During the past decade we have seen a treatment paradigm shift in MCA aneurysm treatment from surgical treatment to endovascular treatment. Developments in 3D angiography, more compliant balloons, dedicated aneurysm stents, complex coils, and antiplatelet therapy regimes have led to this transition for safe and effective management of these patients.
Introduction
Contemporary studies of intracranial stenting have utilised standard or aggressive medical therapy involving dual anti-platelet therapy, but have not evaluated anti-platelet therapy resistance as a component of treatment failure.
Methods
The current study evaluates a prospective aggressive anti-platelet therapy management approach at two institutions in a consecutive series of 154 patients with symptomatic intracranial atherosclerotic disease (ICAD) treated with angioplasty and stenting with the Wingspan self-expanding nitinol stent. Anti-platelet medication therapeutic effects of aspirin and clopidogrel were measured prior to the procedures by platelet function assay, thromboelastography, aggregometry, or Accumetrics VerifyNow systems. Medications were adjusted or changed for subtherapeutic or supratherapeutic values with clopidogrel goal inhibition of 20–80% and aspirin reactive unit (ARU) less than 550.
Results
A total of 154 patients with symptomatic ICAD were treated from 2005 to 2014. The periprocedural complication rate was 3.9% (6/154) with 1 subarachnoid haemorrhage, 0 intraparenchymal haemorrhages, 5 perforator strokes, and no stent thrombosis. With a mean follow up of 2.3 years, the total ipsilateral stroke and death rate was 6.5% (10/154). The relative aspirin resistance rate was 7.8% and the relative clopidogrel resistance rate was 14.9% in this series. Eight of the patients (5.2%) required repeat angioplasty for symptomatic re-stenosis within the first year. The mean time to treatment was 10.7 days following the last stroke.
Conclusions
With aggressive monitoring and management of anti-platelet medications, intracranial stenting complications of stent thrombosis and distal emboli can be reduced, although there is still a significant risk of perforator strokes, particularly in the middle cerebral artery and basilar distributions.
Disclosures
M. Alexander: 1; C; Stryker Neurovascular. M. Nuno: None. J. Alexander: None. C. Agutos: None. W. Yu: 1; C; Stryker Neurovascular.
Introduction:
The majority of peri-procedural ischemic strokes in the SAMMPRIS trial were perforator strokes. Contemporary studies of intracranial stenting have not evaluated the proximity of atherosclerotic target lesions to major perforators.
Methods:
The current study evaluates a prospective aggressive anti-platelet therapy management approach at two institutions in a consecutive series of 158 patients with symptomatic intracranial atherosclerotic disease (ICAD) treated with angioplasty and stenting with self-expanding nitinol stents. Peri-procedural strokes were analyzed with respect to proximity of the target lesion to angiographically seen perforators and grouped as target lesion either within 2 mm, or greater than 2 mm from visible perforators.
Results:
A total of 158 patients with symptomatic ICAD were treated from 2005 to 2014. The periprocedural complication rate was 3.8% (6/158) with 1 subarachnoid hemorrhage, 0 intraparenchymal hemorrhages, 5 perforator strokes, and no stent thrombosis. With a mean follow up of 2.3 years, the total ipsilateral stroke and death rate was 6.3% (10/154). Of the 158 patients, 61 (38.6%) arteries were stented in the Middle Cerebral Artery or Basilar Artery. Twenty one of the target lesions were within 2 mm of visible perforators, and there were 4 perforator strokes (19%) in this subgroup. Forty of the target lesions were greater than 2 mm of visible perforators with one perforator stroke (2.5%) in this group. There was an approximately sevenfold higher risk of stroke with lesions within 2 mm of perforators compared to lesions greater than 2 mm in the same arteries. This was statistically significant (Fisher’s exact test, p = 0.0437).
Conclusions:
With aggressive monitoring and management of anti-platelet medications, intracranial stenting complications of stent thrombosis and distal emboli can be reduced, although there is still a significant risk of perforator strokes, particularly in the middle cerebral artery and basilar distributions. Target lesions within 2 mm of angiographically visualized perforators had a sevenfold higher risk for periprocedural stroke (p = 0.0437) than other lesions in the same arteries.
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