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1.
JAMA Neurol ; 80(7): 732-738, 2023 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-37252708

RESUMO

Importance: Symptomatic intracranial hemorrhage (sICH) is a serious complication of stroke thrombolytic therapy. Many stroke centers have adopted 0.25-mg/kg tenecteplase instead of alteplase for stroke thrombolysis based on evidence from randomized comparisons to alteplase as well as for its practical advantages. There have been no significant differences in symptomatic intracranial hemorrhage (sICH) reported from randomized clinical trials or published case series for the 0.25-mg/Kg dose. Objective: To assess the risk of sICH following ischemic stroke in patients treated with tenecteplase compared to those treated with alteplase. Design, Setting, and Participants: This was a retrospective observational study using data from the large multicenter international Comparative Effectiveness of Routine Tenecteplase vs Alteplase in Acute Ischemic Stroke (CERTAIN) collaboration comprising deidentified data on patients with ischemic stroke treated with intravenous thrombolysis. Data from more than 100 hospitals in New Zealand, Australia, and the US that used alteplase or tenecteplase for patients treated between July 1, 2018, and June 30, 2021, were included for analysis. Participating centers included a mix of nonthrombectomy- and thrombectomy-capacity comprehensive stroke centers. Standardized data were abstracted and harmonized from local or regional clinical registries. Consecutive patients with acute ischemic stroke who were considered eligible and received thrombolysis at the participating stroke registries during the study period were included. All 9238 patients who received thrombolysis were included in this retrospective analysis. Main Outcomes and Measures: sICH was defined as clinical worsening of at least 4 points on the National Institutes of Health Stroke Scale (NIHSS), attributed to parenchymal hematoma, subarachnoid, or intraventricular hemorrhage. Differences between tenecteplase and alteplase in the risk of sICH were assessed using logistic regression, adjusted for age, sex, NIHSS score, and thrombectomy. Results: Of the 9238 patients included in the analysis, the median (IQR) age was 71 (59-80) years, and 4449 patients (48%) were female. Tenecteplase was administered to 1925 patients. The tenecteplase group was older (median [IQR], 73 [61-81] years vs 70 [58-80] years; P < .001), more likely to be male (1034 of 7313 [54%] vs 3755 of 1925 [51%]; P < .01), had higher NIHSS scores (median [IQR], 9 [5-17] vs 7 [4-14]; P < .001), and more frequently underwent endovascular thrombectomy (38% vs 20%; P < .001). The proportion of patients with sICH was 1.8% for tenecteplase and 3.6% for alteplase (P < .001), with an adjusted odds ratio (aOR) of 0.42 (95% CI, 0.30-0.58; P < .01). Similar results were observed in both thrombectomy and nonthrombectomy subgroups. Conclusions and Relevance: In this large study, ischemic stroke treatment with 0.25-mg/kg tenecteplase was associated with lower odds of sICH than treatment with alteplase. The results provide evidence supporting the safety of tenecteplase for stroke thrombolysis in real-world clinical practice.


Assuntos
Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Ativador de Plasminogênio Tecidual/uso terapêutico , Tenecteplase/uso terapêutico , AVC Isquêmico/tratamento farmacológico , Estudos Retrospectivos , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/complicações , Fibrinolíticos , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/complicações , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/induzido quimicamente , Resultado do Tratamento
2.
World Neurosurg ; 140: 237-240, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32387404

RESUMO

BACKGROUND: In-stent thrombosis is a potentially dangerous complication of flow diversion for cerebral aneurysms. The optimal management strategy for such thrombosis is not known. Here we present a case of acute ischemic stroke caused by occlusion of a Pipeline Embolization Device (PED) construct placed 18 months earlier for treatment of a fusiform middle cerebral artery aneurysm. This was successfully treated with mechanical thrombectomy with good neurologic outcome. CASE DESCRIPTION: A 40-year-old woman presented with acute onset of left-sided weakness and occlusion of the right middle cerebral artery harboring a PED construct. Intraarterial glycoprotein IIb/IIIa inhibitor was administered without success. Mechanical thrombectomy was then performed using a stent retriever and aspiration, and the patient was loaded with dual antiplatelet therapy. The patient showed initial neurologic improvement but several hours later demonstrated recurrent symptoms due to reocclusion of the PED construct. This was again treated with mechanical thrombectomy followed by an intravenous P2Y12 inhibitor infusion. She ultimately made an excellent neurologic recovery with persistent patency of the PED construct. CONCLUSIONS: Mechanical thrombectomy with a stent retriever and aspiration is a therapeutic option for treatment of delayed thrombosis of a flow-diverting stent.


Assuntos
Isquemia Encefálica/etiologia , Aneurisma Intracraniano/cirurgia , Stents/efeitos adversos , Acidente Vascular Cerebral/etiologia , Trombectomia/métodos , Trombose/etiologia , Adulto , Isquemia Encefálica/cirurgia , Feminino , Humanos , Acidente Vascular Cerebral/cirurgia , Trombose/cirurgia , Resultado do Tratamento
3.
J Neurointerv Surg ; 7(4): 245-9, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24646693

RESUMO

OBJECTIVE: Intracranial atherosclerotic disease is the cause of up to 10% of ischemic strokes and transient ischemic attacks. Intracranial stenting with off-label balloon mounted coronary stents (BMCS) may be a viable alternative for patients with symptomatic intracranial stenosis who fail best medical therapy. DESIGN: Between December 2005 and June 2012, 42 symptomatic intracranial stenoses were treated with a BMCS after failing medical management. Procedural records, clinical outcomes, and imaging follow-up were reviewed. Outcome measurements included technical success rate, morbidity and mortality, long term stent patency, and clinical outcomes, as measured by the modified Rankin Scale. RESULTS: The technical success rate was 98% (41 of 42 lesions). Morbidity within the first 30 days was 7.1% (three of 42 lesions). Overall morbidity, including both periprocedural and long term evaluation, was 9.5% (four of 42 lesions). There were no deaths. Follow-up imaging was available for 30 stents (71%) with an average follow-up time of 35.1 months. Restenosis (>50%) and retreatment were observed in 20% and 10% of cases, respectively. Clinical evaluation by a neurologist ≥ 30 days postprocedure was available in 40 of 42 cases (95%) with an average of 32.1 months. At presentation, 55% of patients had a modified Rankin Scale (mRS) score of ≤ 2. At follow-up, 74% of patients were found to have an mRS score of ≤ 2. CONCLUSIONS: This study suggests that BMCS may benefit patients with symptomatic intracranial stenosis who experience stroke or transient ischemic attack in spite of best medical therapy.


Assuntos
Angioplastia com Balão/métodos , Arteriosclerose Intracraniana/diagnóstico por imagem , Arteriosclerose Intracraniana/cirurgia , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia com Balão/instrumentação , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Estudos Retrospectivos , Resultado do Tratamento
4.
J Clin Neurosci ; 21(3): 503-6, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24332812

RESUMO

Coil migration during endovascular treatment of intracranial aneurysms occurs in 2-6% of cases. As endovascular coiling of aneurysms has become increasingly popular and as endovascular technology continues to rapidly evolve, the prevalence of intraprocedural coil migration will invariably rise. Since coil masses are highly thrombogenic, migration out of the aneurysm sac into the parent artery may result in large territory infarcts which subsequently manifest as significant neurological morbidity. Therefore safe and timely retrieval of migrated coils is essential to avoiding poor angiographic and clinical outcomes. A 66-year-old woman with an unruptured 5 × 3mm, wide-necked posterior communicating artery aneurysm was referred for endovascular treatment. During coiling with the dual catheter technique, both initially deployed coils dislodged from the aneurysm sac and migrated distally into the middle cerebral artery. After failed retrieval with an Alligator device (Chestnut Medical Technologies, Menlo Park, CA, USA), we used two Trevo devices (Concentric Medical, Mountain View, CA, USA) in succession to successfully retrieve the migrated coils. The aneurysm was then occluded with stent-assisted coil embolization. There were no post-procedural angiographic or clinical complications. The patient was subsequently discharged home without neurological deficit. This case illustrates the first use of the Trevo device for retrieval of migrated coils during endovascular treatment of an intracranial aneurysm to our knowledge. Due to the lack of guidelines defining the standard management of intraprocedural coil migration, current strategies are based on retrospective review of published reports and expert opinion. We present a unique and effective method for endovascular retrieval of displaced coils using a Trevo Stentriever device.


Assuntos
Embolização Terapêutica/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Falha de Equipamento , Aneurisma Intracraniano/terapia , Idoso , Embolização Terapêutica/instrumentação , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Período Intraoperatório , Stents
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