Flow diversion of ruptured intracranial aneurysms: a single-center study with a standardized antithrombotic treatment protocol

BACKGROUND

The use of antithrombotic medication following acute flow diversion for a ruptured intracranial aneurysm (IA) is challenging with no current guidelines. We investigated the incidence of treatment-related complications and patient outcomes after flow diversion for a ruptured IA before and after the implementation of a standardized antithrombotic medication protocol.

METHODS

We conducted a single-center retrospective study including consecutive patients treated for acutely ruptured IAs with flow diversion during 2015-2023. We divided the patients into two groups: those treated before the implementation of the protocol (pre-protocol) and those treated after the implementation of the protocol (post-protocol). The primary outcomes were hemorrhagic and ischemic complications. A secondary outcome was clinical outcome using the modified Ranking Scale (mRS).

RESULTS

Totally 39 patients with 40 ruptured IAs were treated with flow diversion (69% pre-protocol, 31% post-protocol). The patient mean age was 55 years, 62% were female, 63% of aneurysms were in the posterior circulation, 92% of aneurysms were non-saccular, and 44% were in poor grade on admission. Treatment differences included the use of glycoprotein IIb/IIIa inhibitors (pre-group 48% vs. post-group 100%), and the use of early dual antiplatelets (pre-group 44% vs. 92% post-group). The incidence of ischemic complications was 37% and 42% and the incidence of hemorrhagic complications was 30% and 33% in the pre- and post-groups, respectively, with no between-group differences. There were three (11%) aneurysm re-ruptures in the pre-group and none in the post-group. There were no differences in mortality or mRS 0-2 between the groups at 6 months.

CONCLUSION

We found no major differences in the incidence of ischemic or hemorrhagic complications after the implementation of a standardized antithrombotic protocol for acute flow diversion for ruptured IAs. There is an urgent need for more evidence-based guidelines to optimize antithrombotic treatment after flow diversion in the setting of subarachnoid hemorrhage.

Physician Approaches to Antithrombotic Therapies for Recently Symptomatic Carotid Stenosis

BACKGROUND

Whereas the beneficial effect of antiplatelet therapy for recurrent stroke prevention has been well established, uncertainties remain regarding the optimal antithrombotic regimen for recently symptomatic carotid stenosis. We sought to explore the approaches of stroke physicians to antithrombotic management of patients with symptomatic carotid stenosis.

METHODS

We employed a qualitative descriptive methodology to explore the decision-making approaches and opinions of physicians regarding antithrombotic regimens for symptomatic carotid stenosis. We conducted semi-structured interviews with a purposive sample of 22 stroke physicians (11 neurologists, 3 geriatricians, 5 interventional-neuroradiologists, and 3 neurosurgeons) from 16 centers on four continents to discuss symptomatic carotid stenosis management. We then conducted thematic analysis on the transcripts.

RESULTS

Important themes revealed from our analysis included limitations of existing clinical trial evidence, competing surgeon versus neurologist/internist preferences, and the choice of antiplatelet therapy while awaiting revascularization. There was a greater concern for adverse events while using multiple antiplatelet agents (e.g., dual-antiplatelet therapy (DAPT)) in patients undergoing carotid endarterectomy compared to carotid artery stenting. Regional variations included more frequent use of single antiplatelet agents among European participants. Areas of uncertainty included antithrombotic management if already on an antiplatelet agent, implications of nonstenotic features of carotid disease, the role of newer antiplatelet agents or anticoagulants, platelet aggregation testing, and timing of DAPT.

CONCLUSION

Our qualitative findings can help physicians critically examine the rationale underlying their own antithrombotic approaches to symptomatic carotid stenosis. Future clinical trials may wish to accommodate identified variations in practice patterns and areas of uncertainty to better inform clinical practice.

Risk of surgical failure and hemorrhagic complications associated with antithrombotic medication in glaucoma surgery

PURPOSE

The purpose of this retrospective study was to determine the extent to which the use of antithrombotic drugs during glaucoma surgery contributes to surgical failure and postsurgical hemorrhagic complications.

METHODS

Glaucoma surgeries were categorized into three groups: trabeculotomy (TLO), trabeculectomy (TLE), and long-Tube shunt surgery (Tube). At 1 year after surgery, the following criteria for surgical success were met: intraocular pressure (IOP) in the 5-21-mmHg range, IOP reduction of at least 20% from the preoperative level, and no additional glaucoma surgeries. We compared the percentages of the success rates and hemorrhagic complications between antithrombotic medication experiencers and non-experiencers. Furthermore, we adjusted the preoperative factors between the two groups using a propensity score analysis in TLO and TLE surgeries.

RESULTS

A total of 910 glaucoma surgeries were included, with TLO, TLE, and Tube accounting for 353, 444, and 113 surgeries, respectively. Preoperative antithrombotic medications were administered to 149 patients in all glaucoma surgeries: 37 patients used only anticoagulants, 102 used only antiplatelets, and 10 used both. There was no significant difference in the success rates of any of the procedures. The hemorrhagic complications (hyphema and vitreous hemorrhage rate) were significantly higher in the patients who underwent TLE and Tube. The surgical success rates of TLO and TLE were not significantly different after the two groups were matched by propensity score.

CONCLUSION

The perioperative use of antithrombotic drugs did not affect success for any of the procedures. However, it increased early postoperative hemorrhagic complications for TLE and Tube.

Antithrombotic therapy in patients with acute coronary syndrome complicated by cardiogenic shock or out-of-hospital cardiac arrest: a joint position paper from the European Society of Cardiology (ESC) Working Group on Thrombosis, in association with the Acute Cardiovascular Care Association (ACCA) and European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Timely and effective antithrombotic therapy is critical to improving outcome, including survival, in patients with acute coronary syndrome (ACS). Achieving effective platelet inhibition and anticoagulation, with minimal risk, is particularly important in high-risk ACS patients, especially those with cardiogenic shock (CS) or those successfully resuscitated following out-of-hospital cardiac arrest (OHCA), who have a 30-50% risk of death or a recurrent ischaemic event over the subsequent 30 days. There are unique challenges to achieving effective and safe antithrombotic treatment in this cohort of patients that are not encountered in most other ACS patients. This position paper focuses on patients presenting with CS or immediately post-OHCA, of presumed ischaemic aetiology, and examines issues related to thrombosis and bleeding risk. Both the physical and pharmacological impacts of CS, namely impaired drug absorption, metabolism, altered distribution and/or excretion, associated multiorgan failure, co-morbidities and co-administered treatments such as opiates, targeted temperature management, renal replacement therapy and circulatory or left ventricular assist devices, can have major impact on the effectiveness and safety of antithrombotic drugs. Careful attention to the choice of antithrombotic agent(s), route of administration, drug-drug interactions, therapeutic drug monitoring and factors that affect drug efficacy and safety, may reduce the risk of sub- or supra-therapeutic dosing and associated adverse events. This paper provides expert opinion, based on best available evidence, and consensus statements on optimising antithrombotic therapy in these very high-risk patients, in whom minimising the risk of thrombosis and bleeding is critical to improving outcome.

Safety of Cold Polypectomy for Colorectal Polyps in Patients on Antithrombotic Medication

BACKGROUND

The cold polypectomy (CP) technique has been increasingly used in recent years. However, there have been few studies about post-polypectomy bleeding (PPB) in patients who underwent CP and who were on antithrombotic drugs. The objective of this study was to determine the safety of CP in patients on antithrombotic medication.

METHODS

The subjects were patients who underwent CP in our hospital between April 2014 and March 2016. PPB rates were examined in relation to the use of antithrombotic medication.

RESULTS

CP was performed to remove 2,466 polyps in 1,003 patients. There were 549 polyps (22.3%) in186 patients in the antithrombotic group and 1,917 polyps (77.7%) in 817 patients in the non-antithrombotic group. PPB occurred in 0.55% (3/549) of patients in the antithrombotic group and in 0.10% (2/1,917) of patients in the non-antithrombotic group, showing no significant difference (p = 0.07). Patients in the antithrombotic group in whom PPB occurred included 1 aspirin user with 1 polyp and 1 aspirin plus clopidogrel user with 2 polyps. No PPB occurred in patients on other antithrombotic agents or receiving heparin bridging. There was no significant difference between PPB rates in patients with small polyps (6-9 mm) in the antithrombotic and non-antithrombotic groups, but there was a significant difference between PPB rates in the 2 groups for patients with diminutive group (1-5 mm).

CONCLUSION

CP is a safe procedure even in patients on antithrombotic medication.

Evaluation of S100B blood level as a biomarker to avoid computed tomography in patients with mild head trauma under antithrombotic medication

PURPOSE

The goal of this prospective study was to analyze the potential of S100B protein as a negative predictive marker for intracranial hemorrhage (ICH) after mild head trauma (MHT) in patient under antithrombotic medication.

METHODS

Patients under antithrombotic medication who had MHT were consecutively included in this study. S100B blood levels were determined from samples drawn within 6hours after injury and were analyzed with the results of head CT performed within the 24hours after injury. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of S100B levels for the detection of ICH, with a cut-off set at 0.105μg/L, were calculated.

RESULTS

A total of 308 patients (151 men and 157 women) with a mean age of 79.1±10.5years (SD) were included in the analysis. CT was positive for the presence of ICH in 33 patients (10.7%; 95% CI: 7.5-14.7%). In the study population, S100B showed a sensitivity of 84.8% (95%CI: 68.1-94.9%), a specificity of 30.2% (95% CI: 24.8-36.0%), a NPV of 94.3% (95% CI: 87.2-98.1%), and a PPV of 12.7% (95% CI: 8.6-17.9%) for the diagnosis of ICH.

CONCLUSION

The results of this study suggest that a S100B serum level<0.105μg/L has a high NPV for ICH after mild head trauma in patients under antithrombotic medication.

[Traumatic brain injury in anticoagulated patients : Hemostatic therapy for the treatment of intracranial hemorrhage]

Impaired hemostasis represents a major risk factor for increased morbidity and mortality in patients with traumatic intracranial hemorrhage. In cases of polytrauma with major bleeding, hyperfibrinolysis may develop and this may result in excessive coagulopathy. Patients receiving antithrombotic medication and suffering from intracranial hemorrhage are at particular risk for the development of neurological sequelae due to the increased tendency to bleeding. This article outlines the principles of hemostatic therapy of traumatic intracranial hemorrhage during antithrombotic treatment. The basic principles of the pathophysiology and effects of coagulation impairment in this patient population are reviewed. Furthermore, the use of specific coagulation tests and the administration of hemostatic substances are discussed.

Point of care coagulation testing in neurosurgery

Impaired haemostasis represents a major risk factor for bleeding complications in neurosurgical patients. Coagulopathy commonly occurs after (brain) trauma and major haemorrhage or originates from antithrombotic medication. Point of care (POC) devices for bedside assessment of haemostatic parameters are increasingly used in various medical specialties. Results can be instantly implemented into treatment modalities as results are delivered within a very short period. POC coagulation testing has also shown beneficial effects in the treatment of neurosurgical patients. Identification of hyperfibrinolysis is achieved through viscoelastic testing of haemostasis and bedside coagulometry hastens the management of anticoagulated patients in need of urgent neurosurgical procedures. Results of POC testing of platelet function have been correlated with patient outcomes after traumatic brain injury and furthermore, quantification of antiplatelet medication effects on platelet activity is made possible through the use of these devices. Further studies are needed to characterise the potential of POC testing of platelet function. Antiplatelet medication plays an important role in regard to haemorrhagic and thromboembolic risks. Therefore, POC testing of platelet activity may improve treatment modalities in patients undergoing neurosurgical procedures as well as neurointerventional procedures (such as intracranial stent placement). In this article we summarise the available data of POC testing in neurosurgical patients and discuss the potential of these devices in this field. POC technologies have improved patient care in various medical fields and in our view it is likely that this will also apply to the field of neurosurgery.