Antiplatelet Drugs for Neurointerventions: Part 2 Clinical Applications

Pearce, Samuel; Maingard, Julian; Kok, Hong Kuan; Barras, Christen; Russell, Jeremy; Hirsch, Joshua A; Chandra, Ronil V.; Jhamb, Ash; Thijs, Vincent; Brooks, Mark; Asadi, Hamed

doi:10.1007/s00062-021-00997-4

Cited by 11 publications

(12 citation statements)

References 83 publications

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“…By contrast, a common dose of antiplatelet within a short period is used in patients receiving traditional stent than FD stent treatment ( 53 ). For BAC, antiplatelet therapy differs between operators ( 54 ). Antiplatelet treatment is often considered unnecessary in coiling alone ( 55 ).…”

Section: Discussionmentioning

confidence: 99%

Diffusion-weighted imaging lesions after endovascular treatment of cerebral aneurysms: A network meta-analysis

Yue

et al. 2023

Front. Surg.

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BackgroundThromboembolism is one of the common complications in endovascular treatments including coiling alone, stent-assisted coiling (SAC), balloon-assisted coiling (BAC), and flow-diverting (FD) stents. Such treatments are widely used in intracranial aneurysms (IAs), which usually present as positive lesions in diffusion-weighted imaging (DWI). Whether these adjunctive techniques increase postprocedural DWI-positive lesions after endovascular treatment remains unclear.MethodsA thorough electronic search for the literature published in English between January 2000 and October 2022 was conducted on PubMed, Medline, and EMBASE. Eighteen studies (3 cohort studies and 15 case–control studies) involving 1,843 patients with unruptured IAs (UIAs) were included. We performed a frequentist framework network meta-analysis (NMA) to compare the rank risks of cerebral thromboembolism of the above four endovascular treatments. The incoherence test was used to analyze the statistical disagreement between direct and indirect evidence. Funnel plots were used to analyze publication bias.ResultsThe incidences of DWI lesions in patients who received FD stents, SAC, BAC, and coiling alone were 66.1% (109/165), 37.6% (299/795), 31.1% (236/759), and 25.6% (236/921). The incidence of DWI lesions in patients who received FD stents was higher than that in patients who received SAC [OR: 2.40; 95% CI (1.15, 5.00), P < 0.05], BAC [OR: 2.62; 95% CI (1.19, 5.77), P < 0.05], or coiling alone [OR: 2.77; 95% CI (1.26, 6.07), P < 0.05]. The incoherence test showed preferable consistency in this NMA. No obvious publication bias was found in the funnel plot.ConclusionFD stent placement brings more ischemic lesions identified by DWI than any other procedures for patients with UIA. The characteristics of FD stents may result in a high incidence of DWI lesions.

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Section: Discussionmentioning

confidence: 99%

Diffusion-weighted imaging lesions after endovascular treatment of cerebral aneurysms: A network meta-analysis

Yue

et al. 2023

Front. Surg.

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“…26 In the absence of acute carotid reocclusion, it is unknown if a carotid stent should be performed in the acute setting. 26,28 After reperfusion, patients are at risk of hemorrhagic transformation of infarct, and the timing, intensity, and duration of antiplatelet therapy need to be balanced against the risk of intracranial hemorrhage. In-stent thrombus, recurrent stenosis, and delayed stent occlusion are potential risk factors for recurrent stroke.…”

Section: Neurointervention In Acute Strokementioning

confidence: 99%

“…Stent-assisted treatment of an intracranial aneurysm enables higher coil packing densities and helps prevent coil herniation into the parent artery. 28 In flow diversion, the stent design facilitates blood flow past the aneurysm neck along the parent vessel to its branches.…”

Section: Other Neurointerventionsmentioning

confidence: 99%

“…30 The extent to which platelets aggregate depends on the composition of the stent or device, its surface area, and direct shear stress. 28,30 In patients with a coil, the process of detachment can induce thrombus formation, as the generated positive charges attract blood products and platelets to the site of implantation. 31 To date, there are no trials to guide antiplatelet treatment in the aforementioned settings, 28 and guidelines acknowledge these limitations.…”

Section: Other Neurointerventionsmentioning

confidence: 99%

“…28,30 In patients with a coil, the process of detachment can induce thrombus formation, as the generated positive charges attract blood products and platelets to the site of implantation. 31 To date, there are no trials to guide antiplatelet treatment in the aforementioned settings, 28 and guidelines acknowledge these limitations. 3,32 For intracranial stent deployment and stent-like devices, neurointerventionalists usually recommend treatment with aspirin and clopidogrel for 7 to 10 days or loading with aspirin and clopidogrel before an elective procedure.…”

Section: Other Neurointerventionsmentioning

confidence: 99%

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Antiplatelet Resistance: A Review of Concepts, Mechanisms, and Implications for Management in Acute Ischemic Stroke and Transient Ischemic Attack

Krishnan

Nguyen

Appleton

et al. 2023

SVIN

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Acute ischemic stroke is a leading cause of death and major disability worldwide. Approximately 50% of ischemic strokes are caused by atherothrombotic occlusion of the cerebral arteries, and antiplatelets are the mainstay of secondary stroke preventative treatment. Aspirin is beneficial if given early, and short‐term treatment using aspirin and clopidogrel is increasingly used for patients with intracranial atherosclerotic disease, minor stroke, and or transient ischemic attack. However, up to 50% of patients continue to have recurrent stroke and major vascular events, which may be partly attributable to resistance to aspirin and or clopidogrel. Although the precise mechanisms are unknown, clinical and genetic factors associated with bioavailability and binding to target receptors are implicated. This narrative review begins with the concept of aspirin and clopidogrel resistance in ischemic stroke and transient ischemic attack, potential mechanisms including genetic polymorphisms, and an overview of platelet function measures and limitations. We conclude by highlighting practical issues in the management of patients with aspirin andclopidogrel resistance including the emerging interest in ticagrelor, prasugrel, and cilostazol as well as directions for future trials in transient ischemic attack and acute ischemic stroke.

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Safety Profile and Complication Rates in Emergency Off-label Use of Tirofiban in Interventional Neuroradiology

et al. 2022

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Purpose Tirofiban has been approved for the treatment of acute coronary syndrome. Meanwhile, tirofiban is frequently applied in emergency situations in interventional neuroradiology (INR). The objective of this study was to analyze the risk profile for the off-label use of tirofiban in INR patients. Methods Data of 86 patients, who underwent neurointerventional therapy and were treated with tirofiban at 2 neuroendovascular centers between January 2016 and July 2017 were retrospectively analyzed. Despite off-label use, recent stroke (< 30 days), recent hemorrhage, thrombocytopenia (< 150,000/µl), activated partial thromboplastin time (aPTT) > 1.3-fold, internation normalised ratio (INR) < 1.5, severe liver insufficiency (Child-Pugh C), and preceding intravenous thrombolysis were considered as contraindications. Results Median patient age was 62 years (range 26–88 years). Patients received tirofiban for extracranial (n = 35) or intracranial stenting (n = 35), coiling of ruptured cerebral aneurysms (n = 6), continuous intra-arterial nimodipine infusion via microcatheters for subarachnoid hemorrhage (SAH)-related vasospasm (n = 5), or thrombotic complications during neuroendovascular procedures (n = 5). The desired effect of preventing thrombotic complications when applying tirofiban off-label was achieved in 81 of 86 patients (94.2%). Relevant tirofiban-associated complications occurred in 14 patients (16.3%), of which 9 patients received i.v. thrombolysis for treatment of acute ischemic stroke shortly before starting therapy with tirofiban. Of the 86 patients 12 died, while the overall tirofiban-related mortality was 2.3% (2 patients died due to ICH). Logistic regression analysis revealed age to be the only parameter significantly associated with development of tirofiban-associated complications (p = 0.026). Conclusion Whereas the safety profile of tirofiban when applied off-label in INR is acceptable, the highest risk for relevant tirofiban-associated complications is observed in older patients treated by emergency stenting for acute stroke.

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Antiplatelet Drugs for Neurointerventions: Part 2 Clinical Applications

Cited by 11 publications

References 83 publications

Diffusion-weighted imaging lesions after endovascular treatment of cerebral aneurysms: A network meta-analysis

Diffusion-weighted imaging lesions after endovascular treatment of cerebral aneurysms: A network meta-analysis

Antiplatelet Resistance: A Review of Concepts, Mechanisms, and Implications for Management in Acute Ischemic Stroke and Transient Ischemic Attack

Safety Profile and Complication Rates in Emergency Off-label Use of Tirofiban in Interventional Neuroradiology

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