59. The incidence of ischemic and hemorrhagic complications associated with ceasing vs maintaining anticoagulant and/or antiplatelet agents for spine pain interventions targeting the facet joint

The use of antiplatelets is widespread in clinical practice. However, for neurointerventional procedures, protocols for antiplatelet use are scarce and practice varies between individuals and institutions. This is further complicated by the quantity of antiplatelet agents which differ in route of administration, dosage, onset of action, efficacy and ischemic and hemorrhagic complications. Clarifying the individual characteristics for each antiplatelet agent, and their associated risks, will increasingly become relevant as the practice of mechanical thrombectomy, stenting, coiling and flow diversion procedures grows. The aim of this review is to summarize the existing literature for the use of P2Y12 inhibitors in neurointerventional procedures, examine the quality of the evidence, and highlight areas in need of further research.

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Abstract W P223: Treatment of Cervical Artery Dissection with Different Antithrombotic Agents

Stroke ◽

10.1161/str.45.suppl_1.wp223 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Fan Z Caprio ◽

Deborah Bergman ◽

Yvonne Curran ◽

Richard Bernstein ◽

Shyam Prabhakaran

Keyword(s):

Recurrent Stroke ◽

Oral Anticoagulants ◽

Antiplatelet Agents ◽

Novel Oral Anticoagulants ◽

Bleeding Complications ◽

Artery Dissection ◽

Cervical Artery Dissection ◽

Cervical Artery ◽

Hemorrhagic Complications

Background and Purpose: Antiplatelet agents and anticoagulants are both accepted and commonly used agents for treatment of cervical artery dissection (CAD), though randomized clinical trials are lacking. We report on the use of novel oral anticoagulants for CAD and compared their efficacy and safety to traditional anticoagulants. Methods: We retrospectively identified patients diagnosed with CAD at a single academic center between July 2010 and December 2012. Patients treated with novel anticoagulants (NOAC: dabigatran or rivaroxaban), other anticoagulants (AC: warfarin, heparin, or low molecular weight heparin), or antiplatelet agents (AP: aspirin, clopidogrel, or aspirin-dypyridamole) were compared for baseline characteristics, recurrent stroke, vessel recanalization on follow-up, and bleeding complications using Fisher’s exact and student t-tests. Results: During the study period, 110 patients with CAD were included, of whom 20 (18%), 61 (55%), and 29 (26%) were treated initially with a NOAC, AC, and AP, respectively. Clinical follow-up was available in 98 (89.1%) patients while radiographic follow-up was available in 88 (80%) patients. NOAC-treated patients were more likely to have presented with ischemic stroke symptoms (90% vs. 55.7%, p=0.007) but had similar rates of severe stenosis (60% vs. 53.3%, p=0.522) and intraluminal/intramural thrombus (70% vs. 57.6%, p=0.327) on initial vascular imaging compared to AC patients. There was 1 recurrent stroke in the NOAC group and 1 in the AC group. Similar proportions of patients had resolved or improved stenosis on follow-up imaging (NOAC: 66.7 vs. AC: 63.3%, p=0.217). Hemorrhagic complications were more likely to occur in AC compared to NOAC patients (17.0% vs. 0%, p=0.019). Conclusion: In this retrospective study, use of novel oral anticoagulants for CAD was associated with similar rates of recurrent stroke and vessel recanalization on follow-up imaging but with fewer hemorrhagic complications. Given their safety profile, NOACs may be a reasonable alternative to traditional anticoagulants in CAD. Prospective validation of these findings is needed.

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Characterization of the Subchondral Bone and Pain Behavior Changes in a Novel Bipedal Standing Mouse Model of Facet Joint Osteoarthritis

BioMed Research International ◽

10.1155/2020/8861347 ◽

2020 ◽

Vol 2020 ◽

pp. 1-11

Author(s):

Miao Li ◽

Wen-qing Xie ◽

Miao He ◽

Deng-jie Yu ◽

Da-qi Xu ◽

...

Keyword(s):

Stress Distribution ◽

Subchondral Bone ◽

Facet Joint ◽

Axial Loading ◽

Von Mises Stress ◽

Histopathological Changes ◽

Control Groups ◽

Spine Pain ◽

Von Mises

Background. The subchondral bone parallels with the progression of osteoarthritis (OA). However, the biomechanical properties and histopathological changes of subchondral bone changes in the lumbar facet joint (LFJ) after long-term axial loading on the spine have not been explored. In this study, we aimed to investigate the subchondral bone histopathological changes that occur in the LFJ and pain behaviors in a novel bipedal standing mouse model. Methods. Sixteen 8-week-old male C57BL/6 mice were randomly assigned into bipedal standing and control groups. A finite element stimulate model based on the micro-CT data was generated to simulate the von Mises stress distribution on the LFJ during different positions. The spine pain behaviors tests were analysis. In addition, the change in the subchondral bone of the LFJ was assessed by histological and immunohistochemistry staining. Results. The computerized simulation of the von Mises stress distribution in the superior articular process of LFJ at the spine level 5 in the lying position increased and reached a maximum value at the bipedal standing posture. The spine pain behavior test revealed that the threshold of pressure tolerance decreased significantly in bipedal groups relative to control groups, whereas the mechanical hyperalgesia of the hind paw increased significantly in bipedal groups relative to control groups. The axial load accelerates LFJ degeneration with increased histological scores in bipedal groups. The expression of type II collagen and aggrecan (ACAN) was significantly decreased in the bipedal groups compared with the control groups, whereas the expression of MMP13 was increased. Compared with the control groups, the osteoclast activity was activated with higher TRAP-positive staining and associated with increased CD-31-positive vessels and GCRP-positive nerve ending expression in the subchondral bone of LFJ. Conclusion. Collectively, long-term axial loading induces the development of spine hyperalgesia in mice associate with increased osteoclast activity and aberrant angiogenesis and nerve invasion into the subchondral bone of LFJ that stimulates the natural pathological change in human LFJ OA. These results indicate that aberrant bone remodeling associate with aberrant nerve innervation in the subchondral bone has a potential as a therapeutic target in LFJ OA pain.

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Clinical Decision-Making in Chronic Spine Pain: Dilemma of Image-Based Diagnosis of Degenerative Spine and Generation Mechanisms for Nociceptive, Radicular, and Referred Pain

BioMed Research International ◽

10.1155/2018/8793843 ◽

2018 ◽

Vol 2018 ◽

pp. 1-6 ◽

Cited By ~ 3

Author(s):

Haytham Eloqayli

Keyword(s):

Clinical Decision Making ◽

Clinical Presentation ◽

Facet Joint ◽

Case Series ◽

Clinical Decision ◽

Radicular Pain ◽

Referred Pain ◽

Herniated Disc ◽

Spine Pain ◽

Generation Mechanisms

Background. Spine-related pain is a complex heterogeneous condition. Excessive reliance on radiological imaging might lead to overdiagnosis of incidental asymptomatic spinal changes and unnecessary surgery. Approaches to the clinical management of spine pain should (1) identify pain generators, types, patterns, and mechanisms; (2) confirm clinical suspension with a diagnostic injection; and (3) ensure that treatment is aimed at controlling pain and improving patient function rather than image-based surgical success. Method. This case series (7 cases) discusses commonly seen clinical presentation of spine pain analytically, with illustrations of possible pain generators, mechanisms, pathways, and pain types. Each case discusses pain types and location (axial nociceptive, referred, and radicular neuropathic), generators (degenerated disc, herniated disc, facet joint, and sacroiliac joint), pathways (sinuvertebral ventral ramus and medial and lateral branches dorsal ramus), and radiculopathy versus radicular pain, elaborating on coccydynia and cervicogenic headaches, epimere versus hypomere muscle embryology, function, innervation, and role in spine-related pain. Results. Multiple pain generators might coexist in the same patient causing mixed pain types and referral patterns with multiple mechanisms and pathways. History review, physical examination, and diagnostic injections are the mainstays of diagnosis. Conclusions. Image-detected spondylosis might be an asymptomatic process. Clinical presentation is related to stenosis or pain. The mechanism of pain is related to compression, inflammation, or microinstability. Spine pain can be nociceptive axial, neuropathic radicular, and/or referred pain. Although image findings are helpful in radicular neuropathic pain from disc herniation, they are unreliable in nociceptive pain, and correlation with clinical and diagnostic injections is mandatory.

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Dipyridamole: the rearguard on proscenium

Тромбоз, гемостаз и реология ◽

10.25555/thr.2019.2.0875 ◽

2019 ◽

Author(s):

Н.Ю. Левшин ◽

Е.В. Ройтман ◽

А.В. Аршинов ◽

В.М. Печенников

Keyword(s):

Oxidative Stress ◽

Immune Cells ◽

Antiplatelet Agents ◽

Cardiovascular Complications ◽

Clinical Applications ◽

Medical Specialists ◽

Vasodilatory Effect ◽

Hemorrhagic Complications ◽

Microcirculatory Disturbances ◽

High Doses

Антиагрегантная терапия является основой профилактики атеротромбоза и нарушений микроциркуляции при многих видах патологии. Дипиридамол в сочетании с ацетилсалициловой кислотой служит важным компонентом профилактики ишемического инсульта он также доказал свою эффективность в улучшении коронарного кровотока, периферического кровообращения за счет своего антиагрегантного и сосудорасширяющего действия. Синдром обкрадывания является клиническим преувеличением, так как присущ только высоким дозам препарата, вводимым внутривенно. Дипиридамол обладает многими плейотропными эффектами, связанными с его способностью индуцировать синтез интерферона, регулировать оксидативный стресс, активность клеток иммунной системы, матриксных металлопротеиназ и др. Понимание патогенеза различных видов патологии с позиций взаимосвязи гемостаза и воспаления наряду с высокой безопасностью дипиридамола в отношении кровотечений, онкологического роста и его экономической доступностью позволяют применять препарат в ревматологии, акушерстве и гинекологии, нефрологии, гематологии и других областях медицины, проводить актуальные научные исследования. Обзор посвящен обсуждению возможностей коррекции ключевых механизмов патогенеза многих заболеваний с использованием различных свойств дипиридамола и применения данных преимуществ препарата в клинике внутренних болезней. Antiplatelet agents are the main group of drugs using for antiatherothrombotic prophylaxis and correction of microcirculatory disturbances in many fields of medicine. Dipyridamole in combination with acetylsalicylic acid is an important component of stroke prevention. It also demonstrates effectiveness for prevention of cardiovascular complications due to its antiplatelet and vasodilatory effect. Steal phenomenon is clinical exaggeration, because it happens only if high doses of dipyridamole are injected intravenously. Dipyridamole has numerous pleiotropic effects related with its ability to induce interferon synthesis, to regulate oxidative stress, activity of immune cells, matrix metalloproteinases, etc. Understanding of pathogenesis of numerous diseases as the interrelationship between hemostasis and inflammation may leads medical specialists to use dipyridamole in rheumatology, obstetrics, gynecology, nephrology, haematology and other fields of medicine and medical researches. High safety of dipyridamole in regard to hemorrhagic complications, malignant progression and its high economic accessibility are very important features of this wellknown for clinicians drug. Further search of clinical applications for dipyridamole is discussed in this review.

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Algorithm for the Choice of Anticoagulant for Patients with Atrial Fibrillation

Rational Pharmacotherapy in Cardiology ◽

10.20996/1819-6446-2020-04-16 ◽

2020 ◽

Vol 16 (2) ◽

pp. 199-205 ◽

Cited By ~ 1

Author(s):

Yu. P. Skirdenko ◽

N. A. Nikolaev

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Food Preferences ◽

Antiplatelet Agents ◽

Thromboembolic Complications ◽

Adherence To Treatment ◽

Treatment Optimization ◽

Initial Examination ◽

Hemorrhagic Complications

Aim. To evaluate the effectiveness of the anticoagulant choice algorithm in the prevention of complications of atrial fibrillation (AF). Material and methods. Patients with AF (n=98) were included into observational prospective study. The level of adherence to treatment, risk of food interactions and presence of CYP2C9 and VKORC1 genes mutations were determined at the initial examination. These indicators were necessary to specify an eligible anticoagulant according to the evaluated algorithm. Therapy was prescribed by the attending physician. Hemorrhagic and thromboembolic complications were assessed at the next examination after 24 weeks. Results. Hemorrhagic complications were observed in 31.6% of patients during the follow-up. Their number was comparable in individuals taking antiplatelet agents and direct oral anticoagulants (DOACs) (χ2=1.44; p<0.49, Pearson) and significantly more in individuals taking warfarin (as compared to DOACs: χ2=25.08; p<0.000, Pearson; and antiplatelet agents: χ2=34.32; p<0.000, Pearson). Thromboembolic complications were reported in 8.16% of patients. Their number was more in patients taking DOACs than warfarin (χ2=7.03; p<0.03, Pearson). Patients who had to take DOACs according to the algorithm, but in the study took warfarin, demonstrated significantly greater number of thromboembolic complications, with a comparable number of hemorrhagic complications. Patients who could take warfarin according to the algorithm, but in the study took DOACs, had significantly greater number of thromboembolic complications, with a comparable number of hemorrhagic complications. Conclusion. The results of the study demonstrated the potential for reduction in complications, especially thromboembolic, in the choice of anticoagulant using the algorithm; and reduction in complications of therapy, primarily with warfarin, due to the initial prescription of DOACs. The proposed approach, which consists in using the quantitative assessment of adherence to treatment, and only if necessary supplemented by the assessment of food preferences and/or pharmacogenetic studies, contributes to the treatment optimization.

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The Facet Joint and Its Role in Spine Pain

Spine ◽

10.1097/00007632-198410000-00016 ◽

1984 ◽

Vol 9 (7) ◽

pp. 746-750 ◽

Cited By ~ 131

Author(s):

ALAN B. LIPPITT

Keyword(s):

Facet Joint ◽

Spine Pain

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Abstract 1122‐000231: A Review of Effect of Ticagrelor on Platelet Inhibition in Clopidogrel Non‐Responders Undergoing Neuroendovascular Procedure

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000231 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Priyadarshee PATEL ◽

Pascal Jabbour ◽

Stavropoula Tjoumakaris ◽

Michael Gooch ◽

Robert Rosenwasser ◽

...

Keyword(s):

Carotid Artery ◽

Tertiary Care ◽

Antiplatelet Agents ◽

Platelet Inhibition ◽

Arterial Stenosis ◽

Loading Dose ◽

Thrombotic Risk ◽

Increased Risk ◽

Hemorrhagic Complications ◽

Thrombotic Complications

Introduction : Neuroendovascular procedures are becoming more routine in the treatment of intracranial conditions such as aneurysms, arterial stenosis, and ischemic stroke. These patients are frequently treated with antiplatelet agents prior to the procedure to prevent thrombotic complications. The combination of aspirin and a P2Y12 inhibitor such as clopidogrel is often initiated days before elective procedures or as loading doses for emergent procedures. However, some patients may still experience post procedural thrombotic or hemorrhagic complications which may be related to platelet inhibition. Methods : A retrospective review of patients who underwent a neuroendovascular procedure from 1/2017 to 12/2019 in a single tertiary care academic hospital. Procedures included flow‐diverting stent placement for aneurysms, intracranial, and cervical carotid artery stenting. Patients undergoing elective procedure were started on Aspirin and Clopidogrel 75 mg daily. Patients undergoing emergent procedures were given loading doses of Aspirin (650 mg) and Clopidogrel (600 mg). P2Y12 assay was checked prior to receiving Platelet inhibitor and from 3–6 hours after Clopidogrel loading dose. Optimal platelet inhibition was classified as reduction in P2Y12 assay by at least 60%. Patients with suboptimal platelet inhibition <60% were given Ticagrelor loading dose (180 mg) and P2y12 assay was rechecked. Patients who did not have complete chart information, patients with AFib requiring DOAC and patients previously on ADP inhibitors, were excluded from analysis. Results : Total neuroendovascular procedures requiring stents were 687 over the period of 3 years. mean age of patients was 61 years. This neuroendovascular procedure consisted of aneurysm stenting (239), aneurysm stent‐assisted coiling 112, intracranial stent for failed mechanical thrombectomy 62, carotid artery stent 108. Suboptimal platelet inhibition was noted in 54% (282) of 523 patients after receiving Clopidogrel. After receiving Ticagrelor, optimal inhibition was noted in 80% (226) of 282 patients with median increase of 26%. 62 patients with suboptimal response to Ticagrelor, 47 were started on Prasugrel. Thrombotic complications were noted in 7 patients, 6 of them were noted to have <50% platelet inhibition. Hemorrhagic complications were noted in 17 patients, amongst them >70% platelet inhibition was noted in 14 patients with mean P2Y12 value of 59. Conclusions : Patients receiving P2Y12 ADP antiplatelet therapy may have suboptimal platelet inhibition which results in increased thrombotic risk. Patients who have significant platelet inhibition (>70%) after loading dose are at increased risk for hemorrhagic complications. Better platelet inhibition was achieved with Ticagrelor in Clopidogrel hypo‐response patients. In patients with Clopidogrel hyper‐response, dosing was changed to half the dose or alternate day to reduce hemorrhagic complications. As the use of endovascular therapies requiring dual anti‐platelet agents becomes more established, there is an increasing need to develop titration protocols that minimize the risk of thrombotic and hemorrhagic events based on platelet inhibition.

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Risk of ventriculostomy-related hemorrhage in patients with acutely ruptured aneurysms treated using stent-assisted coiling

Journal of Neurosurgery ◽

10.3171/2010.9.jns10445 ◽

2011 ◽

Vol 114 (4) ◽

pp. 1021-1027 ◽

Cited By ~ 96

Author(s):

David K. Kung ◽

Bruno A. Policeni ◽

Ana W. Capuano ◽

James D. Rossen ◽

Pascal M. Jabbour ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Antiplatelet Agents ◽

Vp Shunt ◽

Shunt Placement ◽

Ruptured Aneurysms ◽

Hemorrhagic Complications ◽

Group 2 ◽

Group 1

Object Intracranial stenting has improved the ability to treat wide-neck aneurysms via endovascular techniques. However, stent placement necessitates the use of antiplatelet agents, and the latter may complicate the treatment of patients with acutely ruptured aneurysms who demonstrate hydrocephalus and require ventriculostomy. Antiplatelet agents in this setting could increase the incidence of ventriculostomy-related hemorrhagic complications, but there are insufficient data in the medical literature to quantify this potential risk. The aim of this study was to directly quantify the risk of ventriculostomy-related hemorrhage in patients with acute aneurysmal subarachnoid hemorrhage treated with stent-assisted coiling. Methods The authors retrospectively identified 131 patients who underwent endovascular treatment for an acutely ruptured aneurysm as well as ventriculostomy or ventriculoperitoneal (VP) shunt placement. The rate of hemorrhagic complications associated with ventriculostomy or VP shunt insertion was compared between patients who underwent coiling without a stent (Group 1) and those who underwent stent-assisted coiling and dual antiplatelet therapy (Group 2). Results One hundred nine ventriculostomies or VP shunt placement procedures were performed in 91 patients in Group 1, and 50 procedures were undertaken in 40 patients in Group 2. The rates of radiographic hemorrhage and symptomatic hemorrhage were significantly higher in Group 2 (32% vs 14.7%, p = 0.02; and 8% vs 0.9%, p = 0.03, respectively). On multivariate analyses, Group 2 had 3.42 times the odds of a radiographic hemorrhage (95% CI 1.46–8.04, p = 0.0048) after adjusting for antiplatelet use prior to admission. Conclusions The application of dual antiplatelet therapy in stent-assisted coiling of acutely ruptured aneurysms is associated with an increase in the risk of hemorrhagic complications following ventriculostomy or VP shunt placement, as compared with its use in a coiling procedure without a stent.

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Medial Branch Blocks for Diagnosis of Facet Joint Pain Etiology and Use in Chronic Pain Litigation

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17217932 ◽

2020 ◽

Vol 17 (21) ◽

pp. 7932

Author(s):

Gordon E. Lawson ◽

Paul S. Nolet ◽

Adam R. Little ◽

Anit Bhattacharyya ◽

Vivian Wang ◽

...

Keyword(s):

Joint Pain ◽

Facet Joint ◽

Medical Documentation ◽

Medial Branch ◽

Medical Evidence ◽

Traffic Crash ◽

Spine Pain ◽

Objective Evidence ◽

Post Traumatic ◽

Facet Joint Pain

A commonly disputed medicolegal issue is the documentation of the location, degree, and anatomical source of an injured plaintiff’s ongoing pain, particularly when the painful region is in or near the spine, and when the symptoms have arisen as result of a relatively low speed traffic crash. The purpose of our paper is to provide health and legal practitioners with strategies to identify the source of cervical pain and to aid triers of fact (decision makers) in reaching better informed conclusions. We review the medical evidence for the applications and reliability of cervical medial branch nerve blocks as an indication of painful spinal facets. We also present legal precedents for the legal admissibility of the results of such diagnostic testing as evidence of chronic spine pain after a traffic crash. Part of the reason for the dispute is the subjective nature of pain, and the fact that medical documentation of pain complaints relies primarily on the history given by the patient. A condition that can be documented objectively is chronic cervical spine facet joint pain, as demonstrated by medial branch block (injection). The diagnostic accuracy of medial branch blocks has been extensively described in the scientific medical literature, and evidence of facet blocks to objectively document chronic post-traumatic neck pain has been accepted as scientifically reliable in courts and tribunals in the USA, Canada and the United Kingdom. We conclude that there is convincing scientific medical evidence that the results of cervical facet blocks provide reliable objective evidence of chronic post-traumatic spine pain, suitable for presentation to an adjudicative decision maker.

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