Abstract
An 82-year-old man with a history of arterial hypertension for several years prior and an episode of dizziness and anomic aphasia 3 years prior presented to the referring hospital with transient episodes of dizziness, dysarthria, and partial left facial nerve palsy. DSA revealed proximal stenoses of both vertebral arteries (VAs) and a high-grade midbasilar artery (BA) stenosis. The first endovascular treatment comprised stent-assisted percutaneous transluminal angioplasty of both VAs with drug-eluting coronary stents and the BA (Enterprise) in March 2018. In-stent stenoses of the right VA and the BA required three retreatments with balloon dilatations. Approximately 1 year after the fourth treatment, an acute right V4 occlusion was diagnosed, and the left V4 segment was shown to end in the posterior inferior cerebellar artery. Endovascular treatment included balloon dilatation of the BA, aspiration thrombectomy, and implantation of a Solitaire stent into the BA. Attempted aspiration of a large nonocclusive thrombus in the distal BA failed. The patient received acetylsalicylic acid, ticagrelor, body weight-adapted eptifibatide IV infusion, and subcutaneous low-dose low molecular weight heparin for 5 days. This regimen resulted in complete dissolution of the large thrombus in the BA and clinical recovery. The main topic of this chapter is the dissolution of nonocclusive thrombi in the neurovasculature with extended eptifibatide IV infusion, dual platelet function inhibition, and low-dose heparin administration.
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Abbreviations
- ADP test:
-
Adenosine diphosphate receptor (test)
- ARU:
-
Aspirin reaction units, a result of the VerifyNow test
- ASA:
-
Acetylsalicylic acid
- ASPItest:
-
Part of the Multiplate test, a kit used for monitoring cyclooxygenase inhibitors
- BA:
-
Basilar artery
- CT:
-
Computed tomography
- CTA:
-
Computed tomography angiography
- DSA:
-
Digital subtraction angiography
- DWI:
-
Diffusion-weighted imaging
- FLAIR:
-
Fluid attenuated inversion recovery
- IA:
-
Intra-arterial
- ICU:
-
Intensive care unit
- ISRS:
-
In-stent restenosis
- IU:
-
International units
- IV:
-
intravenous
- lt:
-
Left
- MRA:
-
Magnetic resonance angiography
- MRI:
-
Magnetic resonance imaging
- mRS:
-
Modified Rankin Score
- NIHSS:
-
National Institutes of Health Stroke Scale
- P2Y12 test:
-
Part of the VerifyNow test measures the P2Y12 platelet receptor inhibition
- pa:
-
Posterior-anterior
- PCA:
-
Posterior cerebral artery
- PcomA:
-
Posterior communicating artery
- PICA:
-
Posterior inferior cerebellar artery
- PO:
-
per os (by mouth)
- PTA:
-
Percutaneous transluminal angioplasty
- qd:
-
Quaque die (once per day)
- rt.:
-
Right
- SA:
-
Subclavian artery
- SC:
-
Subcutaneous
- SES:
-
Self-expanding stent
- TOF:
-
Time-of-flight
- TRAPtest:
-
Part of the Multiplate test; sensitive to the action of Gp IIb/IIIa receptor antagonists
- VA:
-
Vertebral artery
References
Aguilar Perez M, AlMatter M, Hellstern V, Wendl C, Ganslandt O, Bäzner H, Henkes H. Use of the pCONus HPC as an adjunct to coil occlusion of acutely ruptured aneurysms: early clinical experience using single antiplatelet therapy. J Neurointerv Surg. 2020;12(9):862–8. https://doi.org/10.1136/neurintsurg-2019-015746.
Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. 1991;337(8756):1521–6. https://doi.org/10.1016/0140-6736(91)93206-o.
Bogousslavsky J, Van Melle G, Regli F. The Lausanne stroke registry: analysis of 1,000 consecutive patients with first stroke. Stroke. 1988;19(9):1083–92. https://doi.org/10.1161/01.str.19.9.1083.
Cao X, Wang J, Tian C, Du Z, Su H, Liu X, Lv B, Yu S, Chen X, Hui F. Solitaire AB stent-angioplasty for stenoses in perforator rich segments: a single-center experience. Interv Neuroradiol. 2020;26(5):608–14. https://doi.org/10.1177/1591019920951651.
Cheddar El Aouni M, Magro E, Abdelrady M, Nonent M, Generic JC, Oxnard J. Safety and efficacy of cangrelor among three antiplatelet regimens during stent-assisted endovascular treatment of unruptured intracranial aneurysm: a single-center retrospective study. Front Neurol. 2022;13:727026. Published 2022 March 4. https://doi.org/10.3389/fneur.2022.727026.
Compter A, van der Worp HB, Schonewille WJ, Vos JA, Boiten J, Nederkoorn PJ, Uyttenboogaart M, Lo RT, Algra A, Kappelle LJ, VAST investigators. Stenting versus medical treatment in patients with symptomatic vertebral artery stenosis: a randomised open-label phase 2 trial. Lancet Neurol. 2015;14(6):606–14. https://doi.org/10.1016/S1474-4422(15)00017-4.
Cortese B, Granada JF, Scheller B, Schneider PA, Tepe G, Scheinert D, Garcia L, Stabile E, Alfonso F, Ansel G, Zeller T. Drug-coated balloon treatment for lower extremity vascular disease intervention: an international positioning document. Eur Heart J. 2016;37(14):1096–103. https://doi.org/10.1093/eurheartj/ehv204.
Coward LJ, McCabe DJ, Ederle J, Featherstone RL, Clifton A, Brown MM, Investigators CAVATAS. Long-term outcome after angioplasty and stenting for symptomatic vertebral artery stenosis compared with medical treatment in the carotid and vertebral artery transluminal angioplasty study (CAVATAS): a randomized trial. Stroke. 2007;38(5):1526–30. https://doi.org/10.1161/STROKEAHA.106.471862.
Cui R, Yan L, Kang K, Yang M, Yu Y, Mo D, Gao F, Wang Y, Lou X, Miao Z, Ma N. Long-term outcome of enterprise stenting for symptomatic ICAS in a high-volume stroke center. Front Neurol. 2021;12:672662. https://doi.org/10.3389/fneur.2021.672662.
Dumont TM, Kan P, Snyder KV, Hopkins LN, Siddiqui AH, Levy EI. Revisiting angioplasty without stenting for symptomatic intracranial atherosclerotic stenosis after the stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis (SAMMPRIS) study. Neurosurgery. 2012;71(6):1103–10. https://doi.org/10.1227/NEU.0b013e318271bcb8.
Flossmann E, Rothwell PM. Prognosis of vertebrobasilar transient ischaemic attack and minor stroke. Brain. 2003;126(pt 9):1940–54. https://doi.org/10.1093/brain/awg197. Epub 2003 Jul 7.
Gomez CR, Misra VK, Liu MW, Wadlington VR, Terry JB, Tulyapronchote R, Campbell MS. Elective stenting of symptomatic basilar artery stenosis. Stroke. 2000;31(1):95–9. https://doi.org/10.1161/01.str.31.1.95.
Gruber P, Berberat J, Kahles T, Anon J, Diapers M, Nedeltchev K, Remonda L. Angioplasty using drug-coated balloons in ostial vertebral artery stenosis. Ann Vasc Surg. 2020;64:157–62. https://doi.org/10.1016/j.avsg.2019.10.043.
Levy EI, Howington JU, Engh JA, Hanel RA, Levy N, Kim SH, Gibbons KJ, Guterman LR, Hopkins LN. Submaximal angioplasty and staged stenting for severe posterior circulation intracranial stenosis: a technique in evolution. Neurocrit Care. 2005;2(2):189–97. https://doi.org/10.1385/ncc:2:2:189.
Levy EI, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, Pride L, Purdy P, Welch B, Woo H, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG, Fiorella DJ. Wingspan in-stent re-stenosis and thrombosis: incidence, clinical presentation, and management. Neurosurgery. 2007;61(3):644–50.; discussion 650-1. https://doi.org/10.1227/01.NEU.0000290914.24976.83.
Lincoff AM. Stent scrutiny. JAMA. 2000;284(14):1839–41. https://doi.org/10.1001/jama.284.14.1839.
Lu H, Zheng P, Zhang W. Long-term outcome of drug-eluting stenting for stenoses of the intracranial vertebrobasilar artery and vertebral ostium. J Neurointerv Surg. 2013;5(5):435–9. https://doi.org/10.1136/neurintsurg-2012-010367.
Maier IL, Karch A, Lipke C, Behme D, Mpotsaris A, Kabbasch C, Liebig T, Faymonville A, Reich A, Nikoubashman O, Buhk JH, von Schoenfeld P, Weber W, Mikolajczyk RT, Bähr M, Knauth M, Kallenberg K, Liman J. Transluminal angioplasty and stenting versus conservative treatment in patients with symptomatic basilar artery stenosis: perspective for future clinical trials. Clin Neuroradiol. 2018;28(1):33–8. https://doi.org/10.1007/s00062-016-0528-x.
Markus HS, Larsson SC, Kuker W, Schulz UG, Ford I, Rothwell PM, Clifton A, VIST Investigators. Stenting for symptomatic vertebral artery stenosis: the vertebral artery ischaemia stenting trial. Neurology. 2017;89(12):1229–36. https://doi.org/10.1212/WNL.0000000000004385.
Marquardt L, Kuker W, Chandratheva A, Geraghty O, Rothwell PM. Incidence and prognosis of > or = 50% symptomatic vertebral or basilar artery stenosis: prospective population-based study. Brain. 2009;132(Pt 4):982–8. https://doi.org/10.1093/brain/awp026.
Ramakrishnan P, Yoo AJ, Rabinov JD, Ogilvy CS, Hirsch JA, Nogueira RG. Intra-arterial eptifibatide in the management of thromboembolism during endovascular treatment of intracranial aneurysms: case series and a review of the literature. Interv Neurol. 2013;2(1):19–29. https://doi.org/10.1159/000354982.
Vajda Z, Miloslavski E, Güthe T, Fischer S, Albes G, Heuschmid A, Henkes H. Treatment of stenoses of vertebral artery origin using short drug-eluting coronary stents: improved follow-up results. AJNR Am J Neuroradiol. 2009 Oct;30(9):1653–6. https://doi.org/10.3174/ajnr.A1715.
Vajda Z, Güthe T, Perez MA, Heuschmid A, Schmid E, Bäzner H, Henkes H. Neurovascular in-stent stenoses: treatment with conventional and drug-eluting balloons. AJNR Am J Neuroradiol. 2011;32(10):1942–7. https://doi.org/10.3174/ajnr.A2644.
Vajda Z, Güthe T, Perez MA, Kurre W, Schmid E, Bäzner H, Henkes H. Prevention of intracranial in-stent re-stenosis: predilatation with a drug-eluting balloon, followed by the deployment of a self-expanding stent. Cardiovasc Intervent Radiol. 2013;36(2):346–52. https://doi.org/10.1007/s00270-012-0450-9.
von Gottberg P, Cimpoca A, Wendl C, Cohen JE, Speck U, Henkes H. Drug-coated balloons in the neurovascular setting: a comprehensive, systematic review of current use and indications. Rev Cardiovasc Med. 2022;23(4):128. https://doi.org/10.31083/j.rcm2304128.
Wang Y, Feng Y, Wang T, Ma Y, Gao P, Chen J, Chen Y, Yang B, Jiao L. Drug-coated balloon for vertebral artery origin stenosis: a pilot study. J Neurointerv Surg. 2021;13(9):827–30. https://doi.org/10.1136/neurintsurg-2020-016723.
Wang Z, Ling Y, Zhao H, Mao Y, Dong Q, Cao W. A comparison of different endovascular treatment for vertebral artery origin stenosis [published online ahead of print, 2022 June 11]. World Neurosurg. 2022; https://doi.org/10.1016/j.wneu.2022.06.026. S1878-8750(22)00811-7
White TG, Shah KA, Koul P, Link T, Dehdashti AR, Katz JM, Patsalides A, Woo HH. The resolute Onyx drug eluting stent for neurointervention: A technical series. Interv Neuroradiol. 2022;15910199221084398. https://doi.org/10.1177/15910199221084398
Xu H, Fu X, Yuan Y, Quan T, Wang Z, Han K, Liu G, Guan S. Feasibility and safety of paclitaxel-coated balloon angioplasty for the treatment of intracranial symptomatic in-stent re-stenosis. Front Neurol. 2020;11:774. https://doi.org/10.3389/fneur.2020.00774.
Zaidat OO, Fitzsimmons BF, Woodward BK, Wang Z, Killer-Oberpfalzer M, Wakhloo A, Gupta R, Kirshner H, Megerian JT, Lesko J, Pitzer P, Ramos J, Castonguay AC, Barnwell S, Smith WS, Gress DR, VISSIT Trial Investigators. Effect of a balloon-expandable intracranial stent vs medical therapy on risk of stroke in patients with symptomatic intracranial stenosis: the VISIT randomized clinical trial. JAMA. 2015;313(12):1240–8. https://doi.org/10.1001/jama.2015.1693.
Zhang J, Zhang X, Zhang J, Song Y, Zheng M, Sun L, Meng Y, Zhao W, Yin H, Wang W, Han J. Drug-coated balloon dilation compared with conventional stenting angioplasty for intracranial atherosclerotic disease. Neurosurgery. 2020;87(5):992–8. https://doi.org/10.1093/neuros/nyaa191.
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von Gottberg, P., Cimpoca, A., Khanafer, A., Cohen, J.E., Bäzner, H., Henkes, H. (2022). Proximal Vertebral Artery and Basilar Artery Stenoses, Followed by Basilar Artery Thrombosis; Repeated Stenting and Angioplasty Procedures, and Dissolution of a Large Nonocclusive Basilar Artery Thrombus with Extended Intravenous Infusion of Eptifibatide, with Good Clinical Outcome. In: Henkes, H., Cohen, J.E. (eds) The Ischemic Stroke Casebook. Springer, Cham. https://doi.org/10.1007/978-3-030-85411-9_29-1
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