Preliminary Study of Tirofiban Infusion in Coil Embolization of Ruptured Intracranial Aneurysms

Safety and efficacy of tirofiban versus traditionaldualantiplatelettherapy in endovasculartreatment of intracranialaneurysms: asystematicreview and meta-analysis

BACKGROUND

The selection of antiplatelet agents plays a crucial role in ensuring the safety and efficacy of endovascular treatment for intracranial aneurysms (IA). Currently, the primary agents used include tirofiban and traditional dual antiplatelet therapy (DAPT). Due to the lack of high-level consolidated evidence in this field, we conducted the first systematic review and meta-analysis aimed at comparing the safety and efficacy of tirofiban vs traditional DAPT in the endovascular treatment of IA.

METHODS

Studies published before November 1, 2024, were searched in PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials. The primary outcome was thrombosis, and secondary outcomes included intracranial hemorrhage (ICH), non-intracranial bleeding events (NoICH-BE), ischemic stroke (IS), and follow-up prognosis. Relative risks (RRs) were synthesized for comparison between tirofiban and DAPT groups.

RESULTS

Nine studies involving 2481 patients were included. Tirofiban significantly reduced the risk of thrombosis compared with DAPT (RR, 0.292; 95% CI, 0.174 to 0.492; P<0.001). It did not increase risks of ICH (RR, 0.633; P=0.125), NoICH-BE (RR, 0.253; P=0.259), IS (RR, 0.730; P=0.172), or poor prognosis (RR, 0.981; P=0.896).

CONCLUSION

Tirofiban effectively lowers the risk of thrombosis without increasing bleeding or adverse prognosis risks compared with DAPT. It shows promise as an alternative antiplatelet therapy for IA treatment, but further large-scale studies are needed to confirm these findings.

Safety and efficacy of tirofiban in the endovascular treatment of intracranial aneurysms: a systematic evaluation and meta-analysis

Patients with intracranial aneurysms (IA) undergoing endovascular treatment face varying risks and benefits when tirofiban is used for thromboprophylaxis during surgery. Currently, there is a lack of high-level evidence summarizing this information. This study aims to conduct a systematic review and meta-analysis to evaluate the efficacy and safety of tirofiban during endovascular treatment of IA. Relevant studies published before November 2024 were searched in the PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials databases. The primary outcomes were intracranial hemorrhage (ICH), thrombosis, and thrombolysis. Secondary outcomes included any non-ICH bleeding events (NoICH-BE), ischemic stroke (IS), intraoperative rupture aneurysm(IRA), follow-up prognosis, and Raymond and Roy classification (RROC). Meta-analysis was performed using Revman 5.3 and StataMP 64 to assess efficacy (thrombosis, IS, thrombolysis) and safety (ICH, NoICH-BE, IRA). A total of 33 studies involving 3,617 IA patients were included. The meta-analysis showed that after the use of tirofiban, the pooled risk (PR) for ICH was 2% ([95% CI, 1-3%]; P < 0.001), for NoICH-BE was 0% ([95% CI, 0-2%]; P > 0.05), for IRA was 2% ([95% CI, 1-3%]; P < 0.001), for thrombosis was 3% ([95% CI, 2-4%]; P < 0.001), for IS was 2% ([95% CI, 0-3%]; P < 0.001), for thrombolysis was 96% ([95% CI, 91-99%]; P < 0.001), for good prognosis (mRS 0-2) was 91% ([95% CI, 85-95%]; P < 0.001), and for RROC 1-2 was 93% ([95% CI, 90-96%]; P < 0.001). This systematic review and meta-analysis demonstrate that the use of tirofiban during endovascular treatment of IA is both feasible and safe.

Safety and efficacy of dual antiplatelet therapy combining aspirin and ticagrelor in patients with undergoing intracranial stenting procedures

BACKGROUND

Thromboembolic complications are one of the major periprocedural complications following neuroendovascular procedures. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel remain the principal agents for prevention of thromboembolic complications. However, clopidogrel resistance is associated with higher risk of thromboembolic complications. This study investigated the safety and efficacy of DAPT with ticagrelor and aspirin in patients undergoing intracranial stenting procedures.

METHODS

This retrospective study was based on patients with intracranial aneurysms who undergoing intracranial stenting procedures at our institution between August 2017 and July 2020. These patients received DAPT with ticagrelor and aspirin were included. DAPT with 90 mg ticagrelor twice daily and aspirin 100 mg daily was continued for 3 months after the intracranial stenting procedure and aspirin continued for 1 year.

RESULTS

In this study, 151 patients were identified. The most common aneurysm location was the internal carotid artery with 127 (71.8%) patients. Of the 151 cases with 160 treated aneurysms, 30 (18.8%) patients were treated by flow diverters (FDs), and 130 (81.2%) by stent-assisted coiling. Five (3.3%) patients had thromboembolic complications. Intraprocedural aneurysmal rupture was observed in one patient because of coil extrusion during coil insertion. None of the patients showed a newly DAPT-related intracerebral hemorrhage. Two patients developed dyspnea, and the symptom resolved without intervention. Furthermore, ecchymoma and gastrointestinal bleeding occurred in one patient respectively. DAPT-related thromboembolic and hemorrhagic complications were not significantly different between the FD group and stent-assisted coiling group.

CONCLUSIONS

In our study, DAPT combining ticagrelor and aspirin seems to be a safe and efficient treatment for preventing thromboembolic complications in patients with intracranial aneurysms, without any increase in hemorrhagic complications. Ticagrelor may be an effective alternative for patients undergoing neurointervention.

Safety and effectiveness of LEO stents for dual stent-assisted embolization combined with IA and IV intra-procedural infusion of tirofiban in the treatment of wide-necked intracranial bifurcation aneurysms

Objective

To evaluate the safety and efficacy of employing LEO stents in dual stent-assisted embolization (DSAE) for wide-necked intracranial bifurcation aneurysms, and to assess the effectiveness of combined IA and IV intra-procedural infusion of tirofiban in mitigating perioperative complications.

Methods

Clinical data and follow-up images from 562 patients with wide-necked intracranial bifurcation aneurysms treated at First Affiliated Hospital of Army Medical University from 2018-2022 were collected. Among them, 65 received DSAE with LEO stents. The study observed treatment success rates, procedure-related complications, perioperative thromboembolic events (TEs) and hemorrhagic events (HEs), immediate postoperative modified Raymond-Roy classification (mRR), and follow-up imaging. Glasgow Outcome Scale (GOS) at discharge and clinical follow-ups were recorded.

Results

The study enrolled 65 patients (mean age: 56.77 ± 10.07) with wide-necked intracranial bifurcation aneurysms. Among them, 58 had unruptured aneurysms, 7 ruptured (Hunt-Hess II-III). All aneurysms were successfully embolized without significant stent or bleeding complications. Only one case had intraoprative thrombosis; two postoperative ischemic incidents occurred within three days, no severe bleeding events. Immediate imaging showed modified Raymond-Roy classification: mRRC I (92.3%), mRRC II (4.6%), mRRC III b (3.1%). A total of 43 patients were followed up postoperatively with DSA. Among them, 41 patients exhibited mRRC I, while 2 patients exhibited mRRC II. No aneurysm was recanalized. Discharge GOS: GOS 5-60, GOS 4-1, GOS 3-4. One patient, GOS 1, died from lung cancer; others improved.

Conclusion

The utilization of LEO stents for dual stent-assisted embolization of wide-necked intracranial bifurcation aneurysms demonstrated remarkable success and safety, yielding favorable postoperative outcomes and no instances of aneurysm recurrence. The concomitant administration of perioperative antiplatelet medications alongside IA and IV intra-procedural infusion of tirofiban effectively attenuated thromboembolic events (TEs) without concomitant elevations in bleeding risks.

Perioperative complications of arteriovenous tirofiban administration versus oral dual antiplatelet therapy for stent-assisted embolization treated aneurysmal subarachnoid hemorrhage: A retrospective, controlled cohort analysis

BACKGROUND

Major perioperative complications of stent-assisted embolization treated for aneurysmal subarachnoid hemorrhage patients include the formation of thromboembolic events (TEs) and hemorrhagic events (HEs), for which antiplatelet protocols play a key role.

METHODS

We conducted a single-center retrospective analysis to compare the differences between arteriovenous tirofiban administration with traditional oral dual antiplatelet therapy (DAPT). A total of 417 consecutive patients were enrolled. General clinical characteristics, as well as the perioperative ischemic and hemorrhagic events, were retracted in digital documents. Logistic regression was conducted to identify both risk and protective factors of perioperative TEs and HEs.

RESULTS

Perioperative TEs occurred in 21 patients, with an overall perioperative TEs rate of approximately 5.04%; among these patients, the incidence of perioperative TEs in the tirofiban group was less than that in the DAPT group. Additionally, 66 patients developed perioperative HEs, with an incidence of approximately 15.83%; among these patients, the incidence of perioperative HEs was less than that in the DAPT group. No significant differences were seen between the two groups in terms of the mRS score at the time of discharge.

CONCLUSION

This study indicated that an improved perioperative antiplatelet drug tirofiban was an independent protective factor for perioperative TEs in stent-assisted embolization of ruptured intracranial aneurysms, but it did not impart an elevated risk of perioperative HEs and had no significant effects on the near-term prognosis of the patients.

Antiplatelet Therapy in Neurointervention

The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.

Worldwide productivity and research trends of publications concerning stent application in acutely ruptured intracranial aneurysms: A bibliometric study

Background

Stenting is a common clinical practice to treat acutely ruptured intracranial aneurysm (RIA). Although multiple studies have demonstrated its long-term safety and effectiveness, there is currently a lack of bibliometric analysis on stent application in acutely RIA. This study sought to summarize the current status of research in this field and lay a foundation for further study.

Materials and methods

Related publications were searched in the Web of Science Core Collection (WoSCC) database. Data analysis and visualization were performed by R and CiteSpace software.

Results

A total of 275 publications published in English from 1997 to 2022 were included in this study. The growth of publications slowed down. The reference co-citation network identified 13 clusters with a significant network (Q = 0.7692) and convincing clustering (S = 0.9082). The research focus was acutely RIA and the application of stents during interventional procedures. The main trends of research were: (1) development of materials, and (2) safety of stent application in acutely RIA. The United States contributed the most articles, and Jianmin Liu was the most prolific author. Mayo Clinic was the leading institution in this field. Most articles were published in Interventional Neuroradiology.

Conclusions

This study analyzed the research trends, hotspots and frontiers of stent application in acutely RIA. It is our hope that the results obtained could provide useful information to researchers to get a clearer picture about their future research directions in this field.

Comparison of Stent-Assisted Coil Embolization Versus Coil Embolization Alone for Ruptured Cerebral Aneurysms with Mild Symptoms: A Single-Clinic Experience

Purpose

To evaluate the safety and efficacy of stent-assisted coil embolization (SAC) in acutely ruptured cerebral aneurysms without severe symptoms, and thus, the usefulness of the stent itself in patients with subarachnoid hemorrhages.

Materials and Methods

From January 2017 to June 2019, 118 patients were treated with coil embolization for acutely ruptured cerebral aneurysms without severe symptoms (Hunt & Hess grade ≤ 3). The periprocedural complications, six-month modified Rankin scores (mRS), and six-month radiologic outcomes were compared between 56 patients with SAC and 62 patients without SAC (non-SAC).

Results

The rate of good clinical outcomes (mRS ≤ 2), as well as the rate of hemorrhagic and ischemic complications, showed no significant difference between the SAC and non-SAC groups. Moreover, compared to the non-SAC group, the SAC group showed a lower recanalization rate on the six-month follow-up angiogram (20% vs. 39.3%, p = 0.001).

Conclusion

Although stent use was not significantly associated with clinical outcomes in coil embolization of ruptured cerebral aneurysms with non-severe symptoms (Hunt & Hess grade ≤ 3), it significantly decreased the rate of recanalization on follow-up cerebral angiograms.

Ventriculostomy-related intracranial hemorrhage following surgical and endovascular treatment of ruptured aneurysms

Endovascular therapy of ruptured aneurysms is regularly accompanied by periprocedural heparinization and requires the use of periprocedural antiplatelets in more complex cases. This raises concerns regarding increased bleeding risks in the case of frequently required ventriculostomy. The aim of this study was to analyze risk factors for ventriculostomy-related intracranial hemorrhages (VS-ICH) in endovascular or surgical treatment of ruptured aneurysms with a focus on antithrombotic therapy. In this retrospective analysis, we included patients admitted to our institution over a 12-year period who had received at least one ventriculostomy due to subarachnoid hemorrhage-related hydrocephalus. Patients were dichotomized into an endovascular and surgical group and rates of VS-ICH were compared. Risk factors for VS-ICH were assessed in uni- and multivariate analyses. A total of 606 ventriculostomies were performed in 328 patients. Within the endovascular group, antiplatelet therapy was used in 44.8% of cases. The overall rate of ventriculostomy-related intracranial hemorrhage was 13.1%. Endovascular treatment was associated with a higher rate of VS-ICH compared to surgical treatment (p = 0.011), but not in cases without antiplatelet therapy (p = 0.166). Application of any antiplatelet therapy (odds ratio, 2.647 [95% confidence interval, 1.141–6.143]) and number of ventriculostomies (odds ratio, 2.513 [95% confidence interval, 1.859–3.395]) were independent predictors of ventriculostomy-related hemorrhages. Our findings indicate an increased risk of VS-ICH in the endovascular group if administration of antiplatelets was required. While this aspect has to be included into treatment decision-making, it must be weighed against the benefits of endovascular techniques.

Percutaneous Mechanical Thrombectomy for Acute Symptomatic Iliofemoral Deep Venous Thrombosis Patients With Recent Aneurysmal Subarachnoid Hemorrhage

PURPOSE

To investigate the efficacy, safety, and mid-term outcomes of percutaneous mechanical thrombectomy (PMT) for acute symptomatic iliofemoral deep venous thrombosis (DVT) patients with recent (within 4 weeks) aneurysmal subarachnoid hemorrhage (aSAH).

MATERIALS AND METHODS

From January 2016 to February 2020, 11 acute symptomatic iliofemoral DVT patients with a recent history of aSAH were enrolled in this study. All patients had a history of aneurysm ligation or clipping previously, computed tomography (CT) scans revealed ventricular hemorrhage had been absorbed obviously and no residual aneurysm. The mean time of DVT onset after aSAH ictus was 19.2±4.5 days, and the mean Glasgow score was 6.8 ± 0.7 (range, 6-8). These patients underwent PMT with an 8 French Aspirex^®S device (Straub Medical AG, Wangs, Switzerland), subsequent stenting was performed to relieve the underlying stenosis, followed by anticoagulation alone. The procedure-related complications were assessed after intervention. The follow-ups were conducted up to 1 year, the patency was evaluated via duplex ultrasonography, and the incidence of post-thrombotic syndrome (PTS) was evaluated using the Villalta scale.

RESULTS

Grade III (>90%) clearance was achieved in all 11 patients. Stenting was performed in 7 patients (63.6%). There were no cerebral rebleeding events or other severe complications except 1 puncture site bleeding during treatment. A total of 90.9% (10 of 11) of patients were alive at the 12 month follow-up, and 7 patients achieved a good functional outcome. At the 1 year follow-up, there was 1 patient (10%) with mild PTS. The ultrasound showed that the patency of the iliofemoral veins was 100%, and femoral valvular incompetence was observed in 1 patient.

CONCLUSION

Percutaneous mechanical thrombectomy seems to be a feasible and safe treatment for acute iliofemoral DVT in selected patients with recent aSAH, and it shows promising results in restoring patency and reducing the risk of PTS.

Glycoprotein IIb/IIIa inhibitors for the neurointerventionalist

Antiplatelet therapies are commonly used in neurointerventional procedures. However, specific guidelines for their use in these settings is lacking and it can often be difficult to balance the potential risks and benefits of these medications. Considering the continued growth and adoption of neurointerventional procedures, it is crucial to understand the properties of these agents in order to use them safely. Large-scale clinical trials are still needed to clarify many of these aspects for this emerging field. However, the existing literature already provides insight into which antiplatelet drugs are of benefit to the neurointerventionalist as well as their associated risks of ischemic and hemorrhagic complications. Hence, this review focuses on the applications of GPIIb/IIIA inhibitors to neurointerventional procedures.

Phase 1/2a Trial of ISPASM

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.

Safety and efficacy of intravenous tirofiban for stent-assisted coiling in acutely ruptured intracranial aneurysms: A single center experience

BACKGROUND

There have been few reports on the use of tirofiban in ruptured intracranial aneurysms and the results were conflicting. However, the safety and efficacy of optimal dosage and the reasonable treatment course of tirofiban have not been determined.

OBJECTIVE

To determine the safety and efficacy of a new protocol for its prophylactic tirofiban application during the endovascular treatment of ruptured intracranial aneurysms with no oral antiplatelet medications.

METHODS

This retrospective study was based on 105 patients with ruptured aneurysms who underwent stent-assisted coiling at our institution between August 2017 and July 2020. Intravenous tirofiban was administered to patients after stent deployment. Tirofiban was administered as an intravenous bolus (5 µg/kg) over a 3 min period immediately after stent deployment, followed by a 0.06-0.08 µg/kg/min maintenance infusion for 12-24 h. Dual oral antiplatelet therapy was overlapped with half the tirofiban dose 2 h before the cessation of the tirofiban infusion. Cases of intracranial hemorrhage or thromboembolism were recorded.

RESULTS

This study included a total of 105 patients with ruptured intracranial aneurysms, who underwent stent-assisted coiling. In terms of clinical severity, a presenting Hunt-Hess clinical-grade I was observed in 47 (44.8%) cases, grade II in 19 (18.1%) cases, grade III in 30 (28.6%) cases, grade IV in 6 (5.6%) cases, and grade V in 3 (2.9%) cases. None of the patients showed a newly developed tirofiban-related intracerebral hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, or ventriculostomy-related hemorrhage. There were 3 (2.8%) patients who had thromboembolic complications.

CONCLUSIONS

We have determined a new protocol for prophylactic intraoperative tirofiban during the endovascular treatment of ruptured intracranial aneurysms with no oral antiplatelet medications. In our study, tirofiban showed a low risk of hemorrhagic or thromboembolic complications. Tirofiban appears to be a safe and alternative during the stent-assisted coiling of ruptured intracranial aneurysms.

Application of covered stent graft in the treatment of complex carotid artery lesions: A single center experience

PURPOSE

To assess the clinical efficiency and imaging outcome of applying covered stent grafts for the treatment of complex carotid artery lesions.

METHOD

A total of 39 consecutive patients with carotid artery lesions treated with covered stent grafts at our institution from December 2016 to December 2019 were reviewed. Two kinds of stent including self-expandable covered stent (Viabahn; W. L. Gore & Associates) and balloon-expandable covered stent (Willis; Microport) were applied. The angiograms immediately after the procedure, perioperative complications, and follow-up outcomes were recorded.

RESULT

Based on imaging features, 11 patients exhibited pseudoaneurysms, 23 patients had blood blister-like aneurysms (BBAs), and five patients were carotid cavernous fistulas. A total of 40 stent implantations were performed, including nine Viabahn stents and 31 Willis stents. Two patients received double implants of Willis stents. Stent failed to perform for one patient due to tortuous parent artery. The angiography reports immediately after the procedure showed that the lesions in 36 patients were completely occluded, whereas two patients had minimal endoleaks. With respect to the occurrence of procedural complications, an aneurysm ruptured during the procedure in one case, which resulted in CCF, and acute in-stent thrombosis occurred in another case. Clinical and angiographic follow-up (11.2±2.4 months) sessions were conducted for 38 patients and a complete lesion exclusion was achieved in 36 patients. The minimal endoleak persisted in one patient and another patient experienced recurrence with stent migration, leading to ipsilateral blepharoptosis. However, none of the patients developed hemorrhage or ischemia and in-stent stenosis was not observed.

CONCLUSION

Covered stent grafts appear to be a safe and feasible for the treatment of complex carotid artery lesions. Despite the potential for stent delivery failure as well as endoleak and procedure-related complications, covered stent grafts should be considered when selecting the optimal treatment strategy.

Antiplatelet Drugs for Neurointerventions: Part 2 Clinical Applications

Endovascular techniques have expanded to include balloon and stent-assistance, flow diversion and individualized endovascular occlusion devices, to widen the treatment spectrum for more complex aneurysm morphologies. While usually well-tolerated by patients, endovascular treatment of intracranial aneurysms carries the risk of complications, with procedure-related ischemic complications being the most common. Several antiplatelet agents have been studied in a neurointerventional setting for both prophylaxis and in the setting of intraprocedural thrombotic complications. Knowledge of these antiplatelet agents, evidence for their use and common dosages is important for the practicing neurointerventionist to ensure the proper application of these agents.Part one of this two-part review focused on basic platelet physiology, pharmacology of common antiplatelet medications and future directions and therapies. Part two focuses on clinical applications and evidence based therapeutic regimens.

Endovascular Treatment of Ruptured Middle Cerebral Artery Aneurysms With a Low-Profile Visualized Intraluminal Support Device

Objective: Stenting in ruptured middle cerebral artery (MCA) aneurysms was reported with a high perioperative complication rate. However, the treatment devices and physician's experience have continued to evolve. We performed this retrospective study to evaluate the safety and efficacy of LVIS stent-assisted coiling for ruptured MCA aneurysms.

Methods: Patients with acutely ruptured MCA aneurysms treated between November 2014 and October 2019 were retrospectively reviewed. Clinical and angiographic data of those treated with LVIS stents were collected from a prospectively maintained database.

Results: A total of 40 patients with 40 ruptured MCA aneurysms were enrolled, which comprised 26.3% (40/152) of all the ruptured MCA aneurysms at the same time. All stents were successfully deployed except for one (2.5%), which had a poor stent opening. Ischemic procedure-related complications were encountered in three patients (7.5%). One patient died of complications related to high-grade SAH on admission. Follow-up (mean 15.9 months) angiography was performed for 36 patients, which showed 33 (91.7%) aneurysms were completely occluded, 1 (2.8%) was improved, 1 (2.8%) was stable, and 1 (2.8%) was recanalized. Clinical follow-up (mean 29.6 months) was available for all survived patients, which showed 38 (95.0%) patients had favorable neurologic outcomes (mRS score 0–2), and 2 (5.0%) patients had poor neurologic outcomes.

Conclusion: The use of LVIS stents is feasible, safe, and effective with glycoprotein IIb/IIIa inhibitor for the treatment of ruptured MCA aneurysms in the acute setting. Prospective, multicenter studies with larger sample sizes are still required to further evaluate the safety and long-term efficacy.

Mechanical thrombectomy for occlusion near a ruptured intracranial aneurysm: A case report

Background:

While recent randomized clinical trials have shown the efficacy of mechanical thrombectomy for acute large vessel anterior cerebral occlusion, cases in patients with a subarachnoid hemorrhage (SAH) were excluded from the study.

Case Description:

A 58-year-old man presented with a SAH as a result of a ruptured middle cerebral artery aneurysm. Coil embolization was performed, and a right intracranial angiography showed remnants of an aneurysmal neck. However, the following angiography also revealed a thromboembolic complication that occurred in the same territory as the ruptured aneurysm. The patient underwent a rescue mechanical thrombectomy under the working projection. We deployed a retrieval stent without covering the aneurysmal neck. The occluded vessel was recanalized without any hemorrhagic complication. Due to minimal intracerebral infarction, the patient had good outcomes.

Conclusion:

Mechanical thrombectomy is a useful option to retrieve a clot from an occluded intracranial vessel located near a ruptured aneurysm. Approaching the clot at the working projection is important to ensure safety in the setting of a ruptured aneurysm.

Tirofiban Protocol Protects Against Delayed Cerebral Ischemia: A Case-Series Study

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.

Timing of Thrombosis in Embolization of Unruptured Intracranial Aneurysms : Tirofiban as Rescue Treatment

PURPOSE

Thrombosis is one of the main complications of endovascular treatment for unruptured intracranial aneurysms (UIA). This article reports the timing and initial location of thrombosis and prognosis after the use of tirofiban for performing coil embolization for UIA.

METHODS

This study retrospectively collected 1686 cases of intracranial aneurysms treated with coil embolization from January 2013 to February 2018. Ruptured cases were excluded. The presumed causes and timing of thrombosis, the response after tirofiban administration and the modified Rankin scale (mRS) score at 3 months were reviewed.

RESULTS

Of the 26 patients 76% were female and middle cerebral artery and basilar artery aneurysms accounted for 7 cases. The initial location of thrombosis was related to the stent (n = 14, 53.8%) or coil (n = 12, 46.2%). Of the patients 19 (73.1%) developed thrombosis during the procedure, and 5 patients (19.2%) developed it within 1 day of the procedure. Median duration between the thrombotic procedure and initial thrombosis was 38.5 min, 12 patients were symptomatic but more than half completely recovered after using tirofiban. Good clinical outcome (mRS 0-2) was seen in 92.3%. In the subgroup analysis, median time from the first thrombotic procedure to initial thrombosis within 1 day was 38.0 min (stent-related group) and 35.0 min (coil-related group, p = 0.651).

CONCLUSION

In most cases of embolization for UIA, thrombosis requiring the use of tirofiban occurs intraprocedurally or on the first day after the procedure. Careful observation of thrombosis during the procedure is important and tirofiban should be used for a better outcome even if the infarction progresses.

Clinical Safety and Effectiveness of Stent-Assisted Coil Embolization with Neuroform Atlas Stent in Intracranial Aneurysm

Objective

Stent-assisted coil embolization (SAC) is commonly used for treating wide-neck intracranial aneurysms. In this study, we aimed to assess the clinical safety and efficacy of the NeuroForm Atlas Stent during SAC of intracranial aneurysms.

Methods

We retrospectively analyzed data from patients with ruptured and unruptured cerebral aneurysms, who underwent SAC using the NeuroForm Atlas between February 2018 and July 2018. Favorable clinical outcomes and degree of aneurysm occlusion were defined as a modified Rankin scale score of ≤2 and a Raymond-Roy occlusion classification (RROC) class I/II during the immediate postoperative period and at the 6-month follow-up, respectively.

Results

Thirty-one consecutive patients with 33 cases, including 11 ruptured and 22 unruptured cases were treated via NeuroForm Atlas SAC. Among the 22 unruptured cases with 24 unruptured aneurysms had favorable clinical outcome. Complete occlusion (RROC I) was achieved in 16 aneurysms (66.7%), while neck remnants (RROC II) were observed in six aneurysms (25%). Among the 11 patients with ruptured aneurysms, two died due to re-bleeding and diabetic ketoacidosis. In ruptured cases, RROC I was observed in eight (72.7%) and RROC II was observed in three cases (27.3%). At the 6-month follow-up, no clinical events were observed in the 22 unruptured cases. In the ruptured nine cases, five patients recovered without neurologic deficits, while four experienced unfavorable outcomes at 6 months. Of the 29 aneurysms examined via angiography at the 6-month follow-up, 19 (65.5%) were RROC I, eight (27.6%) were RROC II and two (6.9%) were RROC III. There were no procedure-related hemorrhagic complications.

Conclusion

In this study, we found that stent-assisted coil embolization with NeuroForm Atlas stent may be safe and effective in the treatment of wide-neck intracranial aneurysms. NeuroForm Atlas SAC is feasible for the treatment of both ruptured and unruptured wide-neck aneurysms.

Safety and Efficacy of Tirofiban Combined With Mechanical Thrombectomy Depend on Ischemic Stroke Etiology

Background and Purpose: The clinical use of tirofiban for patients with acute ischemic stroke (AIS) who underwent mechanical thrombectomy (MT) remains controversial. We aimed to evaluate the safety and efficacy of tirofiban combined with MT in AIS patients.

Methods: Patients with AIS who underwent MT from January 2014 to December 2018 were enrolled in three stroke units in China. Subgroup analyses were performed based on stroke etiology which was classified according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria. Safety outcomes were in-hospital intracerebral hemorrhage (ICH), symptomatic intracerebral hemorrhage (sICH) and mortality at 3-month. Efficacy outcomes were favorable functional outcome and functional independence at 3-month and neurological improvement at 24 h, 3 d and discharge.

Results: In patients with large artery atherosclerosis (LAA) stroke, multivariate analyses revealed that tirofiban significantly decreased the odds of in-hospital ICH (adjusted OR = 0.382, 95% CI 0.180–0.809) and tended to increase the odds of favorable functional outcome at 3-month (adjusted OR = 3.050, 95% CI 0.969–9.598). By contrast, in patients with cardioembolism (CE) stroke, tirofiban was not associated with higher odds of favorable functional outcome at 3-month (adjusted OR = 0.719, 95% CI 0.107–4.807), but significantly decreased the odds of neurological improvement at 24 h and 3d (adjusted OR = 0.185, 95% CI 0.047–0.726; adjusted OR = 0.268, 95% CI 0.087–0.825).

Conclusions: Tirofiban combined with MT appears to be safe and effective in LAA patients, but has no beneficial effect on CE patients.

Association between extracranial internal carotid artery tortuosity and thromboembolic complications during coil embolization of anterior circulation ruptured aneurysms

BACKGROUND

The most frequent neurological complication during coil embolization of a ruptured cerebral aneurysm is a thromboembolic event. The association between the tortuosity of the internal carotid artery (ICA) and thromboembolic events (TEEs) during coil embolization of ruptured cerebral aneurysms remains unclear. The present study aimed to investigate the association between extracranial ICA tortuosity and thromboembolic complications during coil embolization of anterior circulation ruptured aneurysms.

METHODS

A cohort of 57 patients with 57 anterior circulation ruptured aneurysms who underwent endovascular embolization at a single institution was retrospectively investigated. Patients were divided into two groups, those who experienced TEEs and those who did not that were compared and analyzed based on patient baseline characteristics, procedural factors, and anatomical factors including those of aneurysms and extracranial ICA tortuosity. The anatomical factors of the aneurysms included maximum dome size, neck width, dome-to-neck ratio, and dome-to-neck aspect ratio. Extracranial ICA angles in the proximal and distal curvature were evaluated as ICA tortuosity.

RESULTS

Three of the 57 patients were excluded because of unavailability of data regarding ICA tortuosity; 54 patients were finally evaluated. TEEs occurred in six patients with five anterior cerebral and one internal carotid aneurysms. The extracranial distal ICA angle was significantly larger in patients with TEEs than in those without. Procedural factors and anatomical factors of the aneurysms were not associated with TEEs.

CONCLUSIONS

Extracranial ICA tortuosity was significantly associated with an increased incidence of thromboembolic events during endovascular coiling of anterior circulation ruptured aneurysms.