Blunt traumatic occlusion of the internal carotid and vertebral arteries

2014 ◽  
Vol 120 (6) ◽  
pp. 1446-1450 ◽  
Author(s):  
Ryan P. Morton ◽  
Brian W. Hanak ◽  
Michael R. Levitt ◽  
Kathleen R. Fink ◽  
Eric C. Peterson ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Internal Carotid ◽  
Dual Antiplatelet Therapy ◽  
Antiplatelet Agents ◽  
Stroke Rate ◽  
Single Institution ◽  
Decompressive Hemicraniectomy ◽  
Cerebrovascular Occlusion ◽  
Carotid And Vertebral Arteries ◽  
Hemodynamic Failure

Object The stroke rate, management, and outcome after blunt cerebrovascular occlusion (Biffl Grade IV injury) is not well defined, given the rarity of the disease. Both hemodynamic failure and embolic mechanisms have been implicated in the pathophysiology of subsequent stroke after blunt cerebrovascular occlusion. In this study, the authors evaluated their center's experience with Biffl Grade IV injuries, focusing on elucidating the mechanisms of stroke and their optimal management. Methods A retrospective review identified all internal carotid artery (ICA) or vertebral artery (VA) Biffl Grade IV injuries over a 7-year period at a single institution. Results Fifty-nine Biffl Grade IV injuries were diagnosed affecting 11 ICAs, 44 unilateral VAs, and 2 bilateral VAs. The stroke rates were 64%, 9%, and 50%, respectively. Of the 11 Biffl Grade IV ICA injuries, 5 presented with stroke while 2 developed delayed stroke. An ipsilateral posterior communicating artery greater than 1 mm on CT angiography was protective against stroke due to hemodynamic failure (p = 0.015). All patients with Biffl Grade IV injuries affecting the ICA who had at least 8 emboli per hour on transcranial Doppler (TCD) ultrasonography developed an embolic pattern of stroke (p = 0.006). Treatment with aspirin versus dual antiplatelet therapy had a similar effect on stroke rate in the ICA group (p = 0.5) and all patients who suffered stroke either died (n = 3) or required a decompressive hemicraniectomy with subsequent poor outcome (n = 4). All 10 strokes associated with Biffl Grade IV VA injuries were embolic and clinically asymptomatic. In VA Biffl Grade IV injury, neither the presence of emboli nor treatment with antiplatelet agents affected stroke rates. Conclusions At the authors' institution, traumatic ICA occlusion is rare but associated with a high stroke rate. Robust collateral circulation may mitigate its severity. Embolic monitoring with TCD ultrasonography and prophylactic antiplatelet therapy should be used in all ICA Biffl Grade IV injuries. Unilateral VA Biffl Grade IV injury is the most common type of traumatic occlusion and is associated with significantly less morbidity. Embolic monitoring using TCD and prophylactic antiplatelet therapy do not appear to be beneficial in patients with traumatic VA occlusion.

scholarly journals Clopidogrel Resistance: Current Issues

2016 ◽  
Vol 6 (1) ◽  
pp. 38-46
Author(s):  
NS Neki
Keyword(s):  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Ex Vivo ◽  
Platelet Reactivity ◽  
Antiplatelet Agents ◽  
Clinical Problem ◽  
Coronary Intervention ◽  
Platelet Activity ◽  
Clopidogrel Resistance ◽  
Underlying Mechanisms

Antiplatelet agents are mainly used in the prevention and management of atherothrombotic complications. Dual antiplatelet therapy, combining aspirin and clopidogrel, is the standard care for patients having acute coronary syndromes or undergoing percutaneous coronary intervention according to the current ACC/AHA and ESC guidelines. But in spite of administration of dual antiplatelet therapy, some patients develop recurrent cardiovascular ischemic events especially stent thrombosis which is a serious clinical problem. Antiplatelet response to clopidogrel varies widely among patients based on ex vivo platelet function measurements. Clopidogrel is an effective inhibitor of platelet activation and aggregation due to its selective and irreversible blockade of the P2Y12 receptor. Patients who display little attenuation of platelet reactivity with clopidogrel therapy are labeled as low or nonresponders or clopidogrel resistant. The mechanism of clopidogrel resistance remains incompletely defined but there are certain clinical, cellular and genetic factors including polymorphisms responsible for therapeutic failure. Currently there is no standardized or widely accepted definition of clopidogrel resistance. The future may soon be realised in the routine measurement of platelet activity in the same way that blood pressure, cholesterol and blood sugar are followed to help guide the therapy, thus improving the care for millions of people. This review focuses on the methods used to identify patients with clopidogrel resistance, the underlying mechanisms, metabolism, clinical significance and current therapeutic strategies to overcome clopidogrel resistance.J Enam Med Col 2016; 6(1): 38-46

scholarly journals Impact of Diabetes Mellitus on Antithrombotic Management Patterns and Long‐Term Clinical Outcomes in Patients With Acute Coronary Syndrome: Insights From the EPICOR Asia Study

2020 ◽  
Vol 9 (22) ◽  
Author(s):  
Shaoyi Guan ◽  
Xiaoming Xu ◽  
Yi Li ◽  
Jing Li ◽  
Mingzi Guan ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Acute Coronary Syndrome ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Antiplatelet Agents ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Antithrombotic Management

Background Long‐term use of antiplatelet agents after acute coronary syndrome in diabetic patients is not well known. Here, we describe antiplatelet use and outcomes in such patients enrolled in the EPICOR Asia (Long‐Term Follow‐up of Antithrombotic Management Patterns in Acute Coronary Syndrome Patients in Asia) registry. Methods and Results EPICOR Asia is a prospective, observational study of 12 922 patients with acute coronary syndrome surviving to discharge, from 8 countries/regions in Asia. The present analysis included 3162 patients with diabetes mellitus (DM) and 9602 patients without DM. The impact of DM on use of antiplatelet agents and events (composite of death, myocardial infarction, and stroke, with or without any revascularization; individual components, and bleeding) was evaluated. Significant baseline differences were seen between patients with DM and patients without DM for age, sex, body mass index, cardiovascular history, angiographic findings, and use of percutaneous coronary intervention. At discharge, ≈90% of patients in each group received dual antiplatelet therapy. At 2‐year follow‐up, more patients with DM tended to still receive dual antiplatelet therapy (60% versus 56%). DM was associated with increased risk from ischemic but not major bleeding events. Independent predictors of the composite end point of death, myocardial infarction, and stroke in patients with DM were age ≥65 years and use of diuretics at discharge. Conclusions Antiplatelet agent use is broadly comparable in patients with DM and patients without DM, although patients with DM are more likely to be on dual antiplatelet therapy at 2 years. Patients with DM are at increased risk of ischemic events, suggesting an unmet need for improved antithrombotic treatment. Registration URL: https://www.clini​caltr​ials.gov ; Unique identifier: NCT01361386.

The Dual Antiplatelet Therapy Trial after the FDA Update: Noncardiovascular Deaths, Cancer and Optimal Treatment Duration

Cardiology ◽  
2015 ◽  
Vol 132 (2) ◽  
pp. 74-80 ◽  
Author(s):  
Victor L. Serebruany ◽  
Vasily Cherepanov ◽  
Elena Z. Golukhova ◽  
Moo Hyun Kim
Keyword(s):  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Antiplatelet Agents ◽  
Clinical Event ◽  
Cancer Risks ◽  
Full Disclosure ◽  
Cancer Data ◽  
Coronary Syndrome ◽  
Coronary Syndromes

Background: The landmark Dual Antiplatelet Therapy (DAPT) trial revealed an impressive reduction of stent thrombosis and myocardial infarction after prolonged 30-month DAPT compared to the conventional 12-month regimen. However, aside from the expected extra bleeding risks, more cancers and noncardiovascular deaths (NCVD) were observed in the 30-month DAPT arm. Objective: We aimed to comprehend the totality of DAPT trial evidence in the light of the FDA medical review. Results: A significant excess of solid cancers that was picked up after prasugrel treatment in the TRITON trial (Prasugrel versus Clopidogrel in Patients with Acute Coronary Syndromes) and later observed with vorapaxar treatment in the TRACER trial (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) has now been confirmed by the FDA DAPT review for 30-month therapy with prasugrel [hazard ratio (HR) 1.3] and clopidogrel (HR 1.2). The latest randomized evidence with antiplatelet agents rejected the drug-specific cancer risks, clearly indicating the class effect. The NCVD risks were elevated after treatment with both thienopyridines, but were more prominent after clopidogrel treatment (HR 1.91) than prasugrel treatment (HR 1.17). About half of the NCVD were considered to be caused by cancers occurring after the 24 months of extended antiplatelet therapy. Impression: The DAPT trial confirmed that long-term antiplatelet therapy is associated with cancer that contributes to NCVD. Based on the full disclosure of cancer data by the DAPT study, it can be reflected that the optimal duration of antiplatelet therapy with thienopyridines should be limited to no more than 2 years. This duration allows the preservation of most vascular benefits while avoiding additional cancers and NCVD.

Does Dual Antiplatelet Therapy Affect Blood Loss and Transfusion Requirements in Robotic-Assisted Coronary Artery Surgery?

2012 ◽  
Vol 7 (6) ◽  
pp. 399-402 ◽  
Author(s):  
Jonathan M. Hemli ◽  
Lincoln S. Darla ◽  
Christopher R. Panetta ◽  
Joan Jennings ◽  
Valavanur A. Subramanian ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Antiplatelet Agents ◽  
Coronary Surgery ◽  
Robotic Assisted ◽  
Coronary Syndrome ◽  
Perioperative Bleeding ◽  
Transfusion Requirements ◽  
The Impact

Objective Patients who present for coronary surgery often receive preoperative dual antiplatelet therapy with aspirin and a thienopyridine derivative (clopidogrel or prasugrel), especially after a recent acute coronary syndrome. Studies have shown that patients on aspirin and clopidogrel are at increased risk for perioperative bleeding and related events. We sought to examine the impact of dual antiplatelet therapy on bleeding and transfusion requirements in patients undergoing robotic-assisted minimally invasive coronary artery bypass grafting. Methods From January 2010 to November 2011, a total of 110 patients underwent robotic-assisted off-pump coronary surgery at our institution. All patients underwent robotic-assisted harvest of the left internal mammary artery from the chest wall. Some patients then underwent direct coronary anastomosis to the left anterior descending coronary artery via a left minithoracotomy, whereas others had a complete robotic endoscopic procedure within the closed chest. The patients were divided into two groups for outcome analysis on the basis of preoperative antiplatelet therapy: group 1 (either aspirin alone or no antiplatelet agents at all; n = 53) and group 2 (aspirin plus clopidogrel or prasugrel; n = 57). Results Perioperative chest tube drainage was not significantly different between the patient groups, irrespective of the preoperative antiplatelet agents used. Transfusion requirements and other morbidities were also similar in both groups of patients. Conclusions Preoperative dual antiplatelet therapy does not result in significantly increased bleeding or perioperative transfusion requirements. If clinically indicated, it is reasonable to continue preoperative combination antiplatelet therapy in patients undergoing robotic-assisted coronary surgery.

scholarly journals Vorapaxar as an Alternative for Ticagrelor Resistance in Neuroendovascular Intervention

2021 ◽  
Author(s):  
James C. Mamaril‐Davis ◽  
Pedro Aguilar‐Salinas ◽  
Leonardo B. Brasiliense ◽  
Richard Cosgrove ◽  
Judy Dawod ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Antiplatelet Therapy ◽  
Internal Carotid ◽  
Dual Antiplatelet Therapy ◽  
Flow Diversion ◽  
Left Internal Carotid Artery ◽  
Thromboembolic Complications ◽  
Promising Alternative ◽  
Adp Receptor Antagonists

Abstract BACKGROUND Perioperative dual‐antiplatelet therapy for flow diversion limits thromboembolic complications. However, resistance to dual‐antiplatelet therapy medications remains a concern for neuroendovascular intervention. To date, there is no standardized approach for resistance to ADP receptor antagonists. METHODS We report a case of ticagrelor resistance for flow diversion of an intracranial aneurysm treated with vorapaxar, as well as a narrative review of the literature for previous cases of ticagrelor resistance. RESULTS Flow diversion with the Pipeline embolization device was deployed for a left internal carotid artery blister aneurysm and bilateral internal carotid artery dissecting pseudoaneurysms. The patient had 3 thromboembolic complications while on dual‐antiplatelet therapy with ticagrelor or prasugrel, leading to transition of antiplatelet therapy to vorapaxar. At 84 days follow‐up, the patient was fully recovered with complete occlusion of the aneurysms. CONCLUSION Our case suggests that vorapaxar is a promising alternative for patients with ticagrelor resistance in flow diversion–treated intracranial aneurysms. High‐quality randomized controlled trials are needed to elucidate the safety and efficacy of vorapaxar in neuroendovascular procedures.

Antiplatelet Agents

2018 ◽  
Author(s):  
Eelco F. M. Wijdicks ◽  
Sarah L. Clark
Keyword(s):  
Antiplatelet Therapy ◽  
Stroke Prevention ◽  
Endovascular Procedures ◽  
Dual Antiplatelet Therapy ◽  
Antiplatelet Agents ◽  
Mechanisms Of Action ◽  
Secondary Stroke Prevention ◽  
Vascular Medicine ◽  
Optimal Duration ◽  
Pharmacologic Management

Antiplatelet agents are commonly used in vascular medicine and cardiology, but also in the pharmacologic management of patients with ischemic stroke. Aspirin alone remains the mainstay of therapy for secondary stroke prevention. Several landmark studies for the optimal duration and dose of antiplatelet therapy in stroke prevention are discussed. Dual antiplatelet therapy is needed after carotid artery stenting. Situations where antiplatelet agents also come into play are endovascular procedures associated with procedure-related thrombi. Antiplatelet agents have different mechanisms of action, and each will be discussed. Testing of platelet function and the issue of antiplatelet resistance and discontinuation of antiplatelet agents before procedures will be discussed in this Chapter.

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

2011 ◽  
Vol 114 (4) ◽  
pp. 1021-1027 ◽  
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.

P4791Performance of the HAS-BLED, ATRIA, and PRECISE-DAPT Bleeding Risk Scores in Atrial Fibrillation Patients Using Antiplatelet Agents or Oral Anticoagulants

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
S Y Choi ◽  
M H Kim ◽  
K M Lee ◽  
C H Jang ◽  
J Y Choi
Keyword(s):  
Atrial Fibrillation ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Oral Anticoagulants ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Bleeding Events ◽  
C Statistic ◽  
Better Than

Abstract Background Various bleeding risk scores have been proposed to assess the risk of bleeding in atrial fibrillation (AF) patients undergoing anticoagulation. PRECISE DAPT score has been developed to assess the out-of hospital bleeding risk in patients receiving dual antiplatelet therapy (DAPT). Our objective was to compare the predictive performance between the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile International Normalized Ratio, Elderly, Drugs/Alcohol), ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), and PRECISE-DAPT (Predicting Bleeding Complication in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet therapy) score in AF patients using antiplatelet agents or anticoagulants Methods We recruited 1,114 consecutive AF patients (51% male; median age, 71 years) receiving antiplatelet agents or oral anticoagulants from January 2014 through December 2018. Major bleeding was defined as according to the Bleeding Academic Research Consortium (BARC) criteria (type 3 or 5: hemodynamic instability, need for transfusion, drop in hemoglobin ≥3 g, and intracranial, intraocular or fatal bleeding). The performance of risk scores were assessed by C-statistic. Results Bleeding events occurred in 135 patients (12.1%) during 30 days, and 72 patients (6.5%) from 30 days till 1-year follow-up. Based on the C-statistic, PRECISE-DAPT score (AUC: 0.72, 95% CI: 0.69–0.75) had a good performance, significantly better than HAS-BLED (AUC: 0.64, 95% CI: 0.61–0.67) (p=0.008) or ATRIA scores (AUC: 0.57, 95% CI: 0.54–0.60) (p<0.001) for 30-days bleeding prediction. Also, PRECISE-DAPT score had a good C-statistic (AUC: 0.72, 95% CI: 0.69–0.75) for 1-year bleeding events compared with HAS-BLED (AUC: 0.64, 95% CI: 0.60–0.67) (p=0.02) or ATRIA (AUC: 0.61, 95% CI: 0.58–0.65) (p=0.01). ROC curve for bleeding Conclusions The PRECISE-DAPT score has been used for assessing bleeding events during DAPT. Also, the PRECISE-DAPT score predicted bleedings better than HAS-BLED or ATRIA scores in AF patients. So, the PRECISE-DAPT score may be considered as bleeding risk score during DAPT or oral anticoagulation in clinical practice.

scholarly journals Acute ischemic stroke with cervical internal carotid artery steno-occlusive lesion: multicenter analysis of endovascular approaches

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Luigi Cirillo ◽  
Daniele Giuseppe Romano ◽  
Gianfranco Vornetti ◽  
Giulia Frauenfelder ◽  
Chiara Tamburrano ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Acute Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Internal Carotid ◽  
Dual Antiplatelet Therapy ◽  
Intravenous Thrombolysis ◽  
Hemorrhagic Transformation ◽  
Response To Treatment

Abstract Background Occlusion of the internal carotid artery (ICA), whether isolated or in the setting of a tandem lesion (TL) have a poor response to treatment with intravenous thrombolysis. Previous studies ​​have demonstrated the superiority of mechanical thrombectomy in the treatment of acute ischemic stroke (AIS) following large vessel occlusion, compared to standard intravenous fibrinolysis. The aim of our study was to describe endovascular treatment (EVT) in AIS due to isolated ICA occlusion or TL. Methods We assessed the association between 90-day outcome and clinical, demographic, imaging, and procedure data in 51 consecutive patients with acute isolated ICA occlusion or TL who underwent EVT. We evaluated baseline NIHSS and mRS, ASPECTS, type of occlusion, stent placement, use of stent retrievers and/or thromboaspiration, duration of the procedure, mTICI, postprocedural therapy and complications. Results A favorable 90-day outcome (mRS 0–2) was achieved in 34 patients (67 %) and was significantly associated with the use of dual antiplatelet therapy after the procedure (p = 0.008), shorter procedure duration (p = 0.031), TICI 2b-3 (p < 0.001) and lack of post-procedural hemorrhagic transformation (p = 0.001). Four patients did not survive, resulting in a mortality rate of 8 %. Conclusions Our study has shown that EVT in the treatment of AIS due to ICA occlusion is safe, and effective in determining a good functional outcome. ICA stenting led to good angiographic results and therapy with a glycoprotein IIb / IIIa inhibitor immediately after stent release did not result in a greater risk of hemorrhage. The use of post-procedural dual antiplatelet therapy was associated with favorable outcome, without a significant increase in hemorrhagic transformation.

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