Does Antiplatelet Therapy during Bridging Thrombolysis Increase Rates of Intracerebral Hemorrhage in Stroke Patients?

Broeg-Morvay, Anne; Mordasini, Pasquale; Slezak, Agnieszka Anna; Liesirova, Kai Timo; Meisterernst, Julia Anne; Schroth, Gerhard; Arnold, Marcel; Jung, Simon; Mattle, Heinrich; Gralla, Jan; Fischer, Urs

doi:10.1371/journal.pone.0170045

Cited by 25 publications

(23 citation statements)

References 32 publications

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“…17 Similarly, patients with elevated platelet counts on admission undergoing thrombectomy might benefit from more aggressive antiaggregation therapy because it does not necessarily increase the risk of intracranial hemorrhage or impact clinical outcome negatively in those who benefit from carotid stenting despite having received intravenous recombinant tissue-type plasminogen activator. 18 Aspirin may not be sufficient, however, since 4 of 16 (25%) with early reocclusion were under such therapy at the time of admission in our cohort. However, although sustained reperfusion is of utmost importance, an overly aggressive antiplatelet might be counterproductive by theoretically increasing the risk of intracranial hemorrhage.…”

Section: Strokementioning

confidence: 70%

Predictors of Unexpected Early Reocclusion After Successful Mechanical Thrombectomy in Acute Ischemic Stroke Patients

Mosimann¹,

Kaesmacher²,

Gautschi³

et al. 2018

Stroke

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Background and Purpose-Sustained successful reperfusion is an important prognostic factor for good clinical outcome in acute ischemic stroke. We aimed to identify the prevalence, clinical impact, and predictors of early reocclusion after initially successful thrombectomies within a prospective cohort. Methods-A total of 711 stroke patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b/3) followed with magnetic resonance or computed tomographic angiography at 24 to 48 hours were included. Multivariable logistic regression analysis was used to evaluate associated factors and clinical impact. Results are displayed as adjusted odds ratio (aOR) and 95% CI. Improvement in accuracy of additional imaging findings on angiography control runs after the intervention was evaluated by area under the curve. Results-Early reocclusion was observed in 16 of 711 successfully reperfused patients (2.3%; 95% CI: 1.1-3.3; median delay: 20 hours). Suggestive predictors were higher platelets on admission (aOR, 1.01; 95% CI: 1.01-1.02), prestroke functional dependence (aOR, 7.12; 95% CI: 1.49-34.03), and stroke of undetermined or other specified pathogenesis in the TOAST classification (aOR, 7.19; 95% CI: 1.10-47.05 and aOR, 36.50; 95% CI: 4.47-298.11, respectively). When implementing residual embolic fragments or stenosis at the thrombectomy site into the logistic regression model, discrimination between patients with and without reocclusion improved significantly (area under the curve, 0.955 versus 0.854; P=0.023). Early reocclusion was an independent predictor of unfavorable outcome at 90 days (aOR for modified Rankin Scale ≤2, 0.13; 95% CI: 0.03-0.57). Conclusions-Early reocclusion within 48 hours after successful mechanical thrombectomy is rare but associated with poor outcome. Patients with high platelets on admission and residual embolic fragments or stenosis at the thrombectomy site are at high risk for reocclusion, which may be prevented or corrected after carefully re-evaluating the past angiographic run. (Stroke. 2018;49:00-00.

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Section: Strokementioning

confidence: 70%

Predictors of Unexpected Early Reocclusion After Successful Mechanical Thrombectomy in Acute Ischemic Stroke Patients

Mosimann¹,

Kaesmacher²,

Gautschi³

et al. 2018

Stroke

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“…However, the use of adjunctive antiplatelet therapy with PCI poses a significant risk of bleeding with endovascular treatment for AIS. There are presently no clinical trials evaluating the safety, outcomes and the role of dual antiplatelet therapy with endovascular treatment for AIS, but a retrospective study conducted by Broeg-Morvay et al (44), evaluating the use of aspirin + IV-tPA + endovascular therapy versus IV-tPA + endovascular therapy without aspirin showed no increase in intracranial hemorrhage between the groups, and outcomes at 3 months did not differ. Further trials are needed to assess the safety of antiplatelet therapies with cerebral endovascular procedures.…”

Section: Management Of Simultaneous CCImentioning

confidence: 99%

Simultaneous acute cardio-cerebral infarction: is there a consensus for management?

et al. 2018

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Acute ischemic stroke (AIS) and acute myocardial infarction (AMI) are both life-threatening medical conditions with narrow therapeutic time-window that carry grave prognosis if not addressed promptly. The acute management of both condition is well documented in the literature, however the management of a simultaneous presentation of both AIS and AMI is unclear. A delayed intervention of one infarcted territory for the other may result in permanent irreversible morbidity or disability, and even death. In addition, the use of antiplatelet and anticoagulants that are inherently part of an AMI management may increase the risk for hemorrhagic conversion associated with intravenous thrombolysis used in AIS, and the use of a thrombolytic in AIS increases the risk of cardiac wall rupture in the setting of an AMI.Despite this ambiguity, there is no clear evidence-based guideline or clinical studies that have addressed the optimal management of this rare co-occurrence. This review paper examines the existing literature on the management of simultaneous acute cardio-cerebral infarction (CCI) and highlights the existing challenge to management.

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“…Clinical data from 65 stroke patients show that the co-administration of rt-PA with Argatroban, a direct thrombin inhibitor, increases the fibrinolytic effect of rt-PA [ 41 ] and enhances recanalization rates, as shown in the TARTS (rt-PA Argatroban Stroke Study) clinical study [ 42 ]. In humans, although clinical trials evaluating the combination of antiplatelet therapy to thrombolysis were stopped early because of an increased rate of intracerebral hemorrhage [ 43 , 44 ], a recent retrospective analysis of stroke patients who received bridging thrombolysis with aspirin during endovascular intervention showed that the combination therapy does not increase the risk of bleeding complications [ 45 ].…”

Section: Recanalization Failurementioning

confidence: 99%

Improving Cerebral Blood Flow after Arterial Recanalization: A Novel Therapeutic Strategy in Stroke

Amki

Wegener

2017

IJMS

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Ischemic stroke is caused by a disruption in blood supply to a region of the brain. It induces dysfunction of brain cells and networks, resulting in sudden neurological deficits. The cause of stroke is vascular, but the consequences are neurological. Decades of research have focused on finding new strategies to reduce the neural damage after cerebral ischemia. However, despite the incredibly huge investment, all strategies targeting neuroprotection have failed to demonstrate clinical efficacy. Today, treatment for stroke consists of dealing with the cause, attempting to remove the occluding blood clot and recanalize the vessel. However, clinical evidence suggests that the beneficial effect of post-stroke recanalization may be hampered by the occurrence of microvascular reperfusion failure. In short: recanalization is not synonymous with reperfusion. Today, clinicians are confronted with several challenges in acute stroke therapy, even after successful recanalization: (1) induce reperfusion, (2) avoid hemorrhagic transformation (HT), and (3) avoid early or late vascular reocclusion. All these parameters impact the restoration of cerebral blood flow after stroke. Recent advances in understanding the molecular consequences of recanalization and reperfusion may lead to innovative therapeutic strategies for improving reperfusion after stroke. In this review, we will highlight the importance of restoring normal cerebral blood flow after stroke and outline molecular mechanisms involved in blood flow regulation.

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Does Antiplatelet Therapy during Bridging Thrombolysis Increase Rates of Intracerebral Hemorrhage in Stroke Patients?

Cited by 25 publications

References 32 publications

Predictors of Unexpected Early Reocclusion After Successful Mechanical Thrombectomy in Acute Ischemic Stroke Patients

Predictors of Unexpected Early Reocclusion After Successful Mechanical Thrombectomy in Acute Ischemic Stroke Patients

Simultaneous acute cardio-cerebral infarction: is there a consensus for management?

Improving Cerebral Blood Flow after Arterial Recanalization: A Novel Therapeutic Strategy in Stroke

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