Eptifibatide use in ischemic stroke patients undergoing endovascular thrombectomy: A matched cohort analysis

Emergency endovascular treatment of stroke due to cervical artery dissection - impact of periprocedural GP IIb/IIIa inhibitor use on clinical outcome

BACKGROUND

Endovascular therapy (EVT) for large intracranial vessel occlusion or symptomatic hypoperfusion due to cervical artery dissection (CeAD) became the standard therapy in recent years. Stenting is frequently required to secure the dissection with subsequent need for GP IIb/IIIa inhibitors. However, a potential concern of antithrombotic therapy in acute stroke is the increased risk of intracerebral hemorrhage. The aim of the study was to assess the impact of the administration of a GP IIb/IIIa inhibitor imaging during endovascular treatment for acute ischemic stroke caused by CeAD on 90-day clinical outcome and intracranial hemorrhage.

METHODS

This single-center retrospective cohort study enrolled CeAD patients with internal carotid artery (ICA) dissections treated with EVT from January 2015 to August 2022. We analysed the impact of different variables including postinterventional hemorrhage, revascularization success and the use of GP IIb/IIIa Inhibitors (eptifibatide) on 90-day favorable clinical outcome (mRS 0-2). NIHSS Scores were evaluated at different time points in relation to the 90-day clinical outcomes.

RESULTS

Forty-nine patients were included in the study. Thrombectomy was performed in all patients. In 33 patients, stenting was performed in addition to thrombectomy. 20 patients (40.8%) received eptifibatide periinterventionally. 31 out of 49 patients (63.3%) had a favorable 90-day clinical outcome (mRS 0-2). Five patients showed radiologically significant hemorrhage. The rate of successful reperfusion (TICI 2b-3) in the favorable 90-day outcome group was significantly higher than in the unfavorable 90-day outcome group.

CONCLUSIONS

In this study, the use of a GP IIb/IIIa inhibitor use during EVT for stroke caused by CeAD did not affect 90-day clinical outcome nor the incidence of intracranial hemorrhage. Successful reperfusion significantly correlated with favorable clinical outcome.

Comparative Effects of Glenzocimab and Eptifibatide on Bleeding Severity in 2 Mouse Models of Intracranial Hemorrhage

BACKGROUND

Antiplatelet drugs represent potential candidates for protecting the penumbral microcirculation during cerebral ischemia and improving the benefits of arterial recanalization in ischemic stroke. Yet while the efficacy of such adjuvant strategies has been shown to be highly time dependent, antiplatelet therapy at the acute phase of ischemic stroke cannot be envisioned until the diagnosis of stroke and its ischemic nature have been confirmed because of the presumed risk of worsening bleeding in case of intracranial hemorrhage (ICH). Here, we investigated this risk for 2 antiplatelet drugs currently being tested in clinical trials for ischemic stroke, glenzocimab and eptifibatide, in 2 mouse models of ICH.

METHODS AND RESULTS

The severity of ICH was assessed in mice humanized for glycoprotein VI treated or not with glenzocimab or eptifibatide at effective dose, in a model of primary ICH caused by unilateral striatal injection of collagenase type VII, and in a model of hyperglycemia-induced hemorrhagic transformation of cerebral ischemia-reperfusion injury. Glenzocimab had no impact on bleeding severity in either model of ICH. Conversely, eptifibatide caused a significant increase in intracranial bleeding in both models, and a drastic increase in death after hyperglycemia-induced hemorrhagic transformation of cerebral ischemia-reperfusion injury.

CONCLUSIONS

Unlike eptifibatide, glenzocimab is safe in the setting of ICH. These results suggest that glenzocimab could be administered upon suspicion of ischemic stroke, before assessment of its ischemic nature, thus opening the way to hastening of treatment initiation.

Factors affecting the outcomes of tirofiban treatment in posterior circulation stroke

OBJECTIVE

Tirofiban is an effective treatment for ischemic stroke that is frequently used following early neurological deterioration (END). However, studies investigating the effects of tirofiban on patients with posterior circulation stroke (PCS) are scarce. Thus, this study aimed to explore factors affecting the outcomes of tirofiban in PCS.

METHODS

The data of patients with PCS treated with tirofiban at our hospital were retrospectively collected. A modified Rankin scale (mRS) of 0-2 at 90 days was defined as a favorable outcome. A reduction in NIHSS after treatment compared with baseline NIHSS was defined as an early response to tirofiban. Patients' clinical characteristics and laboratory findings were analyzed to identify independent factors affecting the outcomes of tirofiban treatment.

RESULTS

A total of 113 patients were enrolled in this study. 71 patients (62.8 %) exhibited favorable outcomes, whereas the remaining patients (37.2 %) had unfavorable outcomes. Hypertension and high NIHSS at admission were associated with unfavorable outcomes [(OR: 0.151, 95 % CI: 0.026-0.872; p = 0.035), (OR: 0.645, 95 % CI: 0.491-0.847; p < 0.001)], whereas high early response to tirofiban was significantly associated with favorable outcomes (OR: 1.913, 95 %CI: 1.390-2.631; p < 0.001). The cut-off value of early response to tirofiban to predict a favorable outcome was 0.5, with a sensitivity and specificity of 69 % and a Youden index of 0.38.

CONCLUSION

Early response to tirofiban had the highest predictive value on long-term outcomes of PCS patients treated with tirofiban.

Triple platelet inhibition in intracranial thrombectomy with additional acute cervical stent angioplasty due to tandem lesion: a retrospective single-center analysis

BACKGROUND

Acute stroke treatment with intracranial thrombectomy and treatment of ipsilateral carotid artery stenosis/occlusion ("tandem lesion", TL) in one session is considered safe. However, the risk of stent restenosis after TL treatment is high, and antiplatelet therapy (APT) preventing restenosis must be well balanced to avoid intracranial hemorrhage. We investigated the safety and 90-day outcome of patients receiving TL treatment under triple-APT, focused on stent-patency and possible disadvantageous comorbidities.

METHODS

Patients receiving TL treatment in the setting of acute stroke between 2013 and 2022 were analyzed regarding peri-/postprocedural safety and stent patency after 90 days. All patients received intravenous eptifibatide and acetylsalicylic acid and one of the three drugs prasugrel, clopidogrel, or ticagrelor. Duplex imaging was performed 24 h after treatment, at discharge and 90 days, and digital subtraction angiography was performed if restenosis was suspected.

RESULTS

176 patients were included. Periprocedural complications occurred in 2.3% of the patients at no periprocedural death, and in-hospital death in 13.6%. Discharge mRS score was maintained or improved at the 90-day follow-up in 86%, 4.54% had an in-stent restenosis requiring treatment at 90 days. No recorded comorbidity considered disadvantageous for stent patency showed statistical significance, the duration of the endovascular procedure had no significant effect on outcome.

CONCLUSION

In our data, TL treatment with triple APT resulted in a low restenosis rate, low rates of sICH and a comparably high number of patients with favorable outcome. Aggressive APT in the initial phase may therefore have the potential to prevent recurrent stroke better than restrained platelet inhibition. Comorbidities did not influence stent patency.

Intravenous cangrelor use for neuroendovascular procedures: a two-center experience and updated systematic review

Background

The optimal antiplatelet therapy regimen for certain neuroendovascular procedures remains unclear. This study investigates the safety and feasibility of intravenous dose-adjusted cangrelor in patients undergoing acute neuroendovascular interventions.

Methods

We conducted a retrospective chart review of all consecutive patients on intravenous cangrelor for neuroendovascular procedures between September 1, 2020, and March 13, 2022. We also conducted an updated systematic review and meta-analysis using PubMed, Scopus, Web of Science, Embase and the Cochrane Library up to February 22, 2023.

Results

In our cohort, a total of 76 patients were included [mean age (years): 57.2 ± 18.2, males: 39 (51.3), Black: 49 (64.5)]. Cangrelor was most used for embolization and intracranial stent placement (n = 24, 32%). Approximately 44% of our patients had a favorable outcome with a modified Rankin Scale (mRS) score of 0 to 2 at 90 days (n = 25/57); within 1 year, 8% of patients had recurrent or new strokes (n = 5/59), 6% had symptomatic intracranial hemorrhage [sICH] (4/64), 3% had major extracranial bleeding events (2/64), and 3% had a gastrointestinal bleed (2/64). In our meta-analysis, 11 studies with 298 patients were included. The pooled proportion of sICH and intraprocedural thromboembolic complication events were 0.07 [95% CI 0.04 to 1.13] and 0.08 [95% CI 0.05 to 0.15], respectively.

Conclusion

Our study found that intravenous cangrelor appears to be safe and effective in neuroendovascular procedures, with low rates of bleeding and ischemic events. However, further research is needed to compare different dosing and titration protocols of cangrelor and other intravenous agents.

Safety Outcomes of Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions

BACKGROUND

We aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions and whether using intraprocedural antiplatelet therapy influences MT's safety with IVT treatment.

METHODS

This is a subanalysis of a pooled, multicenter cohort of patients with acute anterior circulation tandem lesions treated with MT from 16 stroke centers between January 2015 and December 2020. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2. Additional outcomes included hemorrhagic transformation, successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3), complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3), favorable functional outcome (90-day modified Rankin Scale score 0-2), excellent functional outcome (90-day modified Rankin Scale score 0-1), in-hospital mortality, and 90-day mortality.

RESULTS

Of 691 patients, 512 were included (218 underwent IVT+MT and 294 MT alone). There was no difference in the risk of sICH (adjusted odds ratio [aOR], 1.22 [95% CI, 0.60-2.51]; P=0.583), parenchymal hematoma type 2 (aOR, 0.99 [95% CI, 0.47-2.08]; P=0.985), and hemorrhagic transformation (aOR, 0.95 [95% CI, 0.62-1.46]; P=0.817) between the IVT+MT and MT alone groups after adjusting for confounders. Administration of IVT was associated with an increased risk of sICH in patients who received intravenous antiplatelet therapy (aOR, 3.04 [95% CI, 0.99-9.37]; P=0.05). The IVT+MT group had higher odds of a 90-day modified Rankin Scale score 0 to 2 (aOR, 1.72 [95% CI, 1.01-2.91]; P=0.04). The odds of successful reperfusion, complete reperfusion, 90-day modified Rankin Scale score 0 to 1, in-hospital mortality, or 90-day mortality did not differ between the IVT+MT versus MT alone groups.

CONCLUSIONS

Our study showed that the combination of IVT with MT for tandem lesions did not increase the overall risk of sICH, parenchymal hematoma type 2, or overall hemorrhagic transformation independently of the cervical revascularization technique used. However, intraprocedural intravenous antiplatelet therapy during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT before MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcomes at 90 days.

Eptifibatide, an Older Therapeutic Peptide with New Indications: From Clinical Pharmacology to Everyday Clinical Practice

Therapeutic peptides are oligomers or short polymers of amino acids used for various medical purposes. Peptide-based treatments have evolved considerably due to new technologies, stimulating new research interests. They have been shown to be beneficial in a variety of therapeutic applications, notably in the treatment of cardiovascular disorders such as acute coronary syndrome (ACS). ACS is characterized by coronary artery wall damage and consequent formation of an intraluminal thrombus obstructing one or more coronary arteries, leading to unstable angina, non-ST elevated myocardial infarction, and ST-elevated myocardial infarction. One of the promising peptide drugs in the treatment of these pathologies is eptifibatide, a synthetic heptapeptide derived from rattlesnake venom. Eptifibatide is a glycoprotein IIb/IIIa inhibitor that blocks different pathways in platelet activation and aggregation. In this narrative review, we summarized the current evidence on the mechanism of action, clinical pharmacology, and applications of eptifibatide in cardiology. Additionally, we illustrated its possible broader usage with new indications, including ischemic stroke, carotid stenting, intracranial aneurysm stenting, and septic shock. Further research is, however, required to fully evaluate the role of eptifibatide in these pathologies, independently and in comparison to other medications.