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Pettersson SD, Khorasanizadeh M, Maglinger B, Garcia A, Wang SJ, Taussky P, Ogilvy CS. Trends in the Age of Patients Treated for Unruptured Intracranial Aneurysms from 1990 to 2020. World Neurosurg 2023; 178:233-240.e13. [PMID: 37562685 DOI: 10.1016/j.wneu.2023.08.007] [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: 07/11/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND The decision for treatment for unruptured intracranial aneurysms (UIAs) is often difficult. Innovation in endovascular devices have improved the benefit-to-risk profile especially for elderly patients; however, the treatment guidelines from the past decade often recommend conservative management. It is unknown how these changes have affected the overall age of the patients selected for treatment. Herein, we aimed to study potential changes in the average age of the patients that are being treated over time. METHODS A systematic search of the literature was performed to identify all studies describing the age of the UIAs that were treated by any modality. Scatter diagrams with trend lines were used to plot the age of the patients treated over time and assess the presence of a potential significant trend via statistical correlation tests. RESULTS A total of 280 studies including 83,437 UIAs treated between 1987 and 2021 met all eligibility criteria and were entered in the analysis. Mean age of the patients was 55.5 years, and 70.7% were female. There was a significant increasing trend in the age of the treated patients over time (Spearman r: 0.250; P < 0.001), with a 1-year increase in the average age of the treated patients every 5 years since 1987. CONCLUSIONS The present study indicates that based on the treated UIA patient data published in the literature, older UIAs are being treated over time. This trend is likely driven by safer treatments while suggesting that re-evaluation of certain UIA treatment decision scores may be of great interest.
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Affiliation(s)
- Samuel D Pettersson
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - MirHojjat Khorasanizadeh
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Benton Maglinger
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Alfonso Garcia
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - S Jennifer Wang
- Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Philipp Taussky
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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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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Shen G, Jia Z, Zhao L, Lu G, Liu S, Shi H. The safety and efficacy of a low dose of tirofiban for early complications during and after stent-assisted coiling of ruptured intracranial aneurysms: a propensity matching study. Clin Neurol Neurosurg 2022; 214:107132. [DOI: 10.1016/j.clineuro.2022.107132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/04/2022] [Accepted: 01/14/2022] [Indexed: 11/29/2022]
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Russo R, Bradac GB, Castellan L, Gallesio I, Garbossa D, Iannucci G, Mardighian D, Menozzi R, Pitrone A, Romano G, Venturi F, Bergui M. Neuroform Atlas stent-assisted coiling of ruptured intracranial aneurysms: A multicenter study. J Neuroradiol 2020; 48:479-485. [PMID: 32205256 DOI: 10.1016/j.neurad.2020.02.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/20/2020] [Accepted: 02/24/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess efficacy, safety and to discuss optimal medical therapy of stent-assisted coiling of ruptured intracranial aneurysms. METHODS Ruptured intracranial aneurysms treated with stent-assisted coiling in eight different institutions were retrospectively reviewed. Medical treatment regimens varied among the centers, mainly regarding heparin administration and post-procedural single or double antiplatelet therapy. Clinical and angiographic results, including complications and outcomes were analyzed and related to the different therapies. RESULTS Sixty-one consecutive patients (male/female 23/38), aged 59.1 years (36-86) underwent stent-assisted coiling for ruptured intracranial aneurysm without antiplatelet pre-medication. Intravenous acetylsalicylic acid (ASA) 500mg was administered to all patients immediately after stent deployment. At the same time heparin was given as bolus in 15 patients (24.6%) as part of local protocol. Intravenous glycoprotein 2b/3a inhibitors (antiGP2b3a) were used as bail-out therapy for stent thrombosis. Stent thrombosis occurred in 22 patients (36.1%), of which 4 (6.5%) lead to incomplete and 18 (29.6) to complete occlusion of the stent. Heparin administration had no effect on thrombosis rate. Thrombosis resolution occurred in all cases with intravenous antiGP2b3a (7 tirofiban, 15 abciximab), without increasing overall complication rate. Single antiplatelet therapy with ASA (28 patients, 45.9%) or double antiplatelet therapy including ASA and clopidogrel (33 patients, 54.1%) were administered after procedure, depending on local protocols and on neurointerventionists' experience. Overall complication rate, including ischemia and hemorrhage was higher in patients in which only ASA was administered (21.4% vs. 12.1%). No late stent thrombosis was seen, regardless of whether a single or double antiplatelet regimen was used. Nevertheless, the small sample size suggests caution in interpreting these results. Moreover, a possible bias may arise from the decision whether to modify the maintenance therapy or not depending on the severity of the intracranial hemorrhage in a case-by-case assessment. At three months, 34 out of 38 patients with HH grade 1-2 (89.4%), and 11 out of 23 with Hunt-Hess grade of 3-4 (47.8%) were independent (Modified Ranking Scale 0-2). CONCLUSION Stent assisted coiling of ruptured intracranial aneurysms is a feasible option when simple coiling is not possible. Optimal medical treatment is still controversial because balance between hemorrhagic and ischemic risks is difficult to evaluate. In our series, heparin bolus had no effect on subsequent stent thrombosis. In all cases peri-operative stent thrombosis was successfully managed using bail-out intravenous antiGP2b3a, which did not increase post-procedural hemorrhage rates. A non-significant trend towards increased complications rate was noticed in patients treated with single antiplatelet therapy versus double antiplatelet therapy.
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Affiliation(s)
- Riccardo Russo
- Department of Surgical Sciences, Radiology Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, corso bramante 88, Turin, Italy.
| | - Gianni Boris Bradac
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Lucio Castellan
- Neuroradiology Unit, IRCCS San Martino University Hospital, Genoa, Italy
| | - Ivan Gallesio
- Department of Radiology, Neuroradiological Unit, Azienda ospedaliera "SS Antonio e Biagio e C. Arrigo", Alessandria, Italy
| | - Diego Garbossa
- Department of Neuroscience, Neurosurgery Section, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | | | | | - Roberto Menozzi
- Interventional Neuroradiology Unit, Azienda Ospedaliera Universitaria, Parma, Italy
| | - Antonio Pitrone
- Neuroradiology Unit, Biomedical Sciences and of Morphologic and Functional Images, AOU Policlinico G. Martino, Messina, Italy
| | - Giuseppe Romano
- Neuroradiology Unit, S. Croce e Carle Hospital, Cuneo, Italy
| | - Fabrizio Venturi
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Mauro Bergui
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
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Dornbos D, Katz JS, Youssef P, Powers CJ, Nimjee SM. Glycoprotein IIb/IIIa Inhibitors in Prevention and Rescue Treatment of Thromboembolic Complications During Endovascular Embolization of Intracranial Aneurysms. Neurosurgery 2019; 82:268-277. [PMID: 28472526 DOI: 10.1093/neuros/nyx170] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 03/10/2017] [Indexed: 11/13/2022] Open
Abstract
Thromboembolic complications remain a major risk of endovascular neurosurgery during the treatment of intracranial aneurysms, despite the use of therapeutic heparinization and oral antiplatelet therapy when indicated. Glycoprotein (GP) IIb/IIIa inhibitors target a nonredundant pathway of platelet aggregation following adhesion and activation. Initially established and implemented in the cardiovascular arena, this drug class has provided a new tool in the neurovascular armamentarium as well. Numerous case reports, case series, and retrospective reviews have evaluated the safety and efficacy of abciximab, eptifibatide, and tirofiban in the treatment of acute thromboembolic complications during the endovascular treatment of intracranial aneurysms. The use of this drug class has also been found to be beneficial as a prophylactic agent, providing ischemia protection during the placement of intracranial stents, flow diverters, and thrombogenic coils in the setting of subarachnoid hemorrhage and during elective aneurysmal embolization. While the current published literature clearly establishes efficacy and safety of GP IIb/IIIa inhibitors in the prevention of thromboembolic complications, there does not yet exist an established protocol for their administration in endovascular neurosurgery. This review provides a comprehensive evaluation of the current published literature pertaining to the use of all available GP IIb/IIIa inhibitors for thromboembolic complications, providing recommendations for dosing and administration of abciximab, eptifibatide, and tirofiban based on previously published rates of efficacy and intracranial hemorrhage.
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Affiliation(s)
- David Dornbos
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joel S Katz
- Department of Neurological Surgery, OhioHealth Grant and Riverside Medical Center, Columbus, Ohio
| | - Patrick Youssef
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ciarán J Powers
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Shahid M Nimjee
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Kim KS, Fraser JF, Grupke S, Cook AM. Management of antiplatelet therapy in patients undergoing neuroendovascular procedures. J Neurosurg 2018; 129:890-905. [DOI: 10.3171/2017.5.jns162307] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Neuroendovascular techniques for treating cerebral aneurysms and other cerebrovascular pathology are increasingly becoming the standard of care. Intraluminal stents, aneurysm coils, and other flow diversion devices typically require concomitant antiplatelet therapy to reduce thromboembolic complications. The variability inherent with the pharmacodynamic response to common antiplatelet agents such as aspirin and clopidogrel complicates optimal selection of antiplatelet agents by clinicians. This review serves to discuss the literature related to antiplatelet use in neuroendovascular procedures and provides recommendations for clinicians on how to approach patients with variable response to antiplatelet agents, particularly clopidogrel.
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Affiliation(s)
- Keri S. Kim
- 1Department of Pharmacy Practice, University of Illinois Medical Center at Chicago, Illinois
| | - Justin F. Fraser
- 2Departments of Neurological Surgery, Neurology, Radiology, and Anatomy and Neurobiology, Center for Advanced Translational Stroke Science
| | | | - Aaron M. Cook
- 4UK HealthCare; and
- 5University of Kentucky College of Pharmacy, Lexington, Kentucky
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Li K, Guo Y, Zhao Y, Xu B, Xu K, Yu J. Acute rerupture after coil embolization of ruptured intracranial saccular aneurysms: A literature review. Interv Neuroradiol 2017; 24:117-124. [PMID: 29231793 DOI: 10.1177/1591019917747245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acute rerupture after coil embolization is defined as rerupture within three days after treatment; its prognosis is worse than that of rebleeding at other time periods. However, to date, little is known about complications during the acute phase. Therefore, we used the PubMed database to perform a review of acute rerupture after coil embolization of ruptured intracranial saccular aneurysms and increase our understanding. After reviewing the complications, we found that the cause of acute rerupture is unclear, but the following risk factors are involved: incomplete occlusion of the initial aneurysm, the presence of a hematoma adjacent to a ruptured aneurysm, an aneurysmal outpouching, poor Hunt-Hess grade at the time of treatment, and the location of the aneurysm in an anterior communicating artery. In addition, intraoperative rupture is a non-negligible cause. Acute rerupture after coil embolization mainly occurs within the first 24 hours after the procedure. Brain computed tomography is the gold standard for diagnosing acute rebleeding of a coiled aneurysm. For acute rerupture after coil embolization, prevention is critical, and complete occlusion of the aneurysm in the first session is the best protection against acute rebleeding. In addition, a restricted postembolization anticoagulation strategy is recommended for patients with high-risk aneurysms. For patients with an adjacent hematoma, surgical clipping is recommended. Most patients present no changes immediately after acute rebleeding because of their poor condition. However, surgical or endovascular treatments can be attempted if the patient is in an acceptable condition. Even so, the outcomes are typically unsatisfactory.
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Affiliation(s)
- Kailing Li
- 1 Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Yunbao Guo
- 1 Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Ying Zhao
- 2 Department of Training, The First Hospital of Jilin University, Changchun, China
| | - Baofeng Xu
- 1 Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Kan Xu
- 1 Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- 1 Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
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Mooney MA, Moon K, Gross BA, Ducruet AF, Albuquerque FC. Incidence of delivery wire recapture failure with the Pipeline Flex device. J Neurointerv Surg 2017; 9:571-573. [DOI: 10.1136/neurintsurg-2016-012856] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/28/2016] [Accepted: 12/29/2016] [Indexed: 11/04/2022]
Abstract
BackgroundThe Pipeline Flex embolization device has several advantages over the first-generation Pipeline embolization device (Covidien, Dublin, Republic of Ireland). Despite these advantages, we have observed frequent difficulty in recapturing the device's delivery wire.ObjectiveTo prospectively document the incidence of failure to recapture the delivery wire.MethodsWe tracked our experience in patients undergoing endovascular treatment with a flow-diverting stent for cerebral aneurysms between 1 May and 30 September 2016. Patient and lesion characteristics, device dimensions, and technical outcomes of delivery wire recapture were prospectively recorded for each device.ResultsEighteen devices were deployed in 15 patients by the senior author (FCA) during this period. Failure to recapture the delivery wire occurred in 10 of 18 (56%) cases. No adverse outcomes of delivery wire recapture failure were encountered in this series.ConclusionsThe incidence of delivery wire recapture failure with the Pipeline Flex device is high. Failure to recapture the delivery wire carries a theoretical risk of stent displacement when re-navigating across the device, and endovascular surgeons should be aware of this limitation. Authors are encouraged to report delivery wire recapture failure rates in future clinical series in which the Pipeline Flex device is used.
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