scholarly journals Platelet Function Testing in Neurovascular Procedures: Tool or Gimmick?

2019 ◽  
Vol 8 (2-6) ◽  
pp. 123-134 ◽  
Author(s):  
Nicholas K. Cheung ◽  
Michael W. Carr ◽  
Udayan Ray ◽  
Duncan McKenzie ◽  
Jens J. Froelich
Keyword(s):  
Platelet Function ◽  
Platelet Inhibition ◽  
Thromboembolic Complication ◽  
Individual Variability ◽  
Neurological Deficits ◽  
Complication Rates ◽  
Platelet Inhibitors ◽  
Clinical Tool ◽  
Clopidogrel Resistance ◽  
Neurological Outcomes

Background: Platelet inhibitors are used to prevent thromboembolic complications related to neurovascular stenting (NVS) procedures. Despite substantial inter-individual variability of functional platelet inhibition, the value of platelet function tests (PFT) to assess inhibition remains controversial. Objective: This study was conducted to compare differences in thromboembolic complication rates associated with NVS in platelet-inhibited patients with and without PFT. Clinical neurological outcomes were assessed by differences in the modified Rankin Scale (mRS). Materials and Methods: One hundred seventeen consecutive patients underwent elective NVS procedures within a 7-year period. All patients received aspirin and clopidogrel 8 days before the procedure. Fifty-two patients were treated without assessment of platelet inhibition, and 65 patients were tested for clopidogrel resistance. When clopidogrel resistance was revealed, corresponding patients were converted to ticagrelor. Changes in mRS and thromboembolic event rates were compared between the 2 cohorts. Results: Thirty-five percent of patients from the cohort subjected to PFT tests showed inadequate platelet inhi­bition under clopidogrel and were converted to ticagrelor. Compared to the non-PFT test ­cohort, neurological deficits were significantly reduced (12 vs. 0%; p = 0.009) and a lower number of thromboembolic events was found (12 vs. 3%; p > 0.05) within the test cohort. Conclusion: PFT appears to identify patients with clopidogrel resistance prior to NVS procedures. When non-responders are converted to alternative platelet inhibitors, neurological outcomes and thromboembolic complication rates may improve. Consequently, this study provides preliminary evidence that PFT may be a useful clinical tool to enhance procedural safety and improve clinical outcomes in NVS procedures.

Clopidogrel Resistance and Aspirin Resistance - a Cause of Coronary Artery Stent Thrombosis?.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 4070-4070 ◽  
Author(s):  
Robert Klamroth ◽  
Stefan Hoffmann ◽  
Dietrich Andresen ◽  
Helmut Landgraf
Keyword(s):  
Coronary Artery ◽  
Platelet Aggregation ◽  
Stent Thrombosis ◽  
Platelet Function ◽  
Platelet Rich Plasma ◽  
Platelet Inhibition ◽  
Aspirin Resistance ◽  
Light Transmittance ◽  
Clopidogrel Resistance ◽  
Coronary Artery Stent

Abstract Background: Occlusions of coronary artery stents are a seldom but often fatal complication after coronary artery intervention. With aggressive platelet inhibition therapy (combination of Aspirin (ASS) and clopidogrel) a reduction of stent thrombosis to less than 2% was achieved. The inhibition of platelet function has great interindividual variability and resistance against ASS and/or clopidogrel were previously described. Therefore we studied the relation between coronary artery stent thrombosis and insufficient inhibition of platelet function in patients after coronary artery intervention. Methods: Between 2000 and 2003 we examined 20 patients (pts) with coronary artery stent thrombosis within 4 weeks after coronary artery intervention. All patients received a clopidogrel loading dose of 300mg followed by 75mg/die and ASS 100mg/die. Platelet inhibition was studied by light transmittance aggregometry in platelet rich plasma (Aggregometer PAP 4, moelab inc.). Aggregation was recorded as the maximum percentage change in light transmittance from baseline using platelet poor plasma as a reference. We defined ASS resistance as platelet aggregation > 30% after induction with 0,5mg/ml arachidonic acid and clopidogrel resistance as platelet aggregation > 30% after induction with 20 μmol ADP. We compared these pts with 20 pts without stent thrombosis within 4 weeks after coronary artery intervention. Results: In the group with coronary artery stent thrombosis we found 13/20 patients with insufficient platelet inhibition. 2/20 pts in this group were resistent against both ASS and clopidogrel. In 2/20 pts we observed ASS resistance and in 9/20 pts clopidgrel resistance. In the group of patients without stent thrombosis we found only 1/20 pt with ASS resistance and 1/20 pt with clopidogrel resistance. Conclusions: Insufficient platelet inhibition could be one cause of early stent thrombosis after coronory artery intervention. Platelet function testing is able to detect insufficient platelet inhibition and early testing could be an instrument to prevent coronary artery stent thrombosis.

Failure of platelet function analyser 200 to demonstrate clinical clopidogrel resistance in a patient undergoing intracranial vascular stenting

2020 ◽  
Vol 13 (3) ◽  
pp. e233947
Author(s):  
Hayden Bell ◽  
Brendan Steinfort ◽  
Leonardo Pasalic ◽  
Mark Dexter
Keyword(s):  
Platelet Function ◽  
Medication Compliance ◽  
Artery Aneurysm ◽  
Platelet Inhibition ◽  
High Rate ◽  
Anterior Communicating Artery ◽  
Stent Insertion ◽  
Left Middle Cerebral Artery ◽  
Clopidogrel Resistance ◽  
Impedance Aggregometry

A patient undergoes intracranial stent insertion for stent-assisted coiling of a basilar tip aneurysm and left middle cerebral artery aneurysm. A flow diverting stent is also placed across an anterior communicating artery aneurysm. Prior to the procedure, the patient takes dual antiplatelet medications, being aspirin and clopidogrel. Because of the concern regarding in-stent thrombus and thromboembolic complications related to intracranial stenting and the high rate of clopidogrel resistance, preoperative platelet function testing (PFT) was undertaken to ensure platelet inhibition. In this case, PFT was performed on a platelet function analyser which demonstrated platelet inhibition. Ten days following the procedure, the patient represented with thromboembolic stroke. Repeat PFT performed with whole blood impedance aggregometry and despite full medication compliance demonstrated clopidogrel resistance. Clopidogrel was then ceased and prasugrel commenced. This case demonstrates the importance of appropriate platelet inhibition in patients with intracranial stents and the controversy surrounding PFT.

Platelet function testing to time surgery in patients on dual antiplatelet therapy?

2014 ◽  
Vol 34 (01) ◽  
pp. 40-45 ◽  
Author(s):  
R. Raggam ◽  
W. Toller ◽  
E. Mahla
Keyword(s):  
Platelet Function ◽  
Large Scale ◽  
Current Knowledge ◽  
Function Analysis ◽  
Platelet Reactivity ◽  
Platelet Inhibition ◽  
Individual Variability ◽  
P2y12 Receptor ◽  
European Society Of Cardiology

SummaryIn patients pretreated with P2Y12 receptor inhibitors who need to undergo non-emergent cardiac or major non-cardiac surgery, current guidelines of the European Society of Cardiology recommend postponing surgery for at least five days after last intake of clopidogrel or ticagrelor, and for seven days after last intake of prasugrel, unless there is high risk of ischemic events. However, a fixed five to seven days preoperative waiting period may be challenged, in the presence of inter-individual variability in on-treatment platelet reactivity. Therefore, Society of Thoracic Surgeons guidelines suggest to base decisions about a surgical delay on platelet function although both, the optimal platelet function assay and a bleeding cutoff have not yet been defined by large scale multicenter trials. This review aims to provide an overview on current knowledge of P2Y12 receptor induced platelet inhibition and surgery related bleeding and the potential role of platelet function analysis to time surgery.

The impact of surgeon experience on perioperative complications and operative measures following thoracolumbar 3-column osteotomy for adult spinal deformity: overcoming the learning curve

2020 ◽  
Vol 32 (2) ◽  
pp. 207-220 ◽  
Author(s):  
Darryl Lau ◽  
Vedat Deviren ◽  
Christopher P. Ames
Keyword(s):  
Blood Loss ◽  
Operative Time ◽  
Surgical Complication ◽  
Perioperative Complications ◽  
Adult Spinal Deformity ◽  
Neurological Deficits ◽  
Complication Rates ◽  
Years Of Experience ◽  
Surgeon Experience ◽  
Operative Measures

OBJECTIVEPosterior-based thoracolumbar 3-column osteotomy (3CO) is a formidable surgical procedure. Surgeon experience and case volume are known factors that influence surgical complication rates, but these factors have not been studied well in cases of adult spinal deformity (ASD). This study examines how surgeon experience affects perioperative complications and operative measures following thoracolumbar 3CO in ASD.METHODSA retrospective study was performed of a consecutive cohort of thoracolumbar ASD patients who underwent 3CO performed by the senior authors from 2006 to 2018. Multivariate analysis was used to assess whether experience (years of experience and/or number of procedures) is associated with perioperative complications, operative duration, and blood loss.RESULTSA total of 362 patients underwent 66 vertebral column resections (VCRs) and 296 pedicle subtraction osteotomies (PSOs). The overall complication rate was 29.4%, and the surgical complication rate was 8.0%. The rate of postoperative neurological deficits was 6.2%. There was a trend toward lower overall complication rates with greater operative years of experience (from 44.4% to 28.0%) (p = 0.115). Years of operative experience was associated with a significantly lower rate of neurological deficits (p = 0.027); the incidence dropped from 22.2% to 4.0%. The mean operative time was 310.7 minutes overall. Both increased years of experience and higher case numbers were significantly associated with shorter operative times (p < 0.001 and p = 0.001, respectively). Only operative years of experience was independently associated with operative times (p < 0.001): 358.3 minutes from 2006 to 2008 to 275.5 minutes in 2018 (82.8 minutes shorter). Over time, there was less deviation and more consistency in operative times, despite the implementation of various interventions to promote fusion and prevent construct failure: utilization of multiple-rod constructs (standard, satellite, and nested rods), bone morphogenetic protein, vertebroplasty, and ligament augmentation. Of note, the use of tranexamic acid did not significantly lower blood loss.CONCLUSIONSSurgeon years of experience, rather than number of 3COs performed, was a significant factor in mitigating neurological complications and improving quality measures following thoracolumbar 3CO for ASD. The 3- to 5-year experience mark was when the senior surgeon overcame a learning curve and was able to minimize neurological complication rates. There was a continuous decrease in operative time as the surgeon’s experience increased; this was in concurrence with the implementation of additional preventative surgical interventions. Ongoing practice changes should be implemented and can be done safely, but it is imperative to self-assess the risks and benefits of those practice changes.

scholarly journals Perinatal neuroprotection update

F1000Research ◽  
2016 ◽  
Vol 5 ◽  
pp. 1939 ◽  
Author(s):  
Angie C. Jelin ◽  
Kirsten Salmeen ◽  
Dawn Gano ◽  
Irina Burd ◽  
Mari-Paule Thiet
Keyword(s):  
Preterm Delivery ◽  
Significant Risk ◽  
Autism Spectrum ◽  
Neurological Deficits ◽  
Delayed Cord Clamping ◽  
Neurological Outcomes ◽  
Cord Clamping ◽  
Cognitive Delay ◽  
Neurological Risk

Antepartum, intrapartum, and neonatal events can result in a spectrum of long-term neurological sequelae, including cerebral palsy, cognitive delay, schizophrenia, and autism spectrum disorders [1]. Advances in obstetrical and neonatal care have led to survival at earlier gestational ages and consequently increasing numbers of periviable infants who are at significant risk for long-term neurological deficits. Therefore, efforts to decrease and prevent cerebral insults attempt not only to decrease preterm delivery but also to improve neurological outcomes in infants delivered preterm. We recently published a comprehensive review addressing the impacts of magnesium sulfate, therapeutic hypothermia, delayed cord clamping, infections, and prevention of preterm delivery on the modification of neurological risk [2]. In this review, we will briefly provide updates to the aforementioned topics as well as an expansion on avoidance of toxin and infections, specifically the Zika virus.

scholarly journals Predictors of Survival in Atypical Meningiomas

Cancers ◽  
2021 ◽  
Vol 13 (8) ◽  
pp. 1970
Author(s):  
Michele Da Broi ◽  
Paola Borrelli ◽  
Torstein R. Meling
Keyword(s):  
Neurological Outcome ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
University Hospital ◽  
Neurological Deficits ◽  
Karnofsky Performance Scale ◽  
Free Survival ◽  
Neurological Outcomes ◽  
Progression Of Disease ◽  
Atypical Meningiomas

Introduction: Predictors of survival and progression of disease in atypical meningiomas are less well documented in the literature compared to benign meningiomas. Higher grade meningiomas tend to recur often and one of the most critical aspects is how to best deal with relapses. Methods: A total of 77 consecutive patients who underwent craniotomy for atypical meningioma between 1990–2010 at Oslo University Hospital (OUH) were reviewed. Results: Median age at surgery was 62.21 [interquartile range (IQR): 22.87] years. Fifty-one patients (66.2%) had neurological deficits at presentation. Fifty-four patients (70.1%) underwent gross total resection (GTR). Thirty-nine patients (50.7%) had improved/stable neurological outcomes at 6–12 months. Twenty-two patients (28.6%) underwent retreatment, of whom 20 (26.0%) were subjected to resection followed by adjuvant radiotherapy. Overall survival (OS) was significantly longer in patients <65 years (p < 0.001), with preoperative Karnofsky performance scale (KPS) score of ≥ 70 (p = 0.006), and who required no retreatment (p = 0.033). GTR significantly prolonged the retreatment-free survival rate (p < 0.001). STR carried almost a six-fold greater risk of neurological outcome deterioration (p = 0.044). Conclusions: GTR significantly prolonged retreatment-free survival but had no significant impact on OS. STR was a significant risk factor for deteriorated neurological outcome. Age, preoperative KPS, and retreatment were all strong predictors of OS. Median time-to-retreatment (TTR) did not shorten significantly throughout repeated surgeries.

Abstract 4917: Clopidogrel Resistance and Coronary Artery Plaque Burden in Patients Undergoing Percutaneous Coronary Intervention

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Amala Chirumamilla ◽  
Akiko Maehara ◽  
Gary S Mintz ◽  
Roxana Mehran ◽  
Adriano Caixeta ◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Coronary Intervention ◽  
Platelet Inhibition ◽  
Smoking History ◽  
Plaque Burden ◽  
Process Data ◽  
Clopidogrel Resistance ◽  
Reference Segment ◽  
Percutaneous Coronary ◽  
Verify Now

Background: Clopidogrel anti-inflammatory effect and plaque burden are important factors for atherothrombotic process. Data are lacking on relationship of plaque burden and clopidogrel resistance in patients undergoing percutaneous coronary intervention (PCI) Methods: We identified 138 patients who had intravascular ultrasound during PCI between Jan 2007 to June 2007. Using the Verify Now Point-of-care assay, P2Y12 platelet reaction units (PRU) and percent inhibition of platelet activation (IPA) were measured 16 –24 hours after the loading dose of clopidogrel (600mg for patients not on clopidogrel daily, and 300mg for patients on clopidogrel 75mg daily) but before the next day of clopidogrel dose. CR was defined as PRU >200 or as IPA<10% or <20%. Results: Mean age of patients was 66±11 years and 74% were males. PRU>200 was found in 53 patients (38.4%) and PRU ≤200 in 85 patients (61.6%). Presence of myocardial infarction, hyperlipidemia, renal disease, smoking history, stable or unstable angina at admission were similar between the PRU groups and between IPA groups. Hypertension, diabetes, older age and reference site plaque burden were higher in clopidogrel resistance (Table ). With use of alternative definitions, reference segment plaque burden was also higher in clopidogrel resistance patients: 0.50±0.12 vs 0.41±0.13 in <10% vs ≥10% platelet inhibition (p=0.05), and 0.49±0.12 vs 0.41±0.13 in <20% vs ≥20% platelet inhibition (p=0.03) Conclusion: Clopidogrel resistance patients have more high risk baseline characteristics and higher plaque burden at the reference vessel segment, implying diffuse intracoronary atherosclerosis compared to clopidogrel sensitive patients who underwent PCI

Abstract WP304: Prothrombin Complex Concentrate Rapidly Reverses Coagulopathy but does not Alter Mortality in Warfarin Intracerebral Hemorrhage

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Xuemei Cai ◽  
Susannah Orzell ◽  
Sarah Suh ◽  
Linda Bresette ◽  
Farzaneh Sorond ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Vitamin K ◽  
Conventional Therapy ◽  
Prothrombin Complex Concentrate ◽  
International Normalized Ratio ◽  
Fresh Frozen Plasma ◽  
Thromboembolic Complication ◽  
Complication Rates ◽  
Significant Difference ◽  
Fresh Frozen

INTRODUCTION: Warfarin-associated intracerebral hemorrhage (wICH) remains the most lethal form of iatrogenic stroke. Conventional therapy with fresh frozen plasma (FFP) and intravenous vitamin K takes up to 30 hrs to normalize the international normalized ratio (INR). Prothrombin complex concentrate (PCC) does not require cross-match and is fast acting. We hypothesized that PCC can rapidly reverse coagulopathy and reduce mortality in wICH. Methods: We identified 130 consecutive adult wICH patients over five years from a prospectively collected database. 33 patients were excluded for death or withdrawal of care within 48 hours of admission and 8 patients were excluded for antecedent head trauma, leaving 89 patients for analysis. Forty patients received FFP and vitamin K (conventional therapy) and 49 received PCC in addition to conventional therapy. We compared 6-month mortality, time to INR normalization, quantity of FFP transfused, and thromboembolic complication rates between the two groups. We used logistic regression to adjust for important confounders. Results: PCC-treated and conventional therapy patients had similar distributions of age, sex, co-morbidities, ICH location, initial blood pressure and INR. PCC-treated patients had a higher incidence of intraventicular hemorrhage (IVH) (67% vs 33%). PCC-treated patients required less FFP (mean 6.8 units vs 3.3 units, p<0.0001) and had faster time to INR normalization (mean 3.8 hrs vs 9.8 hrs, p<0.0001). Incidence of ICH expansion was low in both groups. There was no difference in the incidence of deep venous thrombosis and pulmonary embolism (p=0.236) or troponin elevation (p=0.573). There was no significant difference in 6-month mortality (p=0.437) after adjusting for age, ICH location, ICH volume, and presence of IVH. Conclusions: PCC use in wICH was associated with shorter time to INR normalization and reduced FFP transfusion but was not associated with 6-month mortality in this cohort. There was no difference in thromboembolic complication rates between PCC-treated and FFP and vitamin K treated patients. Prospective trials of PCC are necessary to determine if its use can improve morbidity and mortality in wICH and to identify potential subgroups of wICH patients who may benefit from PCC.

Lack of outcome benefit and clopidogrel “resistance”

2010 ◽  
Vol 103 (02) ◽  
pp. 415-418 ◽  
Author(s):  
Victor Serebruany
Keyword(s):  
Case Reports ◽  
Antiplatelet Agent ◽  
Platelet Inhibition ◽  
Cardiovascular Death ◽  
Clopidogrel Resistance ◽  
Mortality Risks ◽  
Vascular Outcome ◽  
Coronary Syndromes ◽  
Fatal Myocardial Infarction

SummaryImpaired response to clopidogrel, or “resistance” is a cornerstone concept for justification of more aggressive antiplatelet regimens, and development of new more potent drugs. There are over 1,000 citations (although predominantly reviews, or case reports) in MEDLINE related to clopidogrel “resistance”, while about 100 of them attempted to link low response to adverse clinical outcomes. However, most of these studies are woefully small, and not randomised. The TRITON trial assessed head-to-head novel antiplatelet agent prasugrel versus clopidogrel in patients with acute coronary syndromes. This study was the first in a decade to challenge clopidogrel monopoly, and to indirectly test the “resistance” hypothesis. The primary endpoint was the rate of cardiovascular death, non-fatal myocardial infarction, or stroke, and occurred in 12.1% of patients treated with clopidogrel, and 9.9% of patients randomised to prasugrel, suggesting impressive vascular outcome benefit of prasugrel over clopidogrel. However, the Food and Drug Administration (FDA) presented more balanced, and realistic outlook on TRITON. While very early periprocedural benefit exists, long-term prasugrel therapy yielded identical to clopidogrel vascular outcomes among 13,608 TRITON patients challenging the postulate that clopidogrel “resistance” phenomenon is clinically relevant. Despite the fact that prasugrel 10 mg/daily cause 2.5 times more potent platelet inhibition than conventional clopidogrel 75 mg/daily, with fewer patients exhibiting broad response variability, and/or antiplatelet “resistance”, the vascular benefit beyond acute phase was identical. Keeping in mind growing over time bleeding, cancer, and mortality risks associated with chronic prasugrel use, small observational studies should be judged with skepticism as hypothesis-generating, pending confirmation in randomised trials.

scholarly journals Dual microcatheter technique for the treatment of a ruptured wide neck basilar tip aneurysm

2019 ◽  
pp. 116-121
Author(s):  
Rares Filep ◽  
Dorin Nicolae Gherasim ◽  
Septimiu Popescu ◽  
Botond Tokes ◽  
Lucian Marginean
Keyword(s):  
Intracranial Aneurysms ◽  
Therapeutic Option ◽  
Intraventricular Haemorrhage ◽  
Acute Onset ◽  
Alternative Methods ◽  
Neurological Deficits ◽  
Complication Rates ◽  
Unruptured Intracranial Aneurysms ◽  
Basilar Tip Aneurysm ◽  
Wide Neck

Endovascular treatment is a safe and efficient therapy for intracranial aneurysms with lower complication and mortality rates compared to surgical clipping. Wide-neck aneurysms still represent a challenge to complete and safe aneurysm occlusion in spite of techniques such as stent-assisted or balloon-assisted coiling, developed in order to achieve better occlusion rates. These techniques themselves may lead to further complications, so alternative methods such as the dual microcatheter technique were developed. This technique assumes that, via two microcatheters inserted into an aneurysm, simultaneous deployment of two coils achieves a stable coil frame without the use of adjunctive devices. The aim of this paper is to present a successfully treated basilar tip wide-neck aneurysm treated with the dual microcatheter technique.Case report. A 46-year-old male patient with acute onset of severe headache presented in the emergency room with altered state of consciousness. Non-enhanced CT scan showed subarachnoid and intraventricular haemorrhage. CT angiography revealed a wide-neck basilar tip aneurysm. Digital subtraction angiography confirmed the presence of an aneurysm with a wide, 4.9 mm neck.Dual microcatheter technique was chosen as the first treatment option, while a hypercompliant balloon was kept as backup. Two microcatheters were placed inside de aneurysm and two coils were introduced in order to form a stable framing coil mass that served as a support for further coils deployed in an alternately manner through each microcatheter. No procedural complication occurred, and the patient’s evolution was uneventful with no neurological deficits at discharge.Conclusion. The dual microcatheter technique is a safe and effective therapeutic option for wide-neck ruptured or unruptured intracranial aneurysms. Periprocedural complication rates are similar to simple coiling or balloon-assisted coiling, but lower than for stent-assisted coiling.

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