dont mix up mechanical thrombectomy and chemical thrombolysis
kellert et al have published a very important article...which is seen in day to day practice....and which I have kept telling to anyone I meet and cares to listen to me....which is "DO ONLY MECH THROMBECTOMY AND DONT MIX UP DIFFERENT TECHNIQUES OF RECANALISATION"
if a vessel gets recanalised by the aspiration and the solitaire device, its well and good, but pushing in antiplatelet drugs or even rTPA in case of failure or for recanalising distal branches, is not a very good idea, as it results in haemorrhage a lot of times.
The reason is not clear but the observation is.. however some hypotheses can definitely be made.
1. GOD does not want this patient to improve !
2. there is distal vessel occlusion and insitu thrombus formation apart from the large vessel occlusion,
3. 'no-reflow' phenomenon
4. poor collateral
5. the parenchymal territory is already damaged irreversibly
6. the mech device has opened the larger proximal artery resulting in hyperperfusion, and the drug directly is toxic to cells, thus resulting in enhanced bleeding ....
most likely a combination of all these is happening....
What I am getting to in acute stroke intervention in my short career is that if a patient comes with acute stroke---
1. be aggressive with intravenous thrombolysis.
2. if CT/MRI/CTA/MRA/CTP show large vessel occlusion with favourable ASPECT score (plus good leptomeningeal score or large mismatch, as per availability of data), the go straight for aspiration and mechanical thrombectomy.... and forget about chemical intravenous or intraarterial thrombolysis
3. however, if the interventionist is not comfortable with mech devices then combined IVT+IAT should be done wherever possible.
the link and the abstract are given underneath
Kellert et al. Tirofiban Is Associated With Risk of Fatal Intracerebral Hemorrhage and Poor Outcome. Stroke. 2013; 44: 1453-1455 Published online before print March 5, 2013, doi: 10.1161/STROKEAHA.111.000502
Abstract
Background and Purpose—To investigate the relationship between severe bleeding complications and outcome after mechanical thrombectomy with or without glycoprotein-IIb/IIIa inhibitor tirofiban treatment.
Methods—The study included prospectively collected data of consecutive patients with acute ischemic stroke in whom mechanical thrombectomy was perfomed in the years 2006 to 2011.
Results—Of 162 patients, 128 patients had anterior circulation stroke, and 34 patients had posterior circulation stroke. Additional treatment with tirofiban was given to 30 of 128 patients with anterior circulation stroke and to 20 of 34 patients with posterior circulation stroke. Treatment with tirofiban did not influence recanalization rates. Fatal intracerebral hemorrhage occurred more frequently in tirofiban-treated patients in the entire cohort (12.0% vs 2.7%; P=0.03) and in tirofiban-treated patients with anterior circulation stroke (13.3% vs 3.1%; P=0.05). Logistic regression found age (odds ratio, 1.17; 95% confidence interval, 1.00–1.37; P=0.05) and tirofiban treatment (odds ratio, 3.03; 95% confidence interval, 1.50–4.05; P=0.04) to be independent predictors for fatal intracerebral hemorrhage. Tirofiban treatment was also an independent predictor for poor outcome (odds ratio, 6.60; 95% confidence interval, 1.06–41.52; P=0.04) in addition to National Institute of Health Stroke Scale (odds ratio, 1.08; 95% confidence interval, 1.00–1.17; P=0.05).
Conclusions—In endovascular stroke therapy, additional treatment with the glycoprotein-IIb/IIIa inhibitor tirofiban is associated with increased risk of fatal intracerebral hemorrhage and poor outcome.
Tags: Acute Ischemic Stroke
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