Impact of leukoaraiosis in patients with acute ischemic stroke treated with thrombectomy: a post hoc analysis of the DIRECT-MT trial.

BACKGROUND: The influence of leukoaraiosis in patients with acute ischemic stroke (AIS) given intra-arterial treatment (IAT) with or without preceding intravenous thrombolysis (IVT) remains unknown. OBJECTIVE: To assess the clinical and radiological outcomes of IAT in patients with or without leukoaraiosis. METHODS: Patients of the direct mechanical thrombectomy trial (DIRECT-MT) whose leukoaraiosis grade could be assessed were included. DIRECT-MT was a randomized clinical trial performed in China to assess the effect of direct IAT compared with intravenous thrombolysis plus IAT. We employed the Age-Related White Matter Changes Scale for grading leukoaraiosis (ARWMC, 0 indicates no leukoaraiosis, 1-2 indicates mild-to-moderate leukoaraiosis, and 3 indicates severe leukoaraiosis) based on brain CT. The primary outcome was the score on the modified Rankin Scale (mRS) assessed at 90 days. RESULTS: There were 656 patients in the trial, 649 patients who were included, with 432 patients without leukoaraiosis, and 217 (33.4%) patients with leukoaraiosis divided into mild-to-moderate (n=139) and severe groups (n=78). Leukoaraiosis was a predictor of a worse mRS score (adjusted OR (aOR)=0.7 (95% CI 0.5 to 0.8)) and higher mortality (aOR=1.4 (1.1 to 1.9)), but it was not associated with symptomatic intracranial hemorrhage (sICH) (aOR=0.9 (0.5 to 1.5)). IVT preceding IAT did not increase sICH risk for patients with no (aOR=1.4 (0.6 to 3.4)), mild-to-moderate (aOR=1.5 (0.3 to 7.8)), or severe (aOR=1.5 (0.1 to 21.3)) leukoaraiosis. CONCLUSION: Patients with leukoaraiosis with AIS due to large vessel occlusion are at increased risk of a poor functional outcome after IAT but demonstrate similar sICH rates, and IVT preceding IAT does not increase the risk of sICH in Chinese patients with leukoaraiosis.

Prophylactic administration of tirofiban for preventing thromboembolic events in flow diversion treatment of intracranial aneurysms.

BACKGROUND: Flow diverter (FD) is widely used in the treatment of intracranial aneurysms. However, thromboembolic events (TEs) continue to be the major complications during the periprocedural phase. To evaluate the safety and efficacy of the prophylactic use of tirofiban, combined with the conventional dual antiplatelet therapy (DAT), as a new antiplatelet protocol in patients with intracranial aneurysms treated with FDs. METHODS: At least 3-5 days before the procedure, daily DAT were administrated to the patients. Tirofiban was administered as an intravenous bolus (5 µg/kg) over a 3 min period during or immediately after FD deployment, followed by a 0.05 µg/kg/min maintenance infusion for 24-48 hours. Periprocedural TEs and hemorrhagic events (HEs) were recorded. RESULTS: A total of 331 patients were included, including 229 (69.2%) who received tirofiban administration (tirofiban group) and 102 (30.8%) who received only DAT (non-tirofiban group). Periprocedural TEs occurred in 12 (3.6%) patients, including eight (7.8%) in the non-tirofiban group and four (1.7%) in the tirofiban group. In multivariate analysis, patients receiving tirofiban administration had significantly lower TEs as compared with those who received only DAT (P=0.004). Balloon angioplasty and longer procedure time (>137 min) were also risk factors for TEs. Also, no increase was observed in the rate of HEs related to tirofiban administration. CONCLUSIONS: The current study suggested that prophylactic administration of tirofiban combined with conventional oral DAT seems safe and efficient for preventing TEs during FD treatment of unruptured intracranial aneurysms. Balloon angioplasty and prolonged procedure are associated with a high risk of TEs.

Effects of and prognostic factors affecting endovascular mechanical thrombectomy of acute vertebrobasilar artery occlusion.

PURPOSE: To investigate the clinical outcome and factors affecting the prognosis of endovascular mechanical thrombectomy of acute vertebrobasilar artery occlusion. MATERIALS AND METHODS: Eighty-three patients with acute vertebrobasilar artery occlusion were treated with endovascular mechanical thrombectomy, and the recanalization rate, clinical outcomes at three months, modified DWI-PC-ASPECTS, and MRA-BATMAN scores were analyzed. RESULTS: Following acute mechanical thrombectomy, the TICI 2B-3 score was achieved in all patients (100%). At three-month evaluation, 56 (67.5%) patients had good prognosis with the mRS score of 0-2, including 13 (23.2%) patients who had arterial occlusion caused by emboli and 43 (76.8%) who had atherosclerotic stenosis. In analyzing factors affecting the prognosis, a significant difference (P < 0.05) existed between patients with good (mRS 0-2) and poor (mRS 3-6) prognosis in the NIHSS (17.3 vs. 31.2, P = 0.000001), modified DWI-PC-ASPECTS (10.4 vs. 7.8, P = 0.021), and MRA-BATMAN (6.3 vs. 4.6, P = 0.003) scores. Univariate Logistic regression analysis demonstrated NIHS score ≥ 21, modified DWI-PC-ASPECTS score ≤ 8.5, and MRA-BATMAN score ≤ 6.5 to be the risk factors for poor prognosis. Multivariate Logistic regression analysis revealed NIHSS score ≥ 21 as an independent risk factor for poor prognosis. CONCLUSION: Endovascular mechanical thrombectomy is safe and effective in recanalizing occluded vertebrobasilar artery occlusion, and NIHS score ≥ 21, modified DWI-PC-ASPECTS score ≤ 8.5, and MRA-BATMAN score ≤ 6.5 are the risk factors for poor prognosis.

Stroke prevention and control system in China: CSPPC-Stroke Program.

In China, stroke is a major cause of mortality, and long-term physical and cognitive impairment. To meet this challenge, the Ministry of Health China Stroke Prevention Project Committee (CSPPC) was established in April 2011. This committee actively promotes stroke prevention and control in China. With government financial support of 838.4 million CNY, 8.352 million people from 536 screening points in 31 provinces have received stroke screening and follow-up over the last seven years (2012-2018). In 2016, the CSPPC issued a plan to establish stroke centers. To shorten the pre-hospital period, the CSPPC established a stroke center network, stroke map, and stroke "Green Channel" to create three 1-h gold rescue circles, abbreviated as "1-1-1" (onset to call time <1 h; pre-hospital transfer time < 1 h, and door-to-needle time < 1 h). From 2017 to 2018, the median door-to-needle time dropped by 4.0% (95% confidence interval (CI), 1.4-9.4) from 50 min to 48 min, and the median onset-to-needle time dropped by 2.8% (95% CI, 0.4-5.2) from 180 min to 175 min. As of 31 December 2018, the CSPPC has established 380 stroke centers in mainland China. From 1 November 2018, the CSPPC has monitored the quality of stroke care in stroke center hospitals through the China Stroke Data Center Data Reporting Platform. The CSPPC Stroke program has led to a significant improvement in stroke care. This program needs to be further promoted nationwide.

Transradial Stenting for Carotid Stenosis in Patients with Bovine Type and Type III Aortic Arch: Experience in 28 Patients.

BACKGROUND: The effects and safety of transradial access for stenting of carotid artery stenosis in patients with bovine-type and type III aortic arch are currently unknown and are the purpose of this study. METHODS: Patients who were treated with stenting via transradial (n = 28) compared with transfemoral (n = 30) access of carotid artery stenosis complicated with bovine-type and type III aortic arch were enrolled. The clinical data were studied for comparison. RESULTS: The success rate of transradial access for carotid artery stenting was 100%. During the transradial access procedure, 3 patients experienced a temporary blood pressure drop and bradycardia that was resolved with atropine injection. No radial artery occlusion or severe cardiac or cerebral events occurred. The success rate of transfemoral access for carotid artery stenting was 90% with failure in 3 patients. No complications occurred during or after the stenting procedure. The irradiation duration was significantly (P = 0.001) smaller in transradial than in transfemoral access stenting (8.6 ± 0.87 vs. 11.4 ± 1.25 minutes). The arterial stenosis ranged 71.25%-96.50% (mean, 86.50% ± 10.15%) for transradial and 78%-97.75% (85.1% ± 10.42%) for transfemoral access groups before treatment, and the residual stenosis following treatment was significantly smaller in either the transradial (2.4%-17.75%; mean, 11.2% ± 6.03%) or transfemoral (4%-18.6%; mean, 12.4% ± 6.3%) groups compared with before treatment, respectively. CONCLUSIONS: The transradial access for stenting of patients with type III aortic arch plus left carotid artery stenosis or in the bovine-type aortic arch combined with right carotid artery stenosis can decrease the stenting difficulty, risks of embolization, and radiation time and increase the success rate.

Safety and efficacy of a new prophylactic tirofiban protocol without oral intraoperative antiplatelet therapy for endovascular treatment of ruptured intracranial aneurysms.

BACKGROUND: Coil embolization of intracranial aneurysms is being increasingly used; however, thromboembolic events have become a major periprocedural complication. OBJECTIVE: To determine the safety and efficacy of prophylactic tirofiban in patients with ruptured intracranial aneurysms. METHODS: Tirofiban was administered as an intravenous bolus (8.0 µg/kg over 3 min) followed by a maintenance infusion (0.10 µg/kg/min) before stent deployment or after completion of single coiling. Dual oral antiplatelet therapy (loading doses) was overlapped with half the tirofiban dose 2 h before cessation of the tirofiban infusion. Cases of intracranial hemorrhage or thromboembolism were recorded. RESULTS: Tirofiban was prophylactically used in 221 patients, including 175 (79.19%) who underwent stent-assisted coiling and 46 (20.81%) who underwent single coiling, all in the setting of aneurysmal subarachnoid hemorrhage. Six (2.71%) cases of intracranial hemorrhage occurred, including four (1.81%) tirofiban-related cases and two (0.90%) antiplatelet therapy-related cases. There were two (0.90%) cases of fatal hemorrhage, one related to tirofiban and the other related to dual antiplatelet therapy. Thromboembolic events occurred in seven (3.17%) patients (6 stent-assisted embolization, 1 single coiling), of which one (0.45%) event occurred during stenting and six (2.72%) occurred during intravenous tirofiban maintenance. No thromboembolic events related to dual antiplatelet therapy were found. CONCLUSIONS: Tirofiban bolus over 3 min followed by maintenance infusion appears to be a safe and efficient prophylactic protocol for the endovascular treatment of ruptured intracranial aneurysms and may be an alternative to intraoperative oral antiplatelet therapy, especially in the case of stent-assisted embolization.

Interventional therapy for the treatment of severe hemobilia after percutaneous transhepatic cholangial drainage: a case series.

From May 2003 to May 2010, a total of 9 patients with severe hemobilia after percutaneous transhepatic cholangial drainage (PTCD) were diagnosed using superselective angiography and cholangiography, and then were treated with interventional procedures. Two patients with hepatic arterio-biliary fistula underwent proximal and distal arterial embolization of the responsible vessel. Six patients with pseudoaneurysm had pseudoaneurysm occlusion with proximal and distal embolization. Another patient with biliary-portal vein fistula received a biliary fully covered stent placement. The effects in these patients were evaluated using superselective angiography immediately after the intervention and at 3- and 6-month follow-up. In all patients, hemobilia was stopped right after the treatment and no sign of recurrence was noted at 3- and 6-month follow-up after the interventional therapy. Our findings demonstrate that interventional therapy is a simple, minimally invasive, and safe approach for treating severe hemobilia in patients receiving PTCD.