A inhibitors are safe and effective in preventing ischemic complications associated with the endoluminal devices. Additionally, our findings indicate that GP2B3A inhibitors can be utilized as prophylactic agents regardless of the rupture status.
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Affiliation(s)
- Cem Bilgin
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA.
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Mostafa Shehata
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Mohamed Ibrahim
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | | | - Hassan Kobeissi
- Central Michigan University College of Medicine, Mt. Pleasant, Michigan, USA
| | | | | | - David F Kallmes
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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5
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Zanaty M, Allan L, Samaniego EA, Piscopo A, Ryan E, Torner JC, Hasan D. Phase 1/2a Trial of ISPASM. Stroke 2021; 52:3750-3758. [PMID: 34470496 DOI: 10.1161/strokeaha.121.034578] [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: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Microthrombosis could play a role in delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Tirofiban has shown promising results in reducing delayed cerebral ischemia in retrospective studies. However, the safety of using tirofiban in aneurysmal subarachnoid hemorrhage is not rigorously established. METHODS A phase 1/2a double-blinded randomized controlled trial (2:1 randomization) to assess the safety of a 7-day intravenous infusion of tirofiban compared with placebo, in patients with aneurysmal subarachnoid hemorrhage treated with ventriculostomy placed in the operative room and coiling was conducted. The primary end point was any intracranial hemorrhage during the hospital stay. The secondary end points were: incidence of radiographic and clinical vasospasm, incidence of delayed cerebral ischemia, and incidence of cerebral ischemic changes noted on magnetic resonance imaging or computed tomography. RESULTS Eighteen patients received intravenous tirofiban and 12 received placebo. There was no difference in baseline characteristics except for higher male proportions in the tirofiban group. There was no difference in death, in development of new or change in existing intracranial hemorrhages, in thrombocytopenia, and need for shunts in the two arms. However, the tirofiban arm had a lower incidence of delayed cerebral ischemia compared with placebo (6% [1/18] versus 33% [4/12]; P=0.04), and less radiographic vasospasm as detected by catheter angiogram or computed tomography angiography (P=0.01) and computed tomography perfusion (P=0.01). CONCLUSIONS The above preliminary results support proceeding with further testing of the safety and efficacy of 7-day intravenous infusion of tirofiban in a pragmatic (placing external ventricular drain by the bedside), multicenter setting, and using a larger population. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03691727.
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Affiliation(s)
- Mario Zanaty
- Department of Neurosurgery (M.Z., A.P., E.R., D.H.), University of Iowa Hospital and Clinics
| | - Lauren Allan
- Department of General Surgery, Department of Surgical and Neuroscience Intensive Care Unit (L.A.), University of Iowa Hospital and Clinics
| | - Edgar A Samaniego
- Department of Neurology, Neuro Interventional Radiology (E.A.S.), University of Iowa Hospital and Clinics
| | - Anthony Piscopo
- Department of Neurosurgery (M.Z., A.P., E.R., D.H.), University of Iowa Hospital and Clinics
| | - Eleanor Ryan
- Department of Neurosurgery (M.Z., A.P., E.R., D.H.), University of Iowa Hospital and Clinics
| | - James C Torner
- Department of Epidemiology and Public Health (J.C.T.), University of Iowa Hospital and Clinics
| | - David Hasan
- Department of Neurosurgery (M.Z., A.P., E.R., D.H.), University of Iowa Hospital and Clinics
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6
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Shi G, Xu S, Gareev I, Ji Z, Pei W, Zhang G, Qi J, Chen R, Liang S, Gu Y, Wang C. Overlapping stent-assisted coil embolization for vertebrobasilar dissecting aneurysms: a single-center study. Neurol Res 2021; 43:701-707. [PMID: 34278976 DOI: 10.1080/01616412.2021.1922172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Effective treatment strategies for vertebrobasilar dissecting aneurysms (VBDAs) remain controversial due to their high morbidity and mortality. The aim of the present study was to evaluate the efficacy of overlapping stent-assisted coil embolization (OSCE) in VBDA patients. A total of 42 patients with VBDA were retrospectively examined by OSCE from May 2015 to August 2019. Patients' clinical and radiological parameters were assessed at discharge and during interim follow-up. Safety, technical feasibility and follow-up clinical and imaging observations for therapy were also evaluated retrospectively. The average age of the 42 patients who underwent OSCE was 54 years (range 33 to 74 years). Overlapping stents were successfully implanted in all patients after coil embolism. Overall clinical results were effective (score on a modified Rankin scale from 0 to 2) in all patients. In the meantime, all patients had favorable outcomes when evaluating telephone calls or digital subtractive angiography (DSA) imaging. Among 42 patients, one patient died due to a perioperative rupture. All the remaining 41 patients had a good prognosis during the follow-up telephone call, with a median follow-up of 28 months (range, 2 to 55 months). The total number of DSA recurrences was 20. Subsequent DSA results showed that all aneurysms were completely occluded while in only one case the parent artery of the aneurysm was completely closed. OSCE in VBDAs patients is safe and effective. This technique showed favorable results in clinical and imaging follow-ups for non-ruptured and ruptured VBDAs.
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Affiliation(s)
- Guangyao Shi
- Queen Mary College, Nanchang University, Nanchang, Jiang Xi Province, People`s Republic of China
| | - Shancai Xu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,Institute of Brain Science, Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,The Chinese-German Center of Academic Excellence in Neuroscience, Harbin, Heilongjiang Province, People's Republic of China
| | - Ilgiz Gareev
- Department of Neurosurgery, Bashkir State Medical University, Ufa, Russia
| | - Zhiyong Ji
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,Institute of Brain Science, Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,The Chinese-German Center of Academic Excellence in Neuroscience, Harbin, Heilongjiang Province, People's Republic of China
| | - Wu Pei
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,Institute of Brain Science, Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,The Chinese-German Center of Academic Excellence in Neuroscience, Harbin, Heilongjiang Province, People's Republic of China
| | - Guang Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,Institute of Brain Science, Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,The Chinese-German Center of Academic Excellence in Neuroscience, Harbin, Heilongjiang Province, People's Republic of China
| | - Jingtao Qi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,Institute of Brain Science, Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,The Chinese-German Center of Academic Excellence in Neuroscience, Harbin, Heilongjiang Province, People's Republic of China
| | - Rui Chen
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,Institute of Brain Science, Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,The Chinese-German Center of Academic Excellence in Neuroscience, Harbin, Heilongjiang Province, People's Republic of China
| | - Shaodong Liang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,Institute of Brain Science, Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,The Chinese-German Center of Academic Excellence in Neuroscience, Harbin, Heilongjiang Province, People's Republic of China
| | - Yan Gu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,Institute of Brain Science, Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,The Chinese-German Center of Academic Excellence in Neuroscience, Harbin, Heilongjiang Province, People's Republic of China
| | - Chunlei Wang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,Institute of Brain Science, Harbin Medical University, Harbin, Heilongjiang Province, People's Republic of China.,The Chinese-German Center of Academic Excellence in Neuroscience, Harbin, Heilongjiang Province, People's Republic of China
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7
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Yıldırım İO, Kolu M, Durak MA, Tetik B, Paşahan R, Gürbüz Ş, Saraç K. Y-stent assisted coiling of ruptured wide neck intracranial aneurysm in the acute phase. Interv Neuroradiol 2021; 27:638-647. [PMID: 33779378 DOI: 10.1177/15910199211005331] [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: 11/16/2022] Open
Abstract
BACKGROUND The objective of the present study is to analyze the outcomes of patients with subarachnoid hemorrhage (SAH) in the acute phase after treatment with Y-stent-assisted coiling (YSAC) embolization. METHODS This retrospective study assessed of 30 patients with acutely ruptured wide-neck aneurysms following YSAC treatment between April 2013 and October 2019. The demographic data, aneurysm occlusion grade, procedural and periprocedural complications, and clinical outcomes were assessed. RESULTS The procedure was completed in 30 cases (90.1%) and technical failure occurred in 3 cases (9.1%). Immediate control angiography revealed that total occlusion Raymond-Ray Class 1 (RR1) was achieved in 21 (70%), neck filling (RR2) in eight (26.6%) and sac filling (RR1) in one (3.3%) aneurysm. Upon angiographic follow-up, RR1 occlusion was observed in 15 (71.4%) patients, RR2 in three (14.3%) patients and RR3 in three (14.3%) patients. In-stent thrombus developed in five (16.6%) patients; procedural ischemic events were observed in four (13.3%) patients; and two (6.6%) patients were symptomatic. A periprocedural asymptomatic intracranial hemorrhage was detected in two patients. At discharge, 17 (56.6%) patients were in good clinical condition, six (20%) were in a severe disability condition, and seven (23.3%) patients had died. At the final follow-up visit (mean: 18.9 months), 16 (76,2%) of 21 patients were in a good clinical condition and five (23.8%) had severe disabilities. CONCLUSIONS Y-stent assisted coiling in might be a feasible and promising option for treatment in acute phase in selected wide-necked ruptured intracranial aneurysms.
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Affiliation(s)
| | - Mehmet Kolu
- Department of Radiology, Harran University School of Medicine, Şanlıurfa, Turkey
| | - Mehmet Akif Durak
- Department of Neurosurgery, Inonu University School of Medicine, Malatya, Turkey
| | - Bora Tetik
- Department of Neurosurgery, Inonu University School of Medicine, Malatya, Turkey
| | - Ramazan Paşahan
- Department of Neurosurgery, Inonu University School of Medicine, Malatya, Turkey
| | - Şükrü Gürbüz
- Department of Emergency, Inonu University School of Medicine, Malatya, Turkey
| | - Kaya Saraç
- Department of Radiology, Inonu University School of Medicine, Malatya, Turkey
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8
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Xiang Y, Zhao H, Ding C, Chen H, Wang D, Liu A. The Prophylactic Use of Tirofiban versus Oral Antiplatelet Medications in Stent-Assisted Coiling of Intracranial Aneurysms: A Meta-analysis. AJNR Am J Neuroradiol 2021; 42:713-719. [PMID: 33707284 DOI: 10.3174/ajnr.a6996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/02/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND The protocol for optimal antiplatelet therapy to prevent thromboembolic and hemorrhagic complications in patients with cerebral aneurysms using an endovascular approach is not clear. PURPOSE Our study analyzed the safety and efficacy of prophylactic tirofiban administration compared with oral antiplatelet drug therapy. DATA SOURCES We used the PubMed, EMBASE, MEDLINE, and Cochrane library data bases. STUDY SELECTION Our study consisted of all case series with >5 patients that reported treatment-related outcomes of patients undergoing endovascular procedures pretreated with tirofiban or oral antiplatelet drug therapy. DATA ANALYSIS Random effects or fixed effects meta-analysis was used to pool the cumulative rate of complications, perioperative mortality, and good clinical outcomes. DATA SYNTHESIS Fifteen studies with 1981 patients were registered. Thromboembolic complications were significantly lower in the tirofiban group (3.6%; 95% CI, 1.9%-5.8%) compared with the dual-antiplatelet therapy group (8.5%, 95% CI, 4.5%-13%; P = .04). Pretreatment with tirofiban did not remarkably increase the rate of hemorrhagic complications (3.5%; 95% CI, 1.8%-5.6%) compared with dual-antiplatelet therapy (5.1%; 95% CI, 2.6%-8.5%; P = .371). There was a trend toward lower perioperative mortality with tirofiban (0.8%; 95% CI, 0.2%-1.6%) compared with dual-antiplatelet therapy (1.2%; 95% CI, 0.7%-2.0%; P = .412). There was no significant difference in the safety and efficacy between the tirofiban bolus plus drip and drip alone. LIMITATIONS The limitations are selection and publication biases. CONCLUSIONS Prophylactic therapy with tirofiban resulted in significantly lower rates of thromboembolic complications with no increase in hemorrhagic events or mortality than the prophylactic use of dual-antiplatelet therapy.
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Affiliation(s)
- Y Xiang
- From the Departments of Pharmacy (Y.X., A.L.)
| | | | - C Ding
- Department of Pharmacy (C.D.), Affiliated Hospital of Weifang Medical University, Weifang Shandong, China
| | - H Chen
- Department of Pharmacy (H.C.), Special Care Hospital of Jinan City, Jinan, Shandong, China
| | - D Wang
- Neurosurgery (D.W.), Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - A Liu
- From the Departments of Pharmacy (Y.X., A.L.)
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9
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Safety and efficacy of stent-assisted coiling for acutely ruptured wide-necked intracranial aneurysms: comparison of LVIS stents with laser-cut stents. Chin Neurosurg J 2021; 7:19. [PMID: 33653398 PMCID: PMC7927374 DOI: 10.1186/s41016-021-00237-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 02/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background To compare the safety and efficacy of LVIS stent-assisted coiling with those of laser-cut stent-assisted coiling for the treatment of acutely ruptured wide-necked intracranial aneurysms. Methods Patients with acutely ruptured wide-necked intracranial aneurysms treated with LVIS stent-assisted coiling (LVIS stent group) and laser-cut stent-assisted coiling (laser-cut stent group) were retrospectively reviewed from January 2014 to December 2017. Propensity score matching was used to adjust for potential differences in age, sex, aneurysm location, aneurysm size, neck width, Hunt-Hess grade, and modified Fisher grade. Perioperative procedure-related complications and clinical and angiographic follow-up outcomes were compared. Univariate and multivariate analyses were performed to determine the associations between procedure-related complications and potential risk factors. Results A total of 142 patients who underwent LVIS stent-assisted coiling and 93 patients who underwent laser-cut stent-assisted coiling were enrolled after 1:2 propensity score matching. The angiographic follow-up outcomes showed that the LVIS stent group had a slightly higher complete occlusion rate and lower recurrence rate than the laser-cut stent group (92.7% vs 80.6%; 3.7% vs 9.7%, P = 0.078). The clinical outcomes at discharge and follow-up between the two groups demonstrated no significant differences (P = 0.495 and P = 0.875, respectively). The rates of intraprocedural thrombosis, postprocedural thrombosis, postoperative early rebleeding, and procedure-related death were 0.7% (1/142), 1.4% (2/142), 2.8% (4/142), and 2.1% (3/142) in the LVIS stent group, respectively, and 4.3% (4/93), 2.2% (2/93), 1.1% (1/93), and 3.2% (3/93) in the laser-cut stent group, respectively (P = 0.082, 0.649, 0.651, and 0.683). Nevertheless, the rates of overall procedure-related complications and intraprocedural rupture in the LVIS stent group were significantly lower than those in the laser-cut stent group (5.6% vs 14.0%, P = 0.028; 0.7% vs 6.5%, P = 0.016). Multivariate analysis showed that laser-cut stent-assisted coiling was an independent predictor for overall procedure-related complications (OR = 2.727, P = 0.037); a history of diabetes (OR = 7.275, P = 0.027) and other cerebrovascular diseases (OR = 8.083, P = 0.022) were independent predictors for ischemic complications, whereas none of the factors were predictors for hemorrhagic complications. Conclusions Compared with laser-cut stent-assisted coiling, LVIS stent-assisted coiling for the treatment of acutely ruptured wide-necked intracranial aneurysms could reduce the rates of overall procedure-related complications and intraprocedural rupture.
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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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Zanaty M, Osorno-Cruz C, Byer S, Roa JA, Limaye K, Ishii D, Nakagawa D, Torner J, Yongjun L, Ortega-Gutiérrez S, Samaniego EA, Allan L, Hasan D. Tirofiban Protocol Protects Against Delayed Cerebral Ischemia: A Case-Series Study. Neurosurgery 2020; 87:E552-E556. [DOI: 10.1093/neuros/nyaa170] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 03/17/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
There has not been any effective prophylaxis for delayed cerebral ischemia delayed cerebral ischemia (DCI) since the introduction of nimodipine. Platelet inhibition may reduce the risk by preventing the formation of microthrombi. Tirofiban has been used as a single monotherapy bridge given its safety profile and controlled platelet inhibition.
OBJECTIVE
To assess the risk of DCI in aneurysmal subarachnoid hemorrhages (aSAH) patients treated with the tirofiban protocol.
METHODS
aSAH patients between December 2010 and March 2019 who were treated with stent assisted coiling or flow-diverting device were started on a continuous tirofiban infusion protocol and were compared with patients who underwent coil embolization without antiplatelet therapy. Safety analysis was performed to assess DCI, hemorrhagic, and ischemic events.
RESULTS
A total of 21 patients were included in the tirofiban series and 81 in the control group. There was no statistical difference in age, gender, Hunt-Hess grade, and Fisher scale between the 2 groups except for a higher Fisher grade II in the tirofiban group. Multivariate analysis revealed tirofiban to reduce the risk of vasospasm by 72 percent (OR .28, P = .03), without affecting the risk of hemorrhagic complications (OR = 0.50, P = .26). Tirofiban reduced the risk of symptomatic stroke endovascular procedure but it did not reach significance (P = .06). DCI, older age, and postprocedural symptomatic stroke were significant predictors of mortality. Tirofiban reduced the mortality risk, but this association was not statistically significant.
CONCLUSION
The tirofiban protocol in aSAH patients reduces the risk of DCI without conferring additional risks. This supports previous findings were antiplatelet therapy reduced DCI in human and animal models.
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Affiliation(s)
- Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Carlos Osorno-Cruz
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Stefano Byer
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Jorge A Roa
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Kaustubh Limaye
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Daizo Ishii
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Daichi Nakagawa
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
- Department of Neurosurgery, University of Tokyo, Tokyo, Japan
| | - James Torner
- Department of Epidemiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Lu Yongjun
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | | - Edgar A Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Lauren Allan
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - David Hasan
- Department of Neurosurgery, University of Tokyo, Tokyo, Japan
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Zhang L, Wang H, Pan Y, Mao L. Effect Analysis of Microsurgical Clipping and Endovascular Embolization for the Treatment of Middle Cerebral Artery Aneurysms. World Neurosurg 2019; 125:e1074-e1081. [PMID: 30790728 DOI: 10.1016/j.wneu.2019.02.004] [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: 12/01/2018] [Revised: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the safety and effectiveness of microsurgical clipping and endovascular embolization for the treatment of middle cerebral artery aneurysm (MCAA). MATERIAL AND METHODS The clinical data of 482 patients with MCAA treated with microsurgical clipping or endovascular embolization were analyzed retrospectively. According to whether the aneurysms were ruptured, patients were divided into a ruptured group and an unruptured group. Demographics, clinical manifestation, and postoperative complications were recorded. RESULTS In the microsurgical clipping group (257 patients), there were 114 male and 143 female patients. The mean age was (55 ± 10) years and the mean course of disease was 3 (1, 36) days. The total numbers of MCAA were 274, including 179 ruptured aneurysms and 95 unruptured aneurysms. In the endovascular embolization group (225 patients), there were 98 male and 127 female patients. The mean age was (54 ± 11) years and the mean course of disease was 10 (1, 55) days. The total numbers of MCAA were 234, including 126 ruptured aneurysms and 108 unruptured aneurysms. There was no difference between the incidence of complications in the ruptured and unruptured groups. The outcome of the endovascular embolization group was better than the microsurgical clipping group in ruptured aneurysms (P = 0.000). The recurrence rate of the endovascular embolization group was greater than the microsurgical clipping group in ruptured aneurysms (P = 0.023). CONCLUSIONS Both microsurgical clipping and endovascular embolization were safe and effective methods for the treatment of MCAA, but patients with ruptured MCAAs treated with endovascular embolization were more likely to experience recurrence.
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Affiliation(s)
- Li Zhang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, P. R. China
| | - Handong Wang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, P. R. China.
| | - Yunxi Pan
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, P. R. China
| | - Lei Mao
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, P. R. China
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