Eptifibatide use following emergent carotid stenting in acute anterior circulation ischemic stroke with tandem occlusion.

BACKGROUND: Early revascularization of the extracranial internal carotid artery in acute anterior circulation ischemic stroke (ACIS) is feasible and may improve clinical outcome. When a stent is deployed, antithrombotic agents should be administered peri-procedurally to ensure stent patency. Our institution implemented a protocol for the use of eptifibatide as a means of maintaining stent patency in the treatment of ACIS associated with cervical internal carotid artery occlusion. METHODS: Our internal database was queried for patients who received emergent endovascular therapy (ET) for ACIS with stent placement and eptifibatide administration between July 2016 and 2019. RESULTS: Twenty nine patients met the study criteria. The etiology was large artery atherosclerosis in 26 cases. Two patients had a dissection (7%), and one had a carotid occlusion related to a recent carotid endarterectomy. Mean NIHSS was 14. Sixteen patients received IVrtPA. Extracranial-intracranial tandem occlusion (TO) was present in 21 of cases. All patients received an eptifibatide bolus followed by an infusion for approximately 24 hours post stent deployment. Head CT was obtained prior to initiation of oral dual antiplatelet therapy with aspirin and clopidogrel. Successful recanalization was achieved in all patients with no evidence of downstream embolization. Symptomatic intracerebral hemorrhage occurred in one patient. Stent occlusion occurred in two patients, only one of which was symptomatic. Favorable clinical outcome with mRS ≤ 2 at 3 months was achieved in seventeen patients. CONCLUSIONS: The use of eptifibatide post procedure was associated with low risk of symptomatic intracranial hemorrhage, including in patients treated with rtPA.

Cavernous carotid aneurysms: a new treatment paradigm in the era of flow diversion.

INTRODUCTION: Cavernous carotid aneurysms can cause significant symptomatology through mass effect and may rupture, resulting in carotid-cavernous fistula or epistaxis. Traditional treatment options included endovascular or surgical parent vessel occlusion, or embolization; in the last decade, the development of flow-diverting stents has changed the management paradigm for these lesions. Areas covered: In this review, we summarize the natural history, clinical presentation, and evolution of treatment options for cavernous carotid aneurysms and discuss developments likely to influence treatment strategies in the future. We performed a Medline search for relevant review articles and original reports and additional searches based on review of referenced articles, abstracts, and conference presentations. Expert commentary: Long-term data are still required to fully assess the efficacy of endoluminal reconstruction using flow diversion, but this approach appears to offer an attractive therapy for many cavernous carotid aneurysms requiring intervention.

Technology developments in endovascular treatment of intracranial aneurysms.

Advances in the management and endovascular treatment of intracranial aneurysms are progressing at a tremendous rate. Developments in novel imaging technology may improve diagnosis, risk stratification, treatment planning, intraprocedural assessment, and follow-up evaluation. Evolution of devices, including microwires, microcatheters, balloons, stents, and novel scaffolding devices, has greatly expanded the potential to treat difficult aneurysms. Although developments in technology have greatly improved the efficiency and efficacy of treatment of neurovascular disorders, novel devices do not always improve outcomes and may be associated with unique complications. As such, it is paramount to have an in-depth understanding of new devices and the implications of their introduction into clinical practice. This review provides an update on developments in endovascular treatment of intracranial aneurysms.

Endovascular treatment of unruptured wide-necked intracranial aneurysms: comparison of dual microcatheter technique and stent-assisted coil embolization.

BACKGROUND: Endovascular treatment of wide-necked aneurysms is challenging. Stent-assisted coiling (SAC) is associated with increased complications and requires dual antiplatelet therapy. OBJECTIVE: To compare treatment of unruptured, wide-necked aneurysms with a dual-microcatheter technique (DMT) versus SAC. METHODS: Between 2006 and 2011, 100 patients with unruptured wide-necked intracranial aneurysms were treated with DMT and 160 with SAC. Over time there was a significant decrease in the use of SAC and a corresponding increase in DMT. The investigators matched 60 patients treated with DMT blinded to outcome in a 1:2 fashion based on maximal aneurysm dome diameter with 120 patients treated with SAC. Outcomes were determined with conditional (matched) multivariate analysis. RESULTS: There were no significant differences in patient or aneurysm characteristics between cohorts, including aneurysm diameter, neck width, or volume. Overall packing density and coil volume achieved was not significantly different between cohorts. There were higher rates of overall complications in those receiving SAC (19.2%) compared with DMT (5.0%; p=0.012), but no significant difference in major complications (8.3% vs 1.7%, respectively; p=0.103). At a mean follow-up of 27.0 ± 18.9 months, rates of retreatment did not differ between DMT (15.1%) and SAC (17.7%). Delayed in-stent stenosis occurred in five patients and in-stent thrombosis in four patients treated with SAC. There was no difference in favorable functional outcome (modified Rankin score 0-2) between those treated with DMT (90.6%) compared with SAC (91.2%). CONCLUSIONS: DMT and SAC are effective endovascular approaches for unruptured, wide-necked aneurysms; however, DMT may result in less morbidity. Further long-term studies are necessary to determine the optimal indications for these treatment options.

Human herpesvirus 6A accelerates AIDS progression in macaques.

Although HIV is the necessary and sufficient causative agent of AIDS, genetic and environmental factors markedly influence the pace of disease progression. Clinical and experimental evidence suggests that human herpesvirus 6A (HHV-6A), a cytopathic T-lymphotropic DNA virus, fosters the progression to AIDS in synergy with HIV-1. In this study, we investigated the effect of coinfection with HHV-6A on the progression of simian immunodeficiency virus (SIV) disease in pig-tailed macaques (Macaca nemestrina). Inoculation of HHV-6A resulted in a rapid appearance of plasma viremia associated with transient clinical manifestations and followed by antibody seroconversion, indicating that this primate species is susceptible to HHV-6A infection. Whereas animals infected with HHV-6A alone did not show any long-term clinical and immunological sequelae, a progressive loss of CD4(+) T cells was observed in all of the macaques inoculated with SIV. However, progression to full-blown AIDS was dramatically accelerated by coinfection with HHV-6A. Rapid disease development in dually infected animals was heralded by an early depletion of both CD4(+) and CD8(+) T cells. These results provide in vivo evidence that HHV-6A may act as a promoting factor in AIDS progression.