J Scholz

Pre-procedure P2Y12 reaction units value predicts perioperative thromboembolic and hemorrhagic complications in patients with cerebral aneurysms treated with the Pipeline Embolization Device

Background There is wide variability in the reported incidence of perioperative thromboembolic (0–14%) and hemorrhagic (0–11%) complications after Pipeline Embolization Device (PED) procedures for cerebral aneurysm treatment, which could be partly due to differences in patient response to the P2Y12 receptor antagonist administered while the PED endothelializes. This study aims to identify an optimal pre-procedure P2Y12 reaction units (PRU) value range and determine the independent predictors of perioperative thromboembolic and hemorrhagic complications after PED procedures. Methods We recorded patient and aneurysm characteristics, P2Y12 receptor antagonist administered, pre-procedure PRU value with VerifyNow, procedural variables and perioperative thromboembolic and hemorrhagic complications up to postoperative day 30 after PED procedures at our institution during an 8-month period. Perioperative complications were considered major if they caused a permanent disabling neurological deficit or death. Multivariate regression analysis was performed to identify independent predictors of perioperative complications in our cohort. Results Forty-four patients underwent 48 PED procedures at our institution during the study period. There were eight thromboembolic and hemorrhagic perioperative complications in our cohort (16.7%), four of which were major (8.3%). A pre-procedure PRU value of <60 or >240 (p=0.02) and a technically difficult procedure (p=0.04) were independent predictors of all perioperative complications. A pre-procedure PRU value of <60 or >240 (p=0.004) and a history of hypertension (p=0.03) were independent predictors of major perioperative complications. Conclusions In our cohort, a pre-procedure PRU value of <60 or >240 was the strongest independent predictor of all and major perioperative thromboembolic and hemorrhagic complications after PED procedures.

Last-Recorded P2Y12 Reaction Units Value Is Strongly Associated with Thromboembolic and Hemorrhagic Complications Occurring Up to 6 Months after Treatment in Patients with Cerebral Aneurysms Treated with the Pipeline Embolization Device

BACKGROUND AND PURPOSE: A recent study identified a preprocedural P2Y12 reaction units value of <60 or >240 as a strong independent predictor of perioperative thromboembolic and hemorrhagic complications after treatment of cerebral aneurysms with the Pipeline Embolization Device. This study aimed to determine whether a last-recorded P2Y12 reaction units value of <60 or >240 predicts thromboembolic and hemorrhagic complications up to 6 months after treatment of cerebral aneurysms with the Pipeline Embolization Device in the same patient cohort. MATERIALS AND METHODS: We recorded patient and aneurysm characteristics, P2Y12 receptor antagonist administered, P2Y12 reaction units value with VerifyNow, procedural variables, and thromboembolic and hemorrhagic complications up to 6 months after Pipeline Embolization Device procedures at our institution during an 8-month period. Complications causing a permanent disabling neurologic deficit or death were considered major. Multivariate regression analysis was performed to identify independent predictors of thromboembolic and hemorrhagic complications. RESULTS: Forty-four patients underwent 48 Pipeline Embolization Device procedures at our institution during the study period. There were 11 thromboembolic and hemorrhagic complications up to 6 months after treatment in our cohort (22.9%), 5 of which were major (10.4%). A last-recorded P2Y12 reaction units value of <60 or >240 was the only independent predictor of all (P = .002) and major (P = .03) thromboembolic and hemorrhagic complications in our cohort. Most patients (71%) required, on average, 2 adjustments to the dose or type of P2Y12 receptor antagonist to remain within the 60–240 target P2Y12 reaction units range. CONCLUSIONS: In our cohort, a last-recorded P2Y12 reaction units value of <60 or >240 was the only independent predictor of all and major thromboembolic and hemorrhagic complications up to 6 months after Pipeline Embolization Device procedures.

Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques

Purpose To compare rates of symptomatic intracranial hemorrhage (SICH) and good clinical outcome at 90 days in patients with ischemic strokes from anterior circulation emergent large vessel occlusions (ELVO) treated with mechanical thrombectomy using either Solumbra or A Direct Aspiration first-Pass Thrombectomy (ADAPT) techniques. Methods We compared clinical characteristics, procedural variables, and clinical outcomes in patients with anterior circulation ELVOs treated with mechanical thrombectomy using either a Solumbra or ADAPT technique at our institution over a 38-month period. SICH was defined using the SITS-MOST criteria. A good clinical outcome was defined as a modified Rankin Scale score of 0–2 at 90 days. Results One hundred patients were included, 55 in the Solumbra group and 45 in the ADAPT group. Patients in the ADAPT group had higher National Institutes of Health Stroke Scale (NIHSS) (19.2 vs 16.8, p=0.02) and a higher proportion of internal carotid artery terminus thrombi (42.2% vs 20%, p=0.03) than patients in the Solumbra group. Patients in the ADAPT group had a trend toward a lower rate of SICH than patients in the Solumbra group (2.2% vs 12.7%, p=0.07). Patients in the ADAPT group had a significantly higher rate of good clinical outcome at 90 days than patients in the Solumbra group (55.6% vs 30.9%, p=0.015). Use of the ADAPT technique (OR 6 (95% CI 1.0 to 31.2), p=0.049) was an independent predictor of a good clinical outcome at 90 days in our cohort. Conclusions In our cohort, the ADAPT technique was associated with significantly higher good clinical outcomes at 90 days in patients with acute ischemic stroke due to anterior circulation ELVOs treated with mechanical thrombectomy.

Variability in initial response to standard clopidogrel therapy, delayed conversion to clopidogrel hyper-response, and associated thromboembolic and hemorrhagic complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms

Background and purpose Variability in response to clopidogrel therapy is increasingly being recognized as an important factor in thromboembolic and hemorrhagic complications encountered after neurointerventional procedures. This study aims to determine the variability in response to clopidogrel therapy and associated complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms. Methods We recorded baseline patient characteristics, co-administered medications, P2Y12 reaction units (PRU) values with VerifyNow, clopidogrel dosing, and thromboembolic and hemorrhagic complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms at our institution during a 19 month period. Results 100 patients were included in the study, 76 women and 24 men, mean age 57.3 years. 15 patients exhibited an initial clopidogrel hypo-response (PRU >240) and 21 patients an initial clopidogrel hyper-response (PRU <60). 36 patients had a follow-up VerifyNow test performed without changes to the standard 75 mg daily clopidogrel dose, which demonstrated that 59% of patients who had initially been within the target 60–240 PRU range exhibited a delayed conversion to clopidogrel hyper-response. In our cohort, a clopidogrel hypo-response was associated with a significantly increased risk of thromboembolic complications in patients undergoing cerebral aneurysm treatment with stent assistance or the pipeline embolization device (60%, p=0.003), while a clopidogrel hyper-response was associated with a significantly increased risk of major hemorrhagic complications in all patients undergoing endovascular treatment of cerebral aneurysms (11%, p=0.016). Conclusions We found wide and dynamic variability in response to clopidogrel therapy in patients undergoing endovascular treatment of unruptured cerebral aneurysms, which was significantly associated with thromboembolic and major hemorrhagic complications in our cohort.

Diagnostic Yield of Catheter Angiography in Patients with Subarachnoid Hemorrhage and Negative Initial Noninvasive Neurovascular Examinations

These authors explored the diagnostic yield of DSA in patients with SAH and previously negative CTA or MRA. A total of 55 patients who presented with diffuse SAH, perimesencephalic SAH, or sulcal SAH received CTA (n= 47) or MRA (n= 8). Despite normal findings on CTA or MRA, DSA showed vascular lesions in 11% of patients with diffuse SAH and in 1 patient with sulcal SAH. The investigators concluded that DSA is a valuable tool in patients with diffuse or sulcal SAH in whom previous noninvasive examinations are negative. BACKGROUND AND PURPOSE: The yield of DSA in patients with SAH and negative initial noninvasive neurovascular examinations (CTA or MRA) is not well-understood. This study aimed to determine the yield of DSA for the detection of causative vascular lesions in this clinical scenario. MATERIALS AND METHODS: We examined the yield of DSA for the detection of causative vascular lesions in a cohort of patients presenting to our institution with SAH and negative initial noninvasive neurovascular examinations during a 5-year period. Two experienced neuroradiologists independently evaluated the NCCT to determine the SAH pattern (diffuse, perimesencephalic, or peripheral sulcal) and the catheter angiograms to assess the presence of a causative vascular lesion. RESULTS: Fifty-five patients were included in the study, with a mean age of 58.2 years (median, 58 years; range, 25–88 years). Twenty-eight patients were men (50.9%), and 27 were women (49.1%). The initial noninvasive examination was a CTA in 47 patients (85.5%) and an MRA in 8 patients (14.5%). Thirty-three patients had diffuse SAH (60%); 11, perimesencephalic SAH (20%); and 11, peripheral sulcal SAH (20%). DSA demonstrated a causative vascular lesion in 6 patients (10.9%), 5 of whom had diffuse SAH (yield of 15.2%) and 1 of whom had peripheral sulcal SAH (yield of 9.1%). No causative vascular lesions were found in patients with perimesencephalic SAH. CONCLUSIONS: DSA is a valuable tool in the evaluation of patients with diffuse and peripheral sulcal SAH who have negative initial noninvasive neurovascular examinations, demonstrating a causative vascular lesion in 15.2% and 9.1% of patients, respectively.

Endovascular treatment of 346 middle cerebral artery aneurysms: results of a 16-year single-center experience.

BACKGROUND The endovascular treatment of middle cerebral artery (MCA) aneurysms has been controversial because of the frequency of complex anatomy and the relative ease of surgical clipping in this location. OBJECTIVE To present a large single-center experience with the endovascular treatment of MCA aneurysms. METHODS The neurointerventional database at our institution was reviewed for all endovascular treatments of MCA aneurysms. Demographics, aneurysm characteristics, treatment modality, intraprocedural hemorrhagic and thromboembolic events, 30-day neurological events, and follow-up angiographic studies were recorded. RESULTS From December 1996 to April 2013, 292 patients underwent endovascular treatment of 346 MCA aneurysms. Of these, 341 (98.6%) were successfully completed. Balloon neck remodeling was used in 230 procedures (66.5%). Ninety-five procedures (27.4%) were for ruptured aneurysms. The rate of intraprocedural hemorrhage was 2.6% (9 of 346). The overall rate of intraprocedural thromboembolic events was 13.6% (47 of 346), significantly more common in patients with acute subarachnoid hemorrhage (27.4%; P < .001). The 30-day major (modified Rankin Scale score > 2) neurological event rate was 2.9% (10 of 346), significantly more common in patients with subarachnoid hemorrhage (8.4%) compared with those without (0.8%; P < .001). The rate of complete or near-complete aneurysm occlusion at was 90.6% ≥ 6 months and 91.8% at ≥ 2 years, with an average of 24 months of follow-up available for 247 procedures. CONCLUSION Endovascular treatment of MCA aneurysms can be safe and effective. However, it is associated with a high asymptomatic thromboembolic event rate that is more frequent in the setting of acute subarachnoid hemorrhage.

Diagnostic yield of delayed neurovascular imaging in patients with subarachnoid hemorrhage, negative initial CT and catheter angiograms, and a negative 7 day repeat catheter angiogram

Purpose The yield of delayed neurovascular imaging in patients with subarachnoid hemorrhage (SAH), negative initial CT and catheter angiograms (CT angiography (CTA), DSA), and negative 7 day repeat DSA is not well understood. Our aim was to determine the yield of delayed neurovascular imaging for the detection of causative vascular lesions in this clinical scenario. Methods We retrospectively examined the yield of delayed CTA and DSA for the detection of causative vascular lesions in patients presenting to our institution with SAH, negative initial CTA and DSA examinations, and a negative 7 day repeat DSA during a 6.5 year period. Two neuroradiologists evaluated the non-contrast CTs to determine the SAH pattern, and the delayed CTAs and DSAs to assess for the presence of a causative vascular lesion. Results 39 patients were included: 23 men (59%) and 16 women (41%), mean age 55.5 years (range 33–75). 25 patients had diffuse SAH (64.1%), 12 had perimesencephalic SAH (30.8%), and two had peripheral sulcal SAH (5.1%). The delayed neurovascular examination was CTA in 30 patients (76.9%) and DSA in nine patients (23.1%). Mean time to delayed CTA or DSA was 34.9 days (median 34, range 14–69 days). Delayed CTA demonstrated a causative vascular lesion in two patients (5.1%, one small internal carotid artery aneurysm and one small pontine arteriovenous malformation), both with diffuse SAH (yield 8%). Conclusions Delayed neurovascular imaging is valuable in the evaluation of patients with diffuse SAH who have negative initial CTA and DSA examinations and a negative 7 day repeat DSA, demonstrating a causative vascular lesion in 8% of patients.

Efficacy of a two-test protocol for achieving a therapeutic response to clopidogrel prior to elective endovascular intracranial aneurysm treatment and an ‘induced’ postoperative hyper-response

Introduction Variable response to clopidogrel can impact perioperative risk in elective endovascular intracranial aneurysm treatment. The present study aims to determine the efficacy of a two-test protocol in reaching in-range preoperative P2Y12 reaction units (PRU) of 60–240 and the rate of postoperative conversion to hyper-response. Methods A 17-day two-test protocol (with tests on days 10 and 17) for patients starting clopidogrel in anticipation of elective endovascular intracranial aneurysm treatment was introduced in February 2013 at our institution. Records for patients started on this protocol through December 2014 were reviewed for preoperative and postoperative PRUs, patient and procedural data, and thromboembolic and hemorrhagic events within 30 days. Logistic regression analyses were performed to identify predictors of postoperative hyper-response (p<0.05 considered significant). Results 103 patients (80 women) of mean age 57 years were included. 74 patients (71.8%) were in range at the first test and 92 patients (89.3%) were in range at the second test. A postoperative test was performed in 82 patients (79.6%) at a median of 9 days. 51 patients (62.2%) converted into hyper-responders. There were five non-disabling strokes and one intracranial hemorrhage within 30 days. There were no major strokes (modified Rankin Scale score >2) or deaths. There was no association between out-of-range PRU and thromboembolic or hemorrhagic neurological complications. Conclusions The protocol achieves in-range preoperative PRU by the second test in almost nine of 10 patients. Nearly two-thirds of patients exhibited postoperative hyper-response to clopidogrel. Out-of-range PRU was not associated with thromboembolic or hemorrhagic neurological complications in this cohort of patients with actively managed P2Y12 inhibition.

A case of right middle cerebral artery ‘tendonectomy’ following mitral valve replacement surgery

Following mechanical mitral valve replacement surgery, a 69-year-old woman had an ischemic stroke in the right middle cerebral artery territory. Mechanical thrombectomy showed the embolus to be a piece of chordae tendineae excised during the valve replacement surgery.

E-057 Process Improvement in Door-to-Groin Puncture Times at a Comprehensive Stroke Center Shows a Trend Towards Reduced Mortality at 90 Days

Introduction Safe and effective endovascular treatment of acute ischemic stroke is dependent on prompt intervention. In light of the positive trials published last year, we intensified our efforts to improve the process of taking patients from the emergency department to the angiography suite for mechanical thrombectomy. Methods At the beginning of 2015, a process improvement project to improve door-to-groin puncture times for mechanical thrombectomy for emergent large vessel occlusions was undertaken at our institution. After a systematic analysis of the process, the following key changes were standardized: early consultation with the neurointerventionalist for patients presenting with a high National Institutes of Health Stroke Scale (NIHSS ≥6), the stroke neurologist and the neurointerventionalist meet the patient in the emergency department for transfers or meet in the CT department for non-transfers, elimination of emergency physician triage for medically stable patients, elimination of lab tests such as creatinine, establishment of a minimum level of clinical information required for the sedation nurse to care for stroke patients safely, institution of a “stroke bag” containing all necessary devices to perform efficient thrombectomy, standardized setup of the procedure table and devices for all operators, calling for patients when the sedation nurse is ready without waiting for the entire team, elimination of unnecessary preoperative steps (e.g. Foley catheter placement, groin shaving, checking of distal pulses), and institution of an abbreviated time-out procedure. All attempted thrombectomies performed in 2013 and 2014 were compared to those performed in 2015 visà-vis the following variables: door-to-groin puncture time, symptomatic intracranial hemorrhage (SICH) rate as defined by SITS-MOST criteria, 90 day mortality rate, and 90 day rate of good clinical outcome defined by a modified Rankin Scale (mRS) of 0–2. A one-tailed Student’s t-test and Fisher’s exact tests were performed. A p-value <0.05 was considered statistically significant. Results From January 2013 to December 2015, we attempted 108 mechanical thrombectomies. Of these, 43 were in 2015 (40%). Both the mean and median door-to-groin puncture times were significantly reduced from the previous two years (35 minutes versus 89 minutes and 22 minutes versus 73 minutes, respectively, p < 0.001). There was a trend towards reduced mortality at 90 days (16% versus 26%, p = 0.166). The rates of SICH and mRS 0–2 at 90 days were not significantly different (see Table 1).Abstract E-057 Table 1 2013 and 2014 2015 p-value Thrombectomies 65 43 Door-to-groin punctureMean time (minutes)Median time (minutes) 8973 3522 <0.001 SICH 3 (5%) 3 (7%) 0.452 90 day mortality 17 (26%) 7 (16%) 0.166 90 day mRS 0–2 24 (37%) 18 (42%) 0.376 Conclusion Our systematic process improvement initiative significantly reduced door-to-groin puncture times and showed a trend towards reduced mortality at 90 days. A multidisciplinary approach and ensuring hospital system investment are key to an effective process. Disclosures Y. Kayan: 2; C; Medtronic, Penumbra. J. Delgado Almandoz: 2; C; Medtronic, Penumbra. M. Young: None. J. Fease: None. J. Scholz: None. A. Milner: None. T. Hehr: None. M. Mulder: None. P. Roohani: None. R. Tarrel: None.