Cardiometabolic Medicine

@cardiomet_CE on Twitter

1) Welcome to a new #accredited #tweetorial on parenteral #antiplatelet therapy in #neurovascular interventions. Our expert author is Fawaz Al-Mufti MD @almuftifawaz, interventional #neurologist Interventional Neurologist @nymedcollege @WestchesterMed @neurocritical @svinsociety

2) This program is intended for #healthcare providers & is accredited for 0.5h CE/#CME for #physicians #PhysicianAssociate #nursepractitioner #nurse #pharmacists and is supported by educational grants from AstraZeneca, Bayer, and Chiesi.

3) Be sure to see prior tweetorials on #antiplatelet management, still available for credit, at Faculty disclosures are listed at

4) Pretreatment with dual antiplatelet therapy #DAPT is recommended to⬇️incidences of both ischemic &hemorrhagic complications in #neurovascular interventions.

5) Data are limited, however, re the optimal timing, dose, and duration of treatment for #carotid artery #angioplasty with stenting #CAS, especially in emergent stenting for complete or near complete occlusion of the internal carotid #ICA.

Cant Decide Fred Armisen GIF by IFC

6) So let’s consider a case that illustrates this. An octogenarian ♂️ with HTN/HLD/CAD presents with severe dysarthria, L homonymous hemianopia. Flaccid L sided face/arm/leg hemiparesis, and profound neglect.
Last know normal=8 hours ago. Baseline mRS=0.
Stroke Code is called.

7) Time is brain!

8) An #NIH #StrokeScale is calculated on this gentleman. (It takes practice, but there’s a handy calculator available at
It’s not good–22.

9) So we must assemble the #stroketeam. #Neurology & #EmergencyMedicine are on the ⏰to plan an immediate treatment approach. CODE BAT (Brain ATTACK)

10) Gather data:
VS: BP 180/102, HR 85, RR 18, T 98.6
LABS: Glucose 110 mg/dL, Labs pending
EKG: EKG not done yet, but normal sinus rhythm on monitor

Ekg Heart Rate GIF

11) Gather more data:
CTH : No ICH, Dense MCA sign, ASPECT 6
CTA : High grade right Internal Carotid Artery stenosis and M1 segment MCA Occlusion
CTP : >160cc of salvageable brain tissue ( #Tmax >6seconds) and 40cc of core (Cerebral Blood Flow #CBF<30)

12) Tandem occlusion, near complete occlusion of the ICA with a type 3 arch? Piece of 🍰, right?
Nope . . gulp . . . call the #neuroangio team in…..

Partner Will Smith GIF

13) OK, warning: this is NOT a pretty picture. #DSA demonstrates near complete occlusion.
Left ICA is out at the origin with minimal collateral flow from the posterior circulation via a posterior communicator.

15) So IRL, #angioplasty is performed, but attempts to cross the lesion following angioplasty were also unsuccessful ➡️decision made to perform acute stenting
You never give up!

17) Mark your best response & return TOMORROW for the correct answer, the resolution of this case & more education, & your link to🆓CE/#CME #physicians #physicianassociates #nurses #nursepractitioners #pharmacists! Hello @stephanamayer @AmuluruKrishna @neurocritical @AshuPJadhav

18) Welcome back! We are learning about IV #P2Y12i in neurovascular intervention from expert author @almuftifawaz. Did u answer the quiz in tweet 17? If not, scroll⤴️& COMMIT before moving onward!👏to @PascalJabbourMD @caseyalbin @WBrinjikji @AmeerEHassan @elghanemmoh @CamStroke

19) It’s B. #Antiplatelets are needed here.

20) Decision is made to go with IV #cangrelor:
– Potent, IV, #P2Y12i, a nonthienopyridine adenosine analog that does not require metabolic activation
– Onset w/in 2 minutes
– T1/2 3–6 min
– Platelet activity returns to normal within 60 min after discontinuation of the infusion

21) There’s an excellent result after carotid stenting under platelet inhibition:

22) Cangrelor is approved by @US_FDA as an adjunct therapy for patients undergoing #PCI. Use in #neuroendovascular procedures has been extrapolated from smaller trials. Cortez et al ( n=66 pts who underwent acute intervention & received cangrelor.

23) Pts were divided into 2 groups: ischemic (42) and aneurysm (24). Periprocedural thromboembolic events, hemorrhagic complications, & outcomes analyzed. Ischemic group periprocedural symptomatic complication rate was 9.5%, mortality was 2.4%. In the aneurysm group ….

24) … 4.2% had a periprocedural complication during or after cangrelor infusion, & favorable clinical outcome was seen in 56.2% & 87.7% of ruptured and unruptured aneurysms, respectively, at discharge.

25) A meta-analysis by Marnat et al ( n=171 pts who received cangrelor as rescue strategy for refractory intracranial occlusion with or without intracranial rescue stent placement, & cervical carotid artery stent placement for cervical occlusion …

26) … (tandem occlusion or isolated cervical carotid occlusion). In all, symptomatic intracerebral hemorrhage occurred in 8.6% of pts & there was favorable outcome in 47.6% of patients. 90-day mortality was 22.6% & there was Day 1 artery patency in 89.7%.

29) There are limited data, but best option is B, start #DAPT within 6h, after confirming no hemorrhagic transformation.

30) Following the endovascular thrombectomy of the M1 MCA occlusion, stenting is performed with TICI 3 recanalization.

31) Check back here soon for an animation of what we did

32) Next, endovascular thrombectomy of the M1 MCA occlusion was performed with the same excellent result–TICI 3 recanalization

33) Postprocedurally the IV regimen can be converted to an oral regimen within 24 hours. Coadministration of aspirin, an irreversible COX-1 inhibitor, & a #P2Y12i–best to use #ticagrelor after #cangrelor, is advised. See 🔓

34) Remember that the multi-societal consensus document states that a P2Y12i should be continued for at least 30 days, and aspirin should be continued indefinitely. This has become the standard perioperative antiplatelet therapy. 🔓

35) Our patient–who started off with that frightening CT imaging–recovered in the ICU and then in the stroke unit. NIHSS was 4⃣on discharge to acute rehabilitation.

Danny Devito GIF

36) The take-home lesson: Cangrelor may be a feasible alternative for patients requiring immediate neurointervention w/ endoluminal devices. It also fosters secure transition to long-term ticagrelor & progression to surgery in the setting of unexpected complications.

37) #Glycoprotein IIb/IIIa receptor antagonists may be used in similar settings. There have been no head-to-head trials, and neither approach is on label per @US_FDA.

38) And you made it: 0.5h CE/#CME credits. Go to & grab your certificate! I am @almuftifawaz. Please FOLLOW @cardiomet_CE for cutting-edge accredited tweetorials! C’mon @AmuluruKrishna @elghanemmoh @SitaraKoneru @SharashidzeVera @gdawod1 @svinsociety

Originally tweeted by cardio-met (@cardiomet_CE) on March 29, 2022.