Antiplatelet agents for acute ischemic stroke

Background: The factors impacting infarct evolution after intra-arterial(IA) intervention for acute ischemic stroke remain uncertain. We studied the infarct evolution on MRI DWI among acute stroke patients who underwent IA therapy. Methods: We reviewed the early ischemic stroke imaging database at Cleveland Clinic Cerebrovascular Center for those undergoing IA therapy in anterior circulation from 2009 to 2012. Patients with both pre-treatment and follow-up MRI were included. Infarct volume was measured on initial and follow-up DWI by region of interest demarcation. Patients were grouped into quartiles by infarct growth from initial to follow-up. Outcome were defined as modified Rankin Score 0-2 at 30 days. Results: Among the 76 patients, the median (range) infarct growth of four quartiles were 0.5 cc (-19.1-4.2), 13.8 cc (4.8-25.8), 38.8 cc (28.0-77.6), and 166.3 cc (78.0-314.5). Baseline characteristics of age, gender, race, diabetes, and hypertension were similar among groups except more smokers (p=0.017) and fewer patients on anticoagulation or antiplatelet agents in large-growth group (p=0.049). Compared to No-growth group (Quartile 1), large-growth group (Quartile 4) had more Hyperdense M1 MCA sign ( 26.3% vs 73.7%, p=0.004), larger initial ischemic lesion measured by CT ASPECT (p=0.002) and DWI volume (p=0.012), and absence of full collaterals on CTA ( 36.8% vs 0, p=0.004). There was a trend of lower recanalization rate in large-growth group (73.7% vs 47.4%, p=0.097). With the increment of infarct growth, there is a decrement in favorable outcomes (mRS 0-2) at 30 days: 42%, 37%, 26% and 10.5% (p=0.027). Conclusion: Infarct growth after IA therapy determines outcome. Initial ischemic lesion size, collaterals, and hyperdense vessel sign are associated with infarct growth.

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Does prior antiplatelet treatment improve functional outcome after intra-arterial treatment for acute ischemic stroke?

International Journal of Stroke ◽

10.1177/1747493016677842 ◽

2016 ◽

Vol 12 (4) ◽

pp. 368-376 ◽

Cited By ~ 9

Author(s):

Maxim JHL Mulder ◽

Olvert A Berkhemer ◽

Puck SS Fransen ◽

Lucie A van den Berg ◽

Hester F Lingsma ◽

...

Keyword(s):

Ischemic Stroke ◽

Confidence Interval ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Treatment Effect ◽

Absolute Risk ◽

Antiplatelet Agents ◽

Antiplatelet Treatment ◽

Vessel Occlusion ◽

Ordinal Logistic Regression Analysis

Background and purpose In patients with acute ischemic stroke who receive antiplatelet treatment, uncertainty exists about the effect and safety of intra-arterial treatment. Our aim was to study whether intra-arterial treatment in patients with prior antiplatelet treatment is safe and whether prior antiplatelet treatment modifies treatment effect. Methods All 500 MR CLEAN patients were included. We estimated the effect of intra-arterial treatment with ordinal logistic regression analysis, and tested for interaction of antiplatelet treatment with intra-arterial treatment on outcome. Furthermore, safety parameters and serious adverse events were analyzed. Results The 144 patients (29%) on antiplatelet treatment were older, more often male, and had more vascular comorbidity. Intra-arterial treatment effect size after adjustments in antiplatelet treatment patients was 1.7 (95% confidence interval 0.9–3.2), and in no antiplatelet treatment patients 1.8 (95% confidence interval: 1.2–2.6). There was no statistically or clinically significant interaction between prior antiplatelet treatment and the relative effect of intra-arterial treatment ( p = 0.78). However, in patients on antiplatelet treatment, the effect of successful reperfusion on functional outcome in the intervention arm of the trial was doubled: the absolute risk difference for favorable outcome after successful reperfusion in patients on prior antiplatelet treatment was 39% versus 18% in patients not on prior antiplatelet treatment (Pinteraction = 0.025). Patients on antiplatelet treatment more frequently had a symptomatic intracranial hemorrhage (15%) compared to patients without antiplatelet treatment (4%), without differences between the control and intervention arm. Conclusions Prior treatment with antiplatelet agents did not modify the effect of intra-arterial treatment in patients with acute ischemic stroke presenting with an intracranial large vessel occlusion. There were no safety concerns. In patients with reperfusion, antiplatelet agents may improve functional outcome.

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Abstract WP54: MR CLEAN-MED - The Effect of Periprocedural Medication in Patients Undergoing Endovascular Treatment for Acute Ischemic Stroke: Heparin, Antiplatelet Agents, Both or Neither

Stroke ◽

10.1161/str.50.suppl_1.wp54 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Rob A van de Graaf ◽

Bob Roozenbeek ◽

Vicky Chalos ◽

Adriaan C van Es ◽

Heleen M den Hertog ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Antiplatelet Agents ◽

Mr Clean

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MR CLEAN-MED -- THE EFFECT OF PERIPROCEDURAL MEDICATION IN PATIENTS UNDERGOING INTRA-ARTERIAL TREATMENT FOR ACUTE ISCHEMIC STROKE: HEPARIN, ANTIPLATELET AGENTS, BOTH OR NEITHER

10.26226/morressier.5aeac941521e300021137fe6 ◽

2018 ◽

Author(s):

Rob van de Graaf

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Antiplatelet Agents ◽

Mr Clean

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Prior therapy with antiplatelet agents is not associated with outcome in patients with acute ischemic stroke/TIA

Journal of Neurology ◽

10.1007/s00415-006-0088-0 ◽

2006 ◽

Vol 253 (5) ◽

pp. 648-652 ◽

Cited By ~ 7

Author(s):

S. Greisenegger ◽

S. Tentschert ◽

M. Weber ◽

J. Ferrari ◽

W. Lang ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Antiplatelet Agents ◽

Prior Therapy

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Anticoagulants and antiplatelet agents in acute ischemic stroke: Report of the Joint Stroke Guideline Development Committee of the American Academy of Neurology and the American Stroke Association (a Division of the American Heart Association)

Neurology ◽

10.1212/wnl.59.1.13 ◽

2002 ◽

Vol 59 (1) ◽

pp. 13-22 ◽

Cited By ~ 41

Author(s):

B. M. Coull ◽

L. S. Williams ◽

L. B. Goldstein ◽

J. F. Meschia ◽

D. Heitzman ◽

...

Keyword(s):

Ischemic Stroke ◽

American Academy ◽

Acute Ischemic Stroke ◽

American Heart Association ◽

American Heart ◽

Guideline Development ◽

Heart Association ◽

Antiplatelet Agents ◽

Development Committee ◽

American Academy Of Neurology

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Abstract TP119: Recurrent Thromboembolic Events After Ischemic Stroke in Patients with Cancer

Stroke ◽

10.1161/str.44.suppl_1.atp119 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Alexander Merkler ◽

Samuel Singer ◽

Natalie T Cheng ◽

Jacqueline B Stone ◽

Hooman Kamel ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Hazard Analysis ◽

Antiplatelet Agents ◽

Large Artery ◽

Thromboembolic Events ◽

Kaplan Meier ◽

Systemic Artery ◽

Significant Difference ◽

Active Cancer

Background: Cancer often causes hypercoagulability, leading to venous and arterial thromboembolic events such as stroke. The rate and type of recurrent thromboembolic events (RTE) in cancer patients after stroke is unknown. Methods: We retrospectively identified consecutive patients with active cancer diagnosed with acute ischemic stroke by MRI at Memorial Sloan-Kettering Hospital from 2008 to 2010. Study neurologists collected demographic and clinical data using a standardized abstraction tool, and reviewed all electronic records after patients’ index stroke for the primary composite outcome of RTE, defined as any recurrent ischemic stroke, TIA, MI, systemic artery thrombosis, DVT, or PE. Kaplan-Meier statistics were used to calculate the cumulative rate of RTE and recurrent ischemic stroke; follow-up was censored when patients experienced an outcome or died. In an exploratory analysis, bivariate Cox proportional hazard analysis was used to compare rates of RTE on anticoagulation compared with antiplatelet agents. Results: Acute ischemic stroke was diagnosed in 119 patients with active cancer (mean age 66 [SD 13]; 49% women) during the study period. Patients’ underlying cancer was usually a carcinoma (83%) and was advanced (systemic metastases in 74%). Using TOAST criteria, stroke mechanisms were classified as 16% large artery atherosclerosis, 21% cardioembolism, 6% small vessel, 4% of other determined cause, and 53% of undetermined etiology. Despite a very short median survival in these patients (85 days [IQR 24-495 days]), RTE were diagnosed in 37 (31%), consisting of 16 DVTs, 12 recurrent ischemic strokes, 3 PEs, 2 MIs, and 2 systemic artery thromboses. Kaplan-Meier cumulative rates of RTE were 20% at 1 month, 29% at 3 months, and 31% at 6 months, while cumulative rates of recurrent ischemic stroke were 7% at 1 month, 15% at 3 months, and 15% at 6 months. There was no significant difference in event rates on anticoagulation compared with antiplatelet agents (HR=1.2, 95% CI 0.5-2.8). Conclusions: The short-term risk of RTE and recurrent ischemic stroke in patients with active cancer and ischemic stroke is substantial.

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