Background Intracranial atherosclerosis (ICAD) is much less common than embolism as a cause of emergency large vessel occlusion (ELVO) in patients presenting for endovascular therapy. The presence of ICAD may be known pre-operatively or discovered during the course of the intervention. Intracranial angioplasty and/or stenting may be employed to establish patency of the target vessel, and emergent anti-platelet medical therapy may be required to maintain vessel patency. The latter must be balanced with the risk of causing intracranial hemorrhage in the acute stroke setting.
Methods We retrospectively reviewed our prospectively maintained endovascular stroke database and identified 6 patients undergoing emergent intracranial angioplasty and/or stenting during endovascular therapy for ELVO. Three were in the middle cerebral artery and three in the posterior circulation. The patients received a bolus of 135 mcg/kg eptifibatide followed by a low dose infusion of 0.5 mcg/kg/min at the time of intervention, with transition to oral therapy at 24 hours.
Results There were no hemorrhages. There were three (50%) acute re-occlusions at the intervention site. Two occurred within a few hours and were re-treated emergently with a second procedure.and patency then maintained with abciximab, One of those two patients had also received tPA intravenously prior to intervention. The third re-occlusion occurred during transition to oral therapy at 24 hours and resulted in a large and fatal brainstem stroke. At 90 day follow-up there was one MRS of 0, one MRS of 3 (both in the anterior circulation), and 3 patients had died. One patient is an MRS of 5 at 2 weeks.
Conclusion The low dose eptifibatide protocol employed here was safe in that no hemorrhages occurred. However, three of six target vessels re-occluded acutely. While the data are limited, the protocol appears to lack adequate potency to prevent re-occlusion of acutely treated ICAD lesions.
Disclosures C. Roels: None. M. Brown: None. R. Janjua: None. D. Heck: 2; C; Stryker.
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