ObjectiveTo examine the comparative efficacy and safety of different antiplatelet regimens in patients with prior non-cardioembolic ischaemic stroke or transient ischaemic attack.DesignSystematic review and network meta-analysis.Data sourcesAs on 31 March 2015, all randomised controlled trials that investigated the effects of antiplatelet agents in the long-term (≥3 months) secondary prevention of non-cardioembolic transient ischaemic attack or ischaemic stroke were searched and identified.Outcome measuresThe primary outcome measure of efficacy was serious vascular events (non-fatal stroke, non-fatal myocardial infarction and vascular death). The outcome measure of safety was any bleeding.ResultsA total of 36 randomised controlled trials (82 144 patients) were included. Network meta-analysis showed that cilostazol was significantly more effective than clopidogrel (OR 0.77, 95% credible interval 0.60–0.98) and low-dose (75–162 mg daily) aspirin (0.69, 0.55–0.86) in the prevention of serious vascular events. Aspirin (50 mg daily) plus dipyridamole (400 mg daily) and clopidogrel reduced the risk of serious vascular events compared with low-dose aspirin; however, the difference was not statistically significant. Furthermore, low-dose aspirin was as effective as higher daily doses. Cilostazol was associated with a significantly lower bleeding risk than most of the other regimens. Moreover, aspirin plus clopidogrel was associated with significantly more haemorrhagic events than other regimens. Direct comparisons showed similar results as the network meta-analysis.ConclusionsCilostazol was significantly more effective than aspirin and clopidogrel alone in the long-term prevention of serious vascular events in patients with prior non-cardioembolic ischaemic stroke or transient ischaemic attack. Cilostazol was associated with a significantly lower bleeding risk than low-dose aspirin (75–162 mg daily) and aspirin (50 mg daily) plus dipyridamole (400 mg daily). Low-dose aspirin was as effective as higher daily doses. However, further large, randomised, controlled, head-to-head trials are needed, especially in non-Asian ethnic groups.

We evaluated the safety and effectiveness of transcatheter patent foramen ovale (PFO) closure for the treatment of migraine in a Chinese population. This non-randomized clinical trial enrolled 258 consecutive substantial or severe migraineurs with a right-to-left shunt (RLS) (grade II–IV) and grouped subjects according to their election or refusal of PFO closure. Migraine was diagnosed according to the International Classification of Headache Disorders III-beta and evaluated using the Headache Impact Test-6 (HIT-6). In total, 241 participants (125 in the transcatheter closure group and 116 in the control group) were included in the study. In general, the PFO closure procedure was found to be safe. At 1 month after closure, 76.1% of patients returned for c-TCD evaluation; of these, 85.7% were downgraded to negative status or a grade-I shunt. Residual shunts and placebo effects were thought to resolve by 12 months post-procedure, when migraine impact was reported to decrease by 73.6%. Transcatheter PFO closure was demonstrated to be effective for the treatment of migraine by comparing HIT-6 scores between the transcatheter closure and control groups (p < 0.001). Our results suggest that transcatheter PFO closure is a safe and effective approach for the treatment of migraine in the Chinese population, especially in females with constant RLS. Clinical trial no. NCT02127294 (registered on April 29, 2014).

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ObjectiveWe aimed to investigate the value of three-dimensional (3D) T1 volumetric isotropic turbo spin echo acquisition (VISTA) in the diagnosis of cervical artery dissection (CAD).MethodsWe prospectively included patients who were suspected as having a CAD within 1 month of onset. For T1 VISTA, the diagnosis of the dissection was based on the presence of intramural high-signal, intimal flap, double lumen and aneurysmal dilation. The final diagnosis of dissection was based on the clinical history, physical examination, and all of the imaging tests.ResultsA total of 46 patients were included in this study. The final diagnosis of CAD was made for 21 patients. Diagnosis of dissection was made for 20 of the 21 patients after assessing T1 VISTA. A definitive diagnosis of dissection was not made for 5 patients (including 3 patients with digital subtraction angiography) before the T1 VISTA examination. The sensitivity and specificity for T1 VISTA were 95.2% (95% CI, 76.2% to 99.9%) and 100% (95% CI, 86.3% to 100%), respectively. The agreement between the two researchers for T1 VISTA for diagnosis of CAD was very good (k=0.91). For patients without acute artery occlusion, all of them had a definite conclusion with or without dissection by T1 VISTA (n=29). However, for 17 patients with acute artery occlusion, the possibility of dissection could not be excluded for 6 of them by T1 VISTA (p=0.001).Conclusions3D T1 VISTA at 3.0 Tesla was useful in the diagnosis of acute CAD. However, for some patients with total occlusion of the artery without typical imaging features of dissection, the unequivocal distinction between intramural haematoma and intraluminal thrombus may be not adequate by T1 VISTA alone. Future studies should investigate whether a follow-up scan, a contrast-enhanced imaging or an optimal VISTA technique could be useful.