Safety and feasibility of intraarterial eptifibatide as a revascularization tool in acute ischemic stroke.
OBJECTIVE
Experience with the use of platelet glycoprotein (GP) IIb-IIIa inhibitor eptifibatide in patients with ischemic stroke is limited. The authors report the off-label use of intraarterial eptifibatide during endovascular ischemic stroke revascularization procedures for reocclusion after documented recanalization or formed fresh thrombi in distal vessels that were inaccessible to endovascular devices.


METHODS
Patients who received intraarterial eptifibatide were identified from a prospectively collected database of patients in whom endovascular revascularization for acute ischemic stroke was attempted between 2005 and 2008. Data were analyzed retrospectively. The intraarterial eptifibatide dose was a single-bolus dose of 180 μg/kg body weight. Primary outcome measures were angiographic recanalization (Thrombolysis in Myocardial Infarction Grade 2 or 3), symptomatic intracranial hemorrhage rate, overall mortality rate, and favorable 3-month modified Rankin Scale score (≤ 2).


RESULTS
The study included 35 patients (mean age 62 years, range 18-85 years). The median presenting National Institutes of Health Stroke Scale score was 13. Two patients received intravenous tissue plasminogen activator before endovascular therapy. The median time from symptom onset to therapy initiation was 230 minutes (range 90-1370 minutes). Twelve patients (34%) received intraarterial tissue plasminogen activator without mechanical measures. Mechanical revascularization measures used were Merci retriever in 19 (54%), Penumbra device in 1 (3%), balloon angioplasty in 15 (43%), and stent placement in 22 (63%) patients. The mean dose of intraarterial eptifibatide was 11.6 mg (range 5-16.6 mg). Partial-to-complete recanalization (Thrombolysis in Myocardial Infarction Grade 2 or 3) was achieved in 27 patients (77%). Postprocedure intracranial hemorrhage occurred in 13 patients (37%), causing symptoms in 5 (14%). In the 5 symptomatic intracranial hemorrhage cases, all patients but one presented more than 8 hours after symptom onset and all received intraarterial recombinant tissue plasminogen activator. The median discharge National Institutes of Health Stroke Scale score was 7 (range 0-17). At 3 months postprocedure, 21 patients (60%) had a modified Rankin Scale score ≤ 2, and 8 patients (23%) had died.


CONCLUSIONS
Adjunctive intraarterial eptifibatide is a feasible option for salvage of reocclusion and thrombolysis of distal inaccessible thrombi during endovascular stroke revascularization. Its safety and efficacy need to be studied further in larger, multicenter, controlled studies.
Memon
Muhammad Zeeshan
MZ
Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York 14209, USA.
Natarajan
Sabareesh K
SK
Sharma
Jitendra
J
Mathews
Marlon S
MS
Snyder
Kenneth V
KV
Siddiqui
Adnan H
AH
Hopkins
L Nelson
LN
Levy
Elad I
EI
D000077284:Abciximab; D000293:Adolescent; D000328:Adult; D000368:Aged; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D002545:Brain Ischemia / Q000150:complications / Q000188:drug therapy* / Q000473:pathology; D002533:Cerebral Angiography; D002548:Cerebral Revascularization / Q000379:methods*; D057510:Endovascular Procedures; D000077542:Eptifibatide; D005240:Feasibility Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006083:Graft Occlusion, Vascular; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000627:therapeutic use; D007269:Injections, Intra-Arterial; D020767:Intracranial Thrombosis / Q000209:etiology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D056687:Off-Label Use; D010455:Peptides / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D012307:Risk Factors; D012449:Safety; D020521:Stroke / Q000188:drug therapy* / Q000209:etiology / Q000473:pathology; D016896:Treatment Outcome; D055815:Young Adult
D000911:Antibodies, Monoclonal; D005343:Fibrinolytic Agents; D007140:Immunoglobulin Fab Fragments; D010455:Peptides; D010975:Platelet Aggregation Inhibitors; D000077542:Eptifibatide; D000077284:Abciximab