Safety of tirofiban and dual antiplatelet therapy in treating intracranial aneurysms

Background Endovascular treatment of intracranial aneurysms usually involves stent-assisted coiling(SAC)and flow diverters.Glycoprotein IIb/IIIa inhibitors such as tirofiban and dual antiplatelet therapy(DAPT)are required to prevent thromboembolic complications afterwards.We sought to determine the safety of tirofiban and DAPT in these cases.Methods We conducted a retrospective analysis of our database for patients with intracranial aneurysms who underwent SAC or flow diversion.The tirofiban-DAPT protocol used is described.Data regarding duration of infusion,placement of external ventricular devices(EVDs),complications,haemoglobin levels and platelet count before and 24 hours after antiplatelet therapy were collected and analysed.results One-hundred and forty-one patients with 148 aneurysms/procedures were included.110 aneurysms were treated acutely and 38 electively.Minor and major haemorrhagic events were recognised in 20%(30/148)aneurysms.Only 5(3.4%)intracerebral haemorrhages were symptomatic:3 cortical/SAH and 2 EVD-related.The average blood volume in symptomatic haemorrhages was 24.8 cc versus 5.42 cc in asymptomatic haemorrhages(p=0.002).The rate of EVD-related haemorrhages was 15.7%(19/121)and only 2(1.7%)were symptomatic.Most haemorrhagic events occurred in ruptured aneurysms(90.1%,p=0.01).No significant change in platelet count or haemoglobin levels before and 24 hours after administration of tirofiban and DAPT was documented.Concomitant administration of heparin did not increase haemorrhagic events.Conclusion The use of the GP IIb/IIIa inhibitors tirofiban and DAPT in this series was safe.Tirofiban and DAPT did not affect platelet count or haemoglobin levels and did not increase rate of symptomatic haemorrhages or thromboembolic complications.

Stroke mechanisms and outcomes of isolated symptomatic basilar artery stenosis

background While diffuse atherosclerotic disease affecting the posterior circulation has been described extensively,the prevalence,natural history and angiographic characteristics of isolated symptomatic basilar artery stenosis(ISBAS)remain unknown.Methods We reviewed our prospective institutional database to identify patients with≥50% symptomatic basilar artery(BA)stenosis without significant atherosclerotic burden in the vertebral or posterior cerebral arteries.Stroke mechanism,collateral circulation,and degree and length of stenosis were analysed.The primary outcome was time from index event to new transient ischaemic attack(TIA),acute ischaemic stroke(AIS)or death.Other outcome variables included modified Rankin Scale(mRS)score on discharge and last follow-up.results Of 6369 patients with AIS/TIA,91(1.43%)had ISBAS.Seventy-three(80.2%)patients presented with AIS and 18(19.8%)with TIA.Twenty-nine(31.9%)were women and the median age was 66.8±13.6 years.The mean follow-up time was 2.7 years.The most common stroke mechanism was artery-to artery thromboembolism(45.2%),followed by perforator occlusion(28.7%)and flow-dependent/hypoperfusion(15.1%).The percentage of stenosis was lower in patients who had favourable outcome compared with those with mRS 3-6 on discharge(78.3±14.3 vs 86.9±14.5,p=0.007).Kaplan-Meier curves showed higher recurrence/death rates in patients with≥80% stenosis,mid-basilar location and poor collateral circulation.Approximately 13% of patients with ISBAS presented with complete BA occlusion.Conclusion ISBAS is an uncommon(1.43%)cause of TIA and AIS.Men in their 60s are mostly affected,and artery-to artery embolism is the most common stroke mechanism.Mid-basilar location,≥80% stenosis and poor collateral circulation are important factors associated with worse prognosis.

Acute ischaemic stroke interventions: large vessel occlusion and beyond

Care for acute ischaemic stroke is one of the most rapidly evolving fields due to the robust outcomes achieved by mechanical thrombectomy.Large vessel occlusion(LVO)accounts for up to 38%of acute ischaemic stroke and comes with devastating outcomes for patients,families and society in the pre-intervention era.A paradigm shift and a breakthrough brought mechanical thrombectomy back into the spotlight for acute ischaemic stroke;this was because five randomised controlled trials from several countries concluded that mechanical thrombectomy for acute stroke offered overwhelming benefits.This review article will present a comprehensive overview of LVO management,techniques and devices used,and the future of stroke therapy.In addition,we review our institution experience of mechanical thrombectomy for posterior and distal circulation occlusion.