Bivalirudin for Endovascular Intervention in Acute Ischemic Stroke: Case Report

Neurosurgery ◽  
2004 ◽  
Vol 54 (1) ◽  
pp. 218-223 ◽  
Author(s):  
Mark R. Harrigan ◽  
Elad I. Levy ◽  
Bernard R. Bendok ◽  
L. Nelson Hopkins
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Scale Score ◽  
Intracranial Hemorrhage ◽  
National Institutes Of Health ◽  
Left Middle Cerebral Artery ◽  
Computed Tomographic ◽  
Left Middle ◽  
Arterial Thrombolysis

Abstract OBJECTIVE AND IMPORTANCE Intra-arterial thrombolysis has been demonstrated to improve recanalization and outcomes among patients with acute ischemic stroke. However, thrombolytic agents have limited effectiveness and are associated with a significant risk of bleeding. Bivalirudin is a direct thrombin inhibitor that has been demonstrated in the cardiology literature to have a more favorable efficacy and bleeding profile than other antithrombotic medications. We report the use of bivalirudin during endovascular treatment of acute stroke, when hemorrhagic complications are not uncommon. CLINICAL PRESENTATION A 71-year-old woman with atrial fibrillation presented with right hemiparesis and aphasia and was found to have a National Institutes of Health Stroke Scale score of 10. Computed tomographic scans revealed no evidence of intracranial hemorrhage, aneurysm, or ischemic stroke. Cerebral angiography revealed thromboembolic occlusion of the superior division of the left middle cerebral artery. INTERVENTION For anticoagulation, a loading dose of bivalirudin was intravenously administered before the interventional procedure, followed by continuous infusion. Attempts to remove the clot with an endovascular snare failed to induce recanalization of the vessel. Bivalirudin was then administered intra-arterially. Immediate postprocedural angiography demonstrated restoration of flow in the left middle cerebral artery. Repeat computed tomographic scans demonstrated no intracranial hemorrhage. The patient's hemiparesis and aphasia were nearly resolved and her National Institutes of Health Stroke Scale score was 2 at the time of her discharge 5 days later. CONCLUSION To our knowledge, this is the first report of the use of bivalirudin for treatment of acute ischemic stroke. Bivalirudin may be a useful agent for intravenous anticoagulation and intra-arterial thrombolysis in this setting.

scholarly journals Urgent Intracranial Angioplasty after Combined Systemic and Intra-Arterial Thrombolysis in Acute Stroke

2008 ◽  
Vol 14 (2_suppl) ◽  
pp. 91-94
Author(s):  
Cindy Sadikin ◽  
Agustinus Iskandar ◽  
Iswanto Pratanu ◽  
Hartono Yudi
Keyword(s):  
Case Report ◽  
Acute Stroke ◽  
Middle Cerebral Artery ◽  
Arterial Occlusion ◽  
National Institutes Of Health ◽  
Left Middle Cerebral Artery ◽  
Tissue Plasminogen ◽  
Left Middle ◽  
Stenotic Segment ◽  
Arterial Thrombolysis

We report a case of a 59-year-old man who presented with an acute stroke involving the territory of his left middle cerebral artery, and who was treated with combined systemic and intra-arterial thrombolysis. After these treatments, the segment remained stenotic. An urgent intracranial angioplasty was performed, resulting in satisfactory recanalization of the stenotic segment, and significant improvement of his National Institutes of Health Stroke Scale (NIHSS) from 14 to 5. This case report suggests an effective alternate protocol for treatment of acute stroke with arterial occlusion: immediate smaller dose of IV tissue plasminogen activator (tPA), followed by angiogram, intra-arterial thrombolysis, and angioplasty if indicated.

MIDDLE CEREBRAL ARTERY STENTING FOR ACUTE ISCHEMIC STROKE AFTER UNSUCCESSFUL MERCI RETRIEVAL

Neurosurgery ◽  
2007 ◽  
Vol 60 (4) ◽  
pp. 701-706 ◽  
Author(s):  
Eric Sauvageau ◽  
Rodney M. Samuelson ◽  
Elad I. Levy ◽  
Alison M. Jeziorski ◽  
Ricky A. Mehta ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Scale Score ◽  
Cerebral Artery ◽  
National Institutes Of Health ◽  
High Rate ◽  
Vessel Occlusion ◽  
Intracranial Stenting ◽  
Acute Cerebral Ischemia

Abstract OBJECTIVE Intracranial stenting has been used in the treatment of ischemic stroke caused by acute intracranial vessel occlusion after unsuccessful recanalization with the Merci retriever. We describe our early experience with this technique. METHODS Patients who had intra-arterial therapy for acute ischemic stroke with concomitant use of the retriever between February 1, 2005 and May 2, 2006 were identified from our endovascular database. Cases in which recanalization was not achieved with the retriever and in which stenting was attempted as a secondary means of mechanical recanalization were retrospectively reviewed. RESULTS Ten patients with unsuccessful Merci retrieval underwent intracranial stenting. The average admission National Institutes of Health Stroke Scale score was 16.4. Occlusions were located in the middle cerebral artery (six extended into M2 branches). Four patients received intra-arterial reteplase (two prestent, one preretriever and poststent, and one poststent). Eptifibatide was administered immediately before stenting in every patient. Successful recanalization (thrombolysis in myocardial infarction 2 or 3) was achieved in nine out of 10 patients. Complications included an extradural perforation with arteriovenous fistula. Six patients had intracranial hematoma and/or subarachnoid hemorrhage; there were four deaths. The six surviving patients experienced at least a 6-point National Institutes of Health Stroke Scale improvement at discharge, although only one had a modified Rankin Scale score of 2 or less. CONCLUSION Angiographic recanalization has been associated with improvement in clinical outcome after acute cerebral ischemia. Recanalization is not always achieved using the Merci retriever. We found that stenting after unsuccessful Merci retrieval resulted in a high rate of angiographic success. Further research into refining indications and optimizing outcome is warranted.

ISCHEMIC STROKE IN COVID-19 PATIENT: A RARE CASE REPORT.

2021 ◽  
pp. 72-73
Author(s):  
Atul Kaushik ◽  
Showkat Nazir Wani ◽  
Anish Garg ◽  
Dev Kumar
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Rare Case ◽  
Cardiovascular Complications ◽  
Left Middle Cerebral Artery ◽  
Early Evaluation ◽  
Rare Case Report ◽  
Ct Head ◽  
Left Middle ◽  
Middle Cerebral Artery Infarct

Background: COVID-19 is shown to be associated with hypercoagulable state which may cause neurological and cardiovascular complications. COVID-19 has been represented as an independent risk factor for acute ischemic stroke. Objective:We report a case of acute ischemic stroke as a COVID-19 complication. Material and methods: A 62-year-old known hypertensive male was diagnosed with COVID-19. He developed neurological symptoms 10 days after being tested positive. On doing an NC-CT head, a large acute ischemic stroke involving left Middle Cerebral Artery infarct was detected. Result and Conclusion: Our case represents the development of acute ischemic stroke as a neurological manifestation in patient with COVID-19. Early evaluation for acute neurological changes and timely management may reduce morbidity and mortality in such cases.

scholarly journals Adverse Outcome of Early Recurrent Ischemic Stroke Secondary to Atrial Fibrillation after Repeated Systemic Thrombolysis

2013 ◽  
Vol 2013 ◽  
pp. 1-4 ◽  
Author(s):  
Luciano A. Sposato ◽  
Valeria Salutto ◽  
Diego E. Beratti ◽  
Paula Monti ◽  
Patricia M. Riccio ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Neurological Outcome ◽  
Left Middle Cerebral Artery ◽  
Cerebrovascular Event ◽  
Middle Cerebral Artery Infarction ◽  
Systemic Thrombolysis ◽  
Left Middle

Background. Recurrent ischemic stroke is associated with adverse neurological outcome in patients with atrial fibrillation. There is very scarce information regarding the neurological outcome of atrial fibrillation patients undergoing repeated systemic thrombolysis after early recurrent ischemic stroke.Clinical Case and Discussion. We describe a case of a 76-year-old woman with known paroxysmal atrial fibrillation who was admitted because of an acute right middle cerebral artery ischemic stroke and who underwent repeated systemic thrombolysis within 110 hours. The patient underwent systemic thrombolysis after the first ischemic stroke with almost complete neurological recovery. On the fourth day after treatment, an acute left middle cerebral artery ischemic stroke was diagnosed and she was treated with full-dose intravenous recombinant tissue plasminogen activator. A hemorrhagic transformation of the left middle cerebral artery infarction was noted on follow-up cranial computed tomographic scans. The patient did not recover from the second cerebrovascular event and died 25 days after admission.Conclusion. To the best of our knowledge, this is the second case reporting the adverse neurological outcome of a patient with diagnosis of atrial fibrillation undergoing repeated systemic thrombolysis after early recurrent ischemic stroke. Our report represents a contribution to the scarce available evidence suggesting that repeated systemic thrombolysis for recurrent ischemic stroke should be avoided.

scholarly journals Successful recanalization using the Embolus Retriever with Interlinked Cage for acute stroke due to calcified cerebral emboli

2018 ◽  
Vol 24 (6) ◽  
pp. 674-677 ◽  
Author(s):  
Hyo S Kwak ◽  
Jung S Park
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Thrombolytic Agent ◽  
Mechanical Thrombectomy ◽  
Computed Tomographic Angiography ◽  
Sudden Onset ◽  
Aspiration Thrombectomy ◽  
Computed Tomographic ◽  
Tomographic Angiography ◽  
Left Middle

Mechanical thrombectomy is a safe and effective treatment in patients with acute ischemic stroke caused by large vessel occlusions. However, in rare cases, the procedure may be challenging due to the composition of the embolus. We describe a case of a mechanical thrombectomy with the Embolus Retriever with Interlinked Cage (ERIC) device in a patient with an acute ischemic stroke due to calcified cerebral emboli in the middle cerebral artery. The procedure was done after a failed recanalization attempt with manual aspiration thrombectomy. An 82-year-old woman presented to the emergency department with a sudden onset of right-sided weakness. A computed tomographic angiography showed left middle cerebral (M1 branch) calcified emboli. After the administration of an intravenous thrombolytic agent, the patient was transferred to the angiographic suite for a mechanical thrombectomy. After failure to recanalize the vessel with manual aspiration thrombectomy, successful recanalization was achieved via mechanical thrombectomy using the ERIC device. Mechanical thrombectomy with an ERIC device can be a useful option in cases of acute ischemic stroke caused by calcified cerebral emboli.

Safety and feasibility of intraarterial eptifibatide as a revascularization tool in acute ischemic stroke

2011 ◽  
Vol 114 (4) ◽  
pp. 1008-1013 ◽  
Author(s):  
Muhammad Zeeshan Memon ◽  
Sabareesh K. Natarajan ◽  
Jitendra Sharma ◽  
Marlon S. Mathews ◽  
Kenneth V. Snyder ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Scale Score ◽  
Intracranial Hemorrhage ◽  
National Institutes Of Health ◽  
Modified Rankin Scale ◽  
Tissue Plasminogen ◽  
Symptomatic Intracranial Hemorrhage

Object Experience with the use of platelet glycoprotein (GP) IIb–IIIa inhibitor eptifibatide in patients with ischemic stroke is limited. The authors report the off-label use of intraarterial eptifibatide during endovascular ischemic stroke revascularization procedures for reocclusion after documented recanalization or formed fresh thrombi in distal vessels that were inaccessible to endovascular devices. Methods Patients who received intraarterial eptifibatide were identified from a prospectively collected database of patients in whom endovascular revascularization for acute ischemic stroke was attempted between 2005 and 2008. Data were analyzed retrospectively. The intraarterial eptifibatide dose was a single-bolus dose of 180 μg/kg body weight. Primary outcome measures were angiographic recanalization (Thrombolysis in Myocardial Infarction Grade 2 or 3), symptomatic intracranial hemorrhage rate, overall mortality rate, and favorable 3-month modified Rankin Scale score (≤ 2). Results The study included 35 patients (mean age 62 years, range 18–85 years). The median presenting National Institutes of Health Stroke Scale score was 13. Two patients received intravenous tissue plasminogen activator before endovascular therapy. The median time from symptom onset to therapy initiation was 230 minutes (range 90–1370 minutes). Twelve patients (34%) received intraarterial tissue plasminogen activator without mechanical measures. Mechanical revascularization measures used were Merci retriever in 19 (54%), Penumbra device in 1 (3%), balloon angioplasty in 15 (43%), and stent placement in 22 (63%) patients. The mean dose of intraarterial eptifibatide was 11.6 mg (range 5–16.6 mg). Partial-to-complete recanalization (Thrombolysis in Myocardial Infarction Grade 2 or 3) was achieved in 27 patients (77%). Postprocedure intracranial hemorrhage occurred in 13 patients (37%), causing symptoms in 5 (14%). In the 5 symptomatic intracranial hemorrhage cases, all patients but one presented more than 8 hours after symptom onset and all received intraarterial recombinant tissue plasminogen activator. The median discharge National Institutes of Health Stroke Scale score was 7 (range 0–17). At 3 months postprocedure, 21 patients (60%) had a modified Rankin Scale score ≤ 2, and 8 patients (23%) had died. Conclusions Adjunctive intraarterial eptifibatide is a feasible option for salvage of reocclusion and thrombolysis of distal inaccessible thrombi during endovascular stroke revascularization. Its safety and efficacy need to be studied further in larger, multicenter, controlled studies.

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