Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Shaheryar Hafeez, Pegah Ghamasaee, Sharmin Amjad, Colleen A Barthol, R. Grandhi
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Abstract

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591
持续输注依替巴肽和康格瑞洛在颈动脉支架置入后大血管闭塞急性缺血性卒中中的应用
对于颅外颈内动脉(ICA)狭窄闭塞性疾病或ICA夹层患者,在大血管闭塞(LVO)的情况下放置颈动脉支架有时是必要的。需要使用抗血小板药物来预防支架内血栓形成;然而,在LVO后,可能需要进行减压性半骨切除术。放置颈动脉支架后,必须在预防支架相关血栓栓塞并发症和维持快速安全地进行减压性半骨切除术的可能性之间取得良好的平衡。在这种情况下,我们讨论了在颈动脉支架置入后持续输注依替巴肽和坎格雷洛的新方法,以维持支架通畅,同时保留紧急半骨切除术的选择。一个55岁的男性提出了左半球缺血症状,由于血流衰竭从左ICA夹层。他接受了急诊血管造影术和血管成形术,并对左颈内动脉的岩段和上行段进行了支架置入术。由于血栓栓塞左大脑中动脉(MCA) M2分支,导致闭塞,无法打开,手术变得复杂。患者静脉注射短效抗血小板药物(依替巴肽输注60 h,康格瑞洛输注24 h)以预防支架内血栓形成,同时密切观察潜在的神经功能下降和是否需要进行半骨减压切除术。经过84小时的观察,患者没有出现下降,在接受阿司匹林和负荷剂量氯吡格雷后停止抗血小板输注。静脉滴注依替巴肽或坎格雷洛是短效抗血小板的选择,可用于左心室血栓形成的急性缺血性卒中患者,当有可能进行减压性半骨切除术时。中华神经科学杂志,2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591
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