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Management of tandem occlusions in patients who receive rtPA

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Abstract

Background

Tandem occlusions exist in 17–32% of large vessel occlusion (LVO) strokes. A significant concern is bleeding when carotid stenting is performed in tandem with thrombectomy due the administration of antiplatelet agents such as glycoprotein IIb/IIIa inhibitors (GP2b3aI) after receiving rtPA, but data are limited in this setting.

Methods

A mutlicenter, retrospective chart review was conducted at two comprehensive stroke centers to assess the safety and efficacy of using GP2b3aI to facilitate carotid stent placement simultaneously with endovascular thrombectomy in patients who have received rtPA.

Results

Overall, 32 patients were included in this study, with average age of 66.3 ± 10.4 years and predominantly male (87.5%). The cause of stroke was mostly large artery atherosclerosis (59.4%) and the thrombectomy target vessels were typically first- or second segment middle cerebral artery (37.5% and 31.3%). Time from symptom onset to rtPA bolus was 1.8 h [interquartile range (IQR) 1.5–2.7], rtPA bolus to first pass was 2 h [IQR 1.5–3.1], rtPA bolus to GP2b3aI bolus was 2 h [IQR 1.6–3.5], and rtPA bolus to aspirin and clopidogrel administration was 4.3 h [IQR 2.6–8.9] and 6.6 h [IQR 4.5–11.6] respectively. No patients had acute in-stent thrombosis or post-op bleeding from the access site. Two patients (6.3%) had significant hemorrhagic conversion.

Conclusion

The use of GP2b3aI in the setting of tandem occlusions that required emergent stent placement post-rtPA appears safe and effective. Given the small sample size, these findings should be interpreted cautiously, and need to be confirmed in a larger patient population.

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References

  1. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333(24):1581–1588. https://doi.org/10.1056/NEJM199512143332401

    Article  Google Scholar 

  2. Gong L, Liu M, Zeng T et al (2015) Crystal structure of the Michaelis complex between tissue-type plasminogen activator and plasminogen activators inhibitor-1. J Biol Chem. https://doi.org/10.1074/jbc.M115.677567

    Article  PubMed  PubMed Central  Google Scholar 

  3. Khan IA, Gowda RM (2003) Clinical perspectives and therapeutics of thrombolysis. Int J Cardiol 91(2–3):115–127. https://doi.org/10.1016/s0167-5273(03)00019-6

    Article  PubMed  Google Scholar 

  4. Stangl K, Laule M, Tenckhoff B et al (1998) Fibrinogen breakdown, long-lasting systemic fibrinolysis, and procoagulant activation during alteplase double-bolus regimen in acute myocardial infarction. Am J Cardiol. https://doi.org/10.1016/S0002-9149(98)00018-6

    Article  PubMed  Google Scholar 

  5. Collen D, Lijnen H (1994) Fibrinolysis and the control of hemostasis. In: Stamatoyannopoulos G (ed) The molecular basis of blood disease, 2nd edn. W.B Saunders, pp 662–688

    Google Scholar 

  6. Berkhemer OA, Fransen PSS, Beumer D et al (2014) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372(1):11–20. https://doi.org/10.1056/NEJMoa1411587

    Article  CAS  PubMed  Google Scholar 

  7. Saver JL, Goyal M, Bonafe A et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. https://doi.org/10.1056/nejmoa1415061

    Article  PubMed  PubMed Central  Google Scholar 

  8. Campbell BCV, Mitchell PJ, Kleinig TJ et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. https://doi.org/10.1056/nejmoa1414792

    Article  PubMed  PubMed Central  Google Scholar 

  9. Goyal M, Demchuk AM, Menon BK et al (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. https://doi.org/10.1056/nejmoa1414905

    Article  PubMed  Google Scholar 

  10. Jovin TG, Chamorro A, Cobo E et al (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. https://doi.org/10.1056/nejmoa1503780

    Article  PubMed  Google Scholar 

  11. Nogueira RG, Jadhav AP, Haussen DC et al (2018) Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. https://doi.org/10.1056/nejmoa1706442

    Article  PubMed  Google Scholar 

  12. Albers GW, Marks MP, Kemp S et al (2018) Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. https://doi.org/10.1056/nejmoa1713973

    Article  PubMed  PubMed Central  Google Scholar 

  13. Sacco RL, Adams R, Albers G et al (2006) Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association council on stroke—Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke. https://doi.org/10.1161/01.STR.0000199147.30016.74

    Article  PubMed  PubMed Central  Google Scholar 

  14. Kim KS, Fraser JF, Grupke S, Cook AM (2018) Management of antiplatelet therapy in patients undergoing neuroendovascular procedures. J Neurosurg. https://doi.org/10.3171/2017.5.JNS162307

    Article  PubMed  PubMed Central  Google Scholar 

  15. Barra ME, Berger K, Tesoro EP, Brophy GM (2019) Periprocedural neuroendovascular antiplatelet strategies for thrombosis prevention in clopidogrel-hyporesponsive patients. Pharmacotherapy. https://doi.org/10.1002/phar.2228

    Article  PubMed  Google Scholar 

  16. Dornbos D, Katz JS, Youssef P, Powers CJ, Nimjee SM (2018) Glycoprotein IIb/IIIa inhibitors in prevention and rescue treatment of thromboembolic complications during endovascular embolization of intracranial aneurysms. Clin Neurosurg. https://doi.org/10.1093/neuros/nyx170

    Article  Google Scholar 

  17. Jadhav AP, Zaidat OO, Liebeskind DS et al (2019) Emergent management of tandem lesions in acute ischemic stroke. Stroke. https://doi.org/10.1161/strokeaha.118.021893

    Article  PubMed  Google Scholar 

  18. Behme D, Mpotsaris A, Zeyen P et al (2015) Emergency stenting of the extracranial internal carotid artery in combination with anterior circulation thrombectomy in acute ischemic stroke: a retrospective multicenter study. AJNR Am J Neuroradiol 36(12):2340–2345. https://doi.org/10.3174/ajnr.A4459

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Assis Z, Menon BK, Goyal M et al (2018) Acute ischemic stroke with tandem lesions: technical endovascular management and clinical outcomes from the ESCAPE trial. J Neurointervent Surg 10(5):429–433. https://doi.org/10.1136/neurintsurg-2017-013316

    Article  Google Scholar 

  20. Yaghi S, Willey JZ, Cucchiara B et al (2017) Treatment and outcome of hemorrhagic transformation after intravenous alteplase in acute ischemic stroke a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. https://doi.org/10.1161/STR.0000000000000152

    Article  PubMed  PubMed Central  Google Scholar 

  21. Sabatine MS, Morrow DA, Giugliano RP et al (2005) Association of hemoglobin levels with clinical outcomes in acute coronary syndromes. Circulation. https://doi.org/10.1161/01.CIR.0000162477.70955.5F

    Article  PubMed  Google Scholar 

  22. Mehran R, Rao SV, Bhatt DL et al (2011) Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the bleeding academic research consortium. Circulation. https://doi.org/10.1161/CIRCULATIONAHA.110.009449

    Article  PubMed  Google Scholar 

  23. Wahlgren N, Ahmed N, Dávalos A et al (2007) Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet (Lond, Engl) 369(9558):275–282. https://doi.org/10.1016/S0140-6736(07)60149-4

    Article  CAS  Google Scholar 

  24. Jacquin G, Poppe AY, Labrie M et al (2019) Lack of consensus among stroke experts on the optimal management of patients with acute tandem occlusion. Stroke. https://doi.org/10.1161/STROKEAHA.118.023758

    Article  PubMed  Google Scholar 

  25. Heck DV, Brown MD (2015) Carotid stenting and intracranial thrombectomy for treatment of acute stroke due to tandem occlusions with aggressive antiplatelet therapy may be associated with a high incidence of intracranial hemorrhage. J Neurointervent Surg 7(3):170–175. https://doi.org/10.1136/neurintsurg-2014-011224

    Article  Google Scholar 

  26. Steglich-Arnholm H, Holtmannspötter M, Kondziella D et al (2015) Thrombectomy assisted by carotid stenting in acute ischemic stroke management: benefits and harms. J Neurol 262(12):2668–2675. https://doi.org/10.1007/s00415-015-7895-0

    Article  CAS  PubMed  Google Scholar 

  27. Papanagiotou P, Roth C, Walter S et al (2011) Carotid artery stenting in acute stroke. J Am Coll Cardiol 58(23):2363–2369. https://doi.org/10.1016/j.jacc.2011.08.044

    Article  PubMed  Google Scholar 

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Funding

No funding was obtained for the conduction of this study.

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Authors and Affiliations

  1. Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA

    Keaton S. Smetana & Casey C. May

  2. Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, OH, 43210, USA

    Amanda Zakeri, Patrick Youssef & Shahid M. Nimjee

  3. Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Jaydevsinh Dolia & Bradley A. Gross

  4. The Ohio State University College of Medicine, Columbus, OH, USA

    Allyson Huttinger

Authors
  1. Keaton S. Smetana
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  2. Amanda Zakeri
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  3. Jaydevsinh Dolia
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  4. Allyson Huttinger
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  5. Casey C. May
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  6. Patrick Youssef
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  8. Shahid M. Nimjee
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Correspondence to Shahid M. Nimjee.

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All authors of this study have no direct or indirect conflicts of interest to disclose.

Ethical approval

Ethical approval was waived by the local Ethics Committee of The Ohio State University in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.

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Smetana, K.S., Zakeri, A., Dolia, J. et al. Management of tandem occlusions in patients who receive rtPA. J Thromb Thrombolysis 52, 1182–1186 (2021). https://doi.org/10.1007/s11239-021-02510-7

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  • DOI: https://doi.org/10.1007/s11239-021-02510-7

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