Influence of the correct placement of external ventricular drainage on puncture channel bleeding in patients with aneurysmal subarachnoid hemorrhage.

Comparative Outcomes of Carotid Endarterectomy, Transfemoral Carotid Artery Stenting, and Transcarotid Artery Revascularization in Community Hospital Settings: A Multicenter Retrospective Study.

Optimal antiplatelet strategy in patients with advanced chronic kidney disease undergoing drug-eluting stent implantation: Design and rationale of the randomized ADAPT-CKD trial.

Outcomes of outpatient thyroidectomy for high-risk patients: A single-site retrospective cohort study.

Neurological worsening after hospital admission frequently correlates with poor clinical prognosis. However, treatment options are limited for acute ischemic stroke patients who are outside the thrombolytic time window and do not have large vessel occlusion (LVO). This study evaluated the safety and efficacy of intravenous tirofiban in this population. A total of 44 patients diagnosed with progressive ischemic stroke were analyzed, defined as an increase of ≥2 points on the NIHSS or a ≥1-point worsening in limb motor score within 24 hours of symptom onset. of these, 26 received intravenous tirofiban in addition to dual antiplatelet therapy, while the remaining 18 received dual antiplatelet therapy alone. The primary efficacy endpoints were the NIHSS score at 7 days and the proportion of patients achieving a superior functional outcome [modified Rankin Scale (mRS) score 0-1] at 3 months. Symptomatic intracranial hemorrhage, systemic bleeding events and thrombocytopenia were monitored. The tirofiban group showed greater neurological improvement at 7 days (p < 0.001) and an increased favorable outcome at 90 days (80.77% vs 27.78%, p = 0.001). Logistic regression confirmed tirofiban as an independent parameter of favorable outcome (adjusted OR 15.67, 95% CI: 2.97-82.61, p = 0.001). Neither group presented symptomatic intracranial hemorrhage, systemic bleeding, or thrombocytopenia. Intravenous tirofiban may represent a potential therapeutic option for patients with progressive ischemic stroke beyond the thrombolytic window and without LVO, showing an association with improved neurological recovery and functional outcomes. Its clinical efficacy and safety shall be further confirmed through large-scale, randomized, prospective studies.

Risk factors associated with ischemic stroke during temporary oral anticoagulant interruption in patients with non-valvular atrial fibrillation.

Previous studies have shown a beneficial effect of clopidogrel-aspirin and intensive statin therapy in acute ischemic stroke; however, the synergistic effect of the 2 treatments is still unclear. The aim of this study was to investigate the effect of combining clopidogrel-aspirin and immediate intensive statin in patients with acute mild ischemic stroke or transient ischemic attack (TIA). We performed a multicenter, randomized, double-blind, placebo-controlled trial with a 2-by-2 factorial design across 222 hospitals in China. Eligible participants were patients with acute mild ischemic stroke or TIA of a presumed atherosclerotic cause within 72 hours of symptom onset. Patients were randomly assigned to receive clopidogrel plus aspirin or aspirin alone and an immediate or delayed intensive statin. The primary efficacy outcome was a new stroke (ischemic or hemorrhagic) within 90 days, and the primary safety outcome was moderate-to-severe bleeding. Between September 17, 2018, and October 15, 2022, 6,100 patients were enrolled (median age, 65 years; 64.2% male), of whom 1,525 each were assigned to the 4 groups. New stroke within 90 days occurred in 116 patients (7.6%) in the clopidogrel-aspirin plus immediate intensive statin group (hazard ratio [HR] 0.76, 95% CI 0.60-0.97), in 106 patients (7.0%) in the clopidogrel-aspirin plus delayed statin group (HR 0.69, 95% Cl 0.54-0.89), and in 129 patients (8.5%) in the aspirin plus immediate statin group (HR 0.85, 95% Cl 0.67 to 1.07), compared with 150 patients (9.9%) in the aspirin plus delayed intensive statin group. Moderate-to-severe bleeding occurred in 17 (1.1%) in the clopidogrel-aspirin plus immediate statin group (p = 0.047), 10 (0.7%) in the clopidogrel-aspirin plus delayed statin group (p = 0.46), and 6 (0.4%) in the aspirin plus immediate statin group (p = 0.80), compared with 7 (0.5%) in the aspirin plus delayed statin group. Among patients with mild ischemic stroke or TIA of presumed atherosclerotic cause, the combination of clopidogrel-aspirin and delayed intensive statin was superior to aspirin plus delayed intensive statin in reducing the risk of new stroke, an effect that was mainly driven by clopidogrel-aspirin and not significantly different from that of clopidogrel-aspirin plus immediate statin. The combination treatment had a low but increased risk of moderate-to-severe bleeding. ClinicalTrials.gov identifier: NCT03635749. This study provides Class I evidence that in patients with mild ischemic stroke or TIA of presumed atherosclerotic cause, the combination of clopidogrel-aspirin plus delayed intensive statin was superior to aspirin plus delayed intensive statin in reducing the 90-day risk of new stroke.

Dual antiplatelet therapy (DAPT) is considered the standard medication regimen after Pipeline Embolization Device (PED) treatment of intracranial aneurysms. However, the optimal duration of DAPT after PED remains uncertain. We compared the safety and efficacy of 3 months vs 6 months or more of DAPT in the PED treatment of intracranial aneurysms. We performed a retrospective cohort comparison study of 257 consecutive patients with intracranial aneurysms treated with PED who were either prescribed a 3-month (early termination) or ≥6-month course (standard duration) of DAPT. All patients had clinical follow-up of at least 3 months after discontinuation of DAPT. Baseline demographics, aneurysm characteristics, periprocedural data, complications before and after discontinuation of DAPT, and aneurysm occlusion rates on follow-up angiography were compared between cohorts. The study cohort consisted of 257 patients, including 155 patients in the early termination group and 102 patients in the standard duration group. Total complications after DAPT discontinuation were significantly lower in the early termination cohort (1.3% vs 9.8%, P = .002). There were no significant differences in total major complications between groups after DAPT cessation, nor were there differences in any specific major complication. Minor thromboembolic complications were significantly lower in the early termination cohort (1.3% vs 8.8%, P = .008) after DAPT discontinuation without a significant difference in any specific event. The rate of complete aneurysm occlusion on 6-month follow-up angiography was significantly higher in the early termination cohort (82.6% vs 70.6%, P = .024). In this study, we found that early termination of DAPT at 3 months after PED treatment has overall similar safety and efficacy outcomes as compared with the current standard 6-month regimen. These preliminary data encourage prospective studies to determine optimal DAPT durations in the PED treatment of intracranial aneurysms.

Modified antiplatelet therapies in patients with high on-treatment platelet reactivity (HTPR) remains unknown in neurointerventional treatment. We aimed to compare the safety and effectiveness of two different modified antiplatelet therapies in patients with HTPR undergoing stent-assisted coil embolization for an unruptured intracranial aneurysm. We conducted a prospective, randomized clinical trial. Participants with HTPR were randomly assigned (1:1) to the triple antiplatelet therapy (TAT, addition of cilostazol) or modified dual antiplatelet therapy (MDAT, switched from clopidogrel to low-dose prasugrel) group. The primary outcome was all-bleeding-events during the 90-day follow-up period. The secondary outcomes were thromboembolic events and changes in the P2Y12 reaction unit (PRU) value throughout the follow-up period. Intention-to-treat (ITT) and per-protocol (PP) analyses were performed. In total, 172 of the 198 participants maintained initial antiplatelet therapy for 90 days. There was no significant difference in the all-bleeding-event rate between the two groups, both in the ITT population (hazard ratio [HR], 0.77 [95% CI, 0.49-1.20]; P = .26) and the PP population (HR, 0.79 [95% CI, 0.50-1.30]; P = .34). The thromboembolic event rate did not differ between the 2 groups in either the ITT population (HR, 0.33 [95% CI, 0.03-3.20]; P = .34) or the PP population (HR, 0.42 [95% CI, 0.04-4.70]; P = .48). Compared with those in the TAT group, the PRU values in the MDAT group greatly decreased over time, particularly for PRU after loading. Among patients with HTPR who underwent stent-assisted coil embolization for an unruptured intracranial aneurysm, there was no significant difference between the TAT and MDAT groups regarding the risk of all bleeding events and thromboembolic events during the 90 days of follow-up.

A multidimensional study of antiplatelet therapy and CYP2C19 genetic testing in patients with ischemic stroke and transient ischemic attack.

Longitudinal changes of BOLD-CSF coupling and its association with the clinical assessments in subcortical ischemic stroke.

Cost-Utility and Budget Impact Analysis of Pharmacogenetic-Guided Antiplatelet Therapy for Acute Coronary Syndrome in Thailand.

The optimal antiplatelet regimen for branch atheromatous disease (BAD)-related stroke remains uncertain. This study aimed to compare the clinical outcomes of dual antiplatelet therapy (DAPT) vs. single antiplatelet therapy (SAPT) in these patients. From the multicenter prospective BAD-study, we collected consecutive patients with BAD who received DAPT and SAPT. Propensity score matching (PSM) was used to balance baseline characteristics. The primary efficacy endpoint was an excellent outcome, defined as a modified Rankin Scale score of 0 to 1 at 90 days. The safety endpoint was bleeding events within 7 or 90 days. A total of 449 patients were enrolled in the analysis, with a median age of 60 years and a median National Institutes of Health Stroke Scale score of 3 at admission. After PSM, there were 112 patients in the SAPT group and 171 patients in the DAPT group, with well-balanced baseline characteristics. Excellent outcome occurred in 69.6% of the SAPT group and 79.5% of the DAPT group (odds ratio, 0.590; 95% confidence interval, 0.341 to 1.022; p = 0.059). No significant differences were observed in other efficacy outcomes between the two groups. In exploratory subgroup analysis, no significant treatment-by-subgroup interactions were observed, and after correction for multiple comparisons, no within-subgroup differences remained statistically significant. No increased bleeding risk was observed in DAPT. In acute BAD-related stroke, DAPT was safe but not statistically superior to SAPT for excellent functional outcome; however, its numerical trend toward benefit warrants further investigation.

Abdominal aortic aneurysm (AAA) pathogenesis reflects a convergence of extracellular matrix degradation, thrombosis, and vascular inflammation (thromboinflammation), where platelets and the intraluminal thrombus (ILT) are implicated in playing central, stage-dependent roles. Beyond their traditional role in hemostasis, activated platelets are known to localize in ILT, releasing chemokines, proteases, and growth factors, which aid in recruiting leukocytes and may drive aneurysm expansion through matrix breakdown. Although preclinical models and tissue analyses suggest platelet adhesion receptors and chemokine interactions contribute to leukocyte influx and aneurysm progression, the availability of preclinical models that recapitulate ILT is limited, and overall translational evidence remains inconclusive. A crucial question is whether ILT acts as a mere bystander in AAAs or actively contributes to aneurysm growth and rupture. Notably, the only randomized controlled trial to date testing an antiplatelet agent (ticagrelor) demonstrated no effect on AAA growth, raising concerns that platelets may not be an appropriate AAA treatment target. The development of AAA models that consistently manifest ILT will be essential for determining the therapeutic potential of targeting platelet inflammatory functions (eg, glycoprotein VI signaling inhibition). Ultimately, clarifying whether ILT-driven platelet inflammation is a modifiable mechanism or a bystander signal will require ILT-specific models and rigorously powered trials to define safe, hemostasis-sparing antiplatelet strategies for AAA.

Scoring Balloon Angioplasty Maintains Parent Artery Patency in Tandem Lesion Stroke until Safe Stent Placement Is Achievable.

Blood pumps generate non-physiological shear stress (NPSS) that activates platelets and disrupts haemostasis. Ticagrelor is used in antiplatelet therapy for mechanical circulatory support, yet its effects under NPSS remain unclear. This study investigated how ticagrelor and NPSS interact to modulate platelet haemostatic function. Citrated bovine blood was circulated in a Rotaflow loop (500 ml, 5.0 l·min-1, ΔP of 0, 100 and 350 mmHg) for up to 3 h. Ticagrelor (20 μM) was administered either before circulation or after shear stress exposure. Flow cytometry and aggregometry quantified platelet activation, P2Y12 receptor surface expression, adhesion and aggregation. Proteomics compared signalling across treatment sequences, and thromboelastography (TEG) assessed clot kinetics. NPSS increased P-selectin, GPIIb/IIIa expression and fibrinogen adhesion and reduced P2Y₁2 receptor surface expression. Ticagrelor suppressed adenosine diphosphate (ADP)-induced aggregation and attenuated shear-driven platelet activation and also mitigates shear-induced loss of platelet P2Y₁2 surface expression. Proteomics showed lower Gi-coupled signalling and relative preservation of cAMP-PKA-related proteins, with the post-ticagrelor group showing the strongest suppression of activation signalling. As the ΔP of loop increases, the drug's ability to inhibit activation decreases. TEG showed faster clot initiation and growth after shear exposure, and these changes were most effectively moderated when ticagrelor was administered after shear exposure. NPSS activates platelets through pathways linked to Gi signalling. Ticagrelor reduced shear-induced activation, with the greatest reduction when used after shear. These findings support timing as a controllable variable during blood pump support.

Optimizing TCAR Antithrombotic Regimens for Patients on Chronic Anticoagulation.

Design and rationale of the clinical trial to obtain the highest efficacy of dual antiplatelet therapy after carotid artery stenting in high bleeding risk patients (CHET): A multicenter, randomized, open-label, superiority trial.

Abbreviated Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Lung Transplant Candidates: Striking a Surgical Balance

Obese patients hospitalized for surgery are at high risk of venous thromboembolism (VTE). The optimal dose and duration of thromboprophylaxis with low molecular weight heparin for these patients are uncertain. To assess the time-course, rates and risk factors for VTE and major bleeding (MB) in a population of surgical patients with obesity receiving pharmacological thromboprophylaxis with enoxaparin. Patients with body mass index (BMI) > 30kg/m2 hospitalized with surgeries between 2010 and 2021 who received thromboprophylaxis with enoxaparin were selected from the US Optum database. Exclusion criteria were VTE, MB, or surgery in previous 90-days, and ongoing anticoagulant treatment or dual antiplatelet therapy. VTE and MB event rates over a 90-day follow-up post enoxaparin initiation were estimated via the Kaplan-Meier (KM) method. Risk factors associated with outcome events were identified via Cox proportional hazard models. A total of 30,492 patients met selection criteria, 12,058 patients received the standard dose, with 18,300 receiving higher doses. KM event rates at 90-days for VTE and MB were 2.5% and 1.2%, respectively. The highest VTE rates were observed in patients hospitalized for thoracic surgery (4.9%). History of VTE was the strongest predictor of post-surgery VTE (HR 5.62, 95% CI 4.71-6.7) while history of MB was the strongest predictor of post-surgery bleeding (HR 2.62, 95% CI 1.29-5.32). The rates of VTE are non-negligible in surgical patients with obesity receiving thromboprophylaxis with enoxaparin. Individual risk stratification is warranted to identify optimal doses/duration of pharmacologic thromboprophylaxis.