The Prophylactic Use of Tirofiban versus Oral Antiplatelet Medications in Stent-Assisted Coiling of Intracranial Aneurysms: A Meta-analysis

Pathway plaques and diffusion-weighted lesion analysis after endovascular treatment of unruptured intracranial aneurysms: a prospective study

OBJECTIVES

To evaluate the prevalence and predictors of ischemic lesions on thin-slice DWI (2 mm) in endovascular treatments for unruptured intracranial aneurysms (UIA), particularly explore the potential relationship with pathway plaques.

METHODS

Participants eligible for endovascular treatments with UIA at a national stroke center between March 2023 and August 2023 were prospectively enrolled. All participants performed thin-slice DWI (slice thickness of 2 mm) before and after procedures. Three-dimensional joint intra-and extracranial vessel wall MRI (3D-vwMRI, voxel size 0.6 × 0.6 × 0.6 mm3) was scheduled to evaluate the pathway plaques for all participants. The DWI-positive numbers were ordered and divided into four equal parts, with each quartile representing 25% of the data set.

RESULTS

A total of 106 participants were included. Overall, none of the participants exhibited preoperative DWI-positive lesions. Following the intervention, 93.4% (99/106) of participants exhibited new DWI-positive lesions on postoperative MRI, including 5.7% (6/106) with symptomatic ischemic stroke. Compared with the lowest quartile of ischemic lesions, the highest quartile was associated with increased odds of the presence of plaque (OR = 9.4, 95% CI: 2.0-45.4; p = 0.005). The history of previous stroke (OR = 4.6, 95% CI: 1.6-14.6; p = 0.007) and the presence of plaque in the pathway (OR = 3.4, 95% CI: 1.6-7.7; p = 0.002) were identified as independent predictors of higher quartiles of DWI-positive numbers.

CONCLUSIONS

As revealed by thin-slice DWI, ischemic lesions related to the endovascular treatments for UIA occurred more frequently than anticipated. A history of the previous stroke and the pathway plaques were independent predictors of higher quartiles of DWI-positive numbers.

KEY POINTS

Question Previous studies using conventional MRI may underestimate DWI-positive lesions. The procedural risk of UIA coexisting with atherosclerotic plaques is still unclear. Findings Thin-slice DWI showed ischemic lesions occurred frequently (93.4%). Three-dimensional-intra-and extracranial Vessel Wall MRI revealed a positive correlation between pathway plaques and DWI lesions. Clinical relevance Neuro-interventionalists should exercise caution when managing patients with a history of previous stroke in the presence of plaques in the treatment pathway. More vigilant pre-procedural imaging should be considered to assess unstable plaque in high-risk patients.

Propensity score-adjusted analysis on early tirofiban administration to prevent thromboembolic complications during stand-alone coil embolization of ruptured aneurysms

The glycoprotein IIb/IIIa antagonist tirofiban has been shown to prevent thromboembolic events during endovascular procedures, but the benefits and risks of its prophylactic early intraprocedural administration for stand-alone coil embolization of acutely ruptured aneurysms are still unclear. We conducted a retrospective single-center analysis of patients treated for aneurysmal subarachnoid hemorrhage with stand-alone coil embolization. Two study cohorts were compared according to the primary prophylactic antithrombotic medication during the procedure: patients receiving only intravenous heparin (HEP) versus patients receiving tirofiban in addition to heparin prior to final aneurysm obliteration (HEP + TF). Outcome endpoints were the incidence of angiographically visible thrombus formation or distal embolization, and the incidence of periprocedural intracranial hemorrhage (ICH). Of 204 cases, 159 were prophylactically treated with HEP and 45 with HEP + TF. Intraprocedural thromboembolic events were less frequent with HEP + TF before and after propensity score matching (PSM) (2.5% vs. 19.7%, p = 0.017). The incidence of ICH and symptomatic ICH did not differ between HEP + TF and HEP before and after PSM (20.5% vs. 30.7%, p = 0.29; and 5.1% vs. 4%, p = 0.88). Early intraprocedural tirofiban administration may be effective in preventing thromboembolic complications during stand-alone coil embolization of acutely ruptured aneurysms without increasing the risk of ICH.

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.

Safety and efficacy of stent-assisted coil embolization with periprocedural dual antiplatelet therapy for the treatment of acutely ruptured intracranial aneurysms

PURPOSE

Despite growing evidence for the effectiveness of stent-assisted coil embolization (SAC) in treating acutely ruptured aneurysms, the safety of stent placement in acute phase remains controversial because of concerns for stent-induced thromboembolism and hemorrhagic events attributable to the necessity of antiplatelet therapy. Therefore, we investigated the safety and efficacy of SAC with periprocedural dual antiplatelet therapy (DAPT) compared with the coiling-only technique to determine whether it is a promising treatment strategy for ruptured aneurysms.

METHODS

We retrospectively evaluated 203 enrolled patients with acutely ruptured aneurysms, categorizing them into two groups: SAC and coiling-only groups. Comparative analyses between the two groups regarding angiographic results, clinical outcomes, and procedure-related complications were performed. A subgroup analysis of procedural complications was conducted on patients who did not receive chronic antithrombotic medications to alleviate their influence before hospitalization.

RESULTS

130 (64.0%) patients were treated using the coiling-only technique, whereas 73 (36.0%) underwent SAC. There was a trend to a higher complete obliteration rate (p = 0.061) and significantly lower recanalization rate (p = 0.030) at angiographic follow-up in the SAC group compared to the coiling-only group. Postprocedural cerebral infarction occurred less frequently in the SAC group (8.2%) than in the coiling-only group (17.7%), showing a significant difference (p = 0.044). Although the ventriculostomy-related hemorrhage rate was significantly higher in the SAC group than in the coiling-only group (26.2% vs. 9.3%, p = 0.031), the incidence of symptomatic ventriculostomy-related hemorrhage was comparable. Subgroup analysis excluding patients receiving chronic antithrombotic medications showed similar results.

CONCLUSION

SAC with periprocedural DAPT could be a safe and effective treatment strategy for acutely ruptured aneurysms. Moreover, it might have a protective effect on postprocedural cerebral infarction without increasing the risk of symptomatic hemorrhagic complications.

Efficacy and Safety of Tirofiban Before Stenting for Symptomatic Intracranial Atherosclerotic Stenosis: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVES

Acute stent thrombosis (AST) is not uncommon and even catastrophic during intracranial stenting angioplasty in patients with symptomatic high-grade intracranial atherosclerotic stenosis (ICAS). The purpose of this study was to investigate whether adjuvant intravenous tirofiban before stenting could reduce the risk of AST and periprocedural ischemic stroke in patients receiving stent angioplasty for symptomatic ICAS.

METHODS

A prospective, multicenter, open-label, randomized clinical trial was conducted from September 9, 2020, to February 18, 2022, at 10 medical centers in China. Patients intended to receive stent angioplasty for symptomatic high-grade ICAS were enrolled and randomly assigned to receive intravenous tirofiban or not before stenting in a 1:1 ratio. The primary outcomes included the incidence of AST within 30 minutes after stenting, periprocedural new-onset ischemic stroke, and symptomatic intracranial hemorrhage. The outcomes were analyzed using logistic regression analysis to obtain an odds ratio and 95% confidence interval.

RESULTS

A total of 200 participants (122 men [61.0%]; median [interquartile ranges] age, 57 [52-66] years) were included in the analysis, with 100 participants randomly assigned to the tirofiban group and 100 participants to the control (no tirofiban) group. The AST incidence was lower in the tirofiban group than that in the control group (4.0% vs 14.0%; adjusted odds ratio, 0.25; 95% CI 0.08-0.82; p = 0.02). No significant difference was observed in the incidence of periprocedural ischemic stroke (7.0% vs 8.0%; p = 0.98) or symptomatic intracranial hemorrhage between the 2 groups.

DISCUSSION

This study suggests that adjuvant intravenous tirofiban before stenting could lower the risk of AST during stent angioplasty in patients with symptomatic high-grade ICAS.

TRIAL REGISTRATION INFORMATION

URL: chictr.org.cn; Unique identifier: ChiCTR2000031935.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that for patients with symptomatic high-grade ICAS, pretreatment with tirofiban decreases the incidence of acute stent thrombosis. This study is Class II due to the unequal distribution of involved arteries between the 2 groups.

Trends in Dual Antiplatelet Therapy Use for Neurointerventional Procedures for the Management of Intracranial Aneurysms

The use of periprocedural dual antiplatelet therapy (DAPT) has significantly evolved along with innovations in the endovascular management of intracranial aneurysms. Historically, aspirin and clopidogrel have been the most commonly employed regimen due to its safety and efficacy. However, recent studies highlight the importance of tailoring DAPT regimens to individual patient characteristics which may affect clopidogrel metabolism, such as genetic polymorphisms. In the present report, a systematic review of the literature was performed to determine optimal antiplatelet use with flow diverting stents, intracranial stents, intrasaccular devices, and stent-assisted coiling. Studies were analyzed for the number of aneurysms treated, DAPT regimen, and any thromboembolic complications. Based on inclusion criteria, 368 studies were selected, which revealed the increasing popularity of alternative DAPT regimens with the aforementioned devices. Thromboembolic or hemorrhagic complications associated with antiplatelet medications were similar across all medications. DAPT with ticagrelor, tirofiban, or prasugrel are effective and safe alternatives to clopidogrel and do not require enzymatic activation. Further clinical trials are needed to evaluate different antiplatelet regimens with various devices to establish highest-level evidence-based guidelines and recommendations.

Anticoagulation Options for Cranial Procedures: A Comparative Review of Aspirin, Plavix, and Aggrastat

Anticoagulation therapy is critical to avoiding thrombotic events in patients following cranial surgery. Although Aspirin, Plavix, and Aggrastat are used as anticoagulants for this purpose, there is no consensus on which agent is the most effective and safe. In this comparative study, we analyze the current evidence on the efficacy and safety of these three anticoagulants in the context of cranial surgeries. This review focuses on the advantages and disadvantages of each anticoagulant, such as its pharmacokinetics, indications, contraindications, and possible consequences. The outcomes of this study will help physicians choose the best anticoagulant for their patients based on individual patient characteristics and the kind of cranial procedure. Aggrastat's potential to be included as a recommended anticoagulant for cranial procedures warrants further study.

The Prophylactic Use of Glycoprotein 2b/3a Inhibitors in the Endovascular Treatment of Intracranial Aneurysms: A Systematic Review and Meta-Analysis

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.