Registry Report on Kinetics of Rescue Antiplatelet Treatment to Abolish Cerebral Microemboli After Carotid Endarterectomy

Abstract

Background and Purpose— Cerebral microemboli signals (MES) are associated with increased risk of acute stroke syndromes. We compared the effects on cerebral microemboli after carotid endarterectomy of tirofiban with dextran-40. Methods— We used transcranial Doppler ultrasound to study transient MES acutely after carotid endarterectomy between August 2000 and December 2010 in 128 subjects refractory to preoperative antiplatelet treatment. Antithrombotic treatment was given for MES ≥50 hour −1 (tirofiban: 40 patients [age 74 ± 1 {SEM}, males 27, and white 38]; dextran-40: 34 patients [age 69 ± 2, males 22, white 30]). In 54 patients with MES <50 hour −1 (age 71 ± 1, male 36, white 52), MES were monitored during their spontaneous resolution (controls). Data are median (interquartile range). Results— The time to 50% reduction in MES (tirofiban 23 minutes [15–28]; dextran-56 [43–83]; controls 30 [22–38]; P <0.001, Kruskal-Wallis analysis) and for complete MES resolution (tirofiban 68 minutes [53–94]; dextran-113 [79–146]; controls 53 [49–68]; P <0.001, Kruskal-Wallis analysis) were shorter with tirofiban. The early cardiovascular event rate was similar with tirofiban compared with controls but increased in patients who received dextran. Conclusions— These findings suggest that transcranial Doppler-directed tirofiban therapy is more effective than dextran-40 in suppression of cerebral microemboli after carotid endarterectomy.

Prospective validation study of transorbital Doppler ultrasound imaging for the detection of transient cerebral microemboli

“…In acute symptomatic carotid disease, the presence of microemboli, rather than the rate or number of microemboli, has been associated with recurrent stroke following TIA or non‐disabling stroke. In contrast, acutely following CEA, a sustained high rate of microemboli has been associated with an increased risk of thrombotic stroke; antiplatelet treatment may be initiated to suppress these microemboli.…”

“…The diagnostic accuracy parameters of TOD in comparison with TCD were reported based on the STAndards for the Reporting of Diagnostic accuracy studies (STARD) statement recommendations. For this experimental study, false positive was defined as cerebral microemboli detected by means of TOD only, as TCD remains the standard imaging modality for identification of microemboli and monitoring antiplatelet treatment. During this study, the decision to treat cerebral microemboli acutely after CEA was based on the findings of TCD alone, as TOD is not a validated method.…”

Reply

“…These authors found TCD-directed infusion of the glycoprotein IIb/IIIa antagonist tirofiban was more effective than dextran in reducing transient cerebral microemboli before and after CEA. 5 Their conclusions suggest a potential role of TCDdirected tirofiban infusion during CEA. Although these findings are provocative, widespread use of tirofiban cannot be recommended from on these data alone.…”

“…We therefore attempted to use a more selective TCDdirected intravenous antiplatelet agent, a glycoprotein IIb/IIIa receptor antagonist (tirofiban), to control transient cerebral microemboli both before and after CEA. 5 In view of our previous experience of the effectiveness and tolerability of the intravenous glycoprotein IIb/IIIa antagonist antiplatelet agent (tirofiban), 5 we have recently compared the efficacy of dextran with tirofiban and found that TCD-directed tirofiban therapy appears more effective than dextran-40 in suppression of cerebral microemboli after CEA, with a lower side effect profile 6 (Fig).…”

Reply

“…28); B, patients (n ¼ 4) who developed early stroke, despite dextran-40 infusion; -, tirofiban (n ¼ 32); :, no additional antiplatelet treatment (n ¼ 36). 6 Reproduced with permission from Saedon et al 6 …”