Risks and Benefits of Early Antithrombotic Therapy after Thrombolytic Treatment in Patients with Acute Stroke

Abstract

BackgroundCurrent guidelines recommend withholding antithrombotic therapy (ATT) for at least 24 h in patients with acute ischemic stroke treated with thrombolytic therapy. Herein, we report a retrospective analysis of a single-centre experience on the safety and efficacy of antithrombotic therapy (ATT) started before or after 24 h of intravenous thrombolysis in a cohort of acute ischemic stroke patients.MethodsA total of 139 patients (Rapid ATT group) received antithrombotic therapy before 24 h of thrombolysis, and 33 patients (Standard ATT group) after 24 h. The brain parenchyma and vessel status were assessed using simple CT scan on admission, multimodal CT scan at the end of thrombolysis, and angio-CT/MRI scan at day 3. Functional outcome was scored using the modified Rankin Scale (mRS) at day 90.ResultsThe two ATT groups had similar demographics, stroke subtypes, baseline NIHSS, thrombolytic strategies, vessel-patency rates at the end of thrombolysis, and incidence of bleeding complications at follow up. At day 3, the Rapid ATT group had a non-significant improved vessel-patency rate than the Standard ATT group. At day 90, a greater proportion of patients in the rapid ATT group had shifted down the mRS, and had improved in the NIHSS score.ConclusionsATT initiated before 24 h of intravenous thrombolytic therapy in acute stroke patients disclosed no safety concerns compared with a conventional antithrombotic therapy delay of 24 h and showed better functional outcome at follow up. The value of early initiation of ATT after thrombolysis deserves further assessment in randomized controlled trials.

Mechanisms of Unexplained Neurological Deterioration After Intravenous Thrombolysis

“…За исключением одного пациента (#4), представители этой группы не принимали антиагреганты до развития инсульта. Повторную МРТ провели через 29,4 часа [20,4] (медиана [межквартильный размах]) после начала системного тромболизиса ТАП в случаях РНУ, без существенных отличий от контрольной группы (25,4 часа [22,8]; р=0,288). РНУ развилось в тече-ние 0,5-23 часов после начала введения ТАП.…”

“…По всей видимости, в основе таких нарушений гемо-динамики не лежат системные факторы, например, резкое снижение артериального давления. Несмотря на то, что в настоящем исследовании не проводилась непосредственная оценка частоты развития вторичных тромбоэмболических событий, в случае их появле-ния стоит поднять вопрос о том, каковы методы их ранней и эффективной профилактики после внутривен-ного тромболизиса в рамках и за пределами рекоменду-емых в настоящее время низких доз аспирина, лечение которым следует начинать через 24 часа после тром-болизиса [22]. Для решения этих проблем в будущих исследованиях необходимо использовать комплексные продольные методы визуализации сосудов, тромбов и перфузии, а также интенсивный/непрерывный мони-торинг сердечного ритма, артериального давления, насыщения кислорода и глюкозы в крови, с целью выявления потенциально неблагоприятных событий и картирования коллатерального кровотока в качестве потенциального фактора риска развития РНУ.…”

“…Although secondary thromboembolic processes were not directly assessed here, if present they would raise the issue of how early and best to prevent them after intravenous thrombolysis over and beyond the currently recommended low-dose aspirin therapy started 24 hours after treatment. 22 To address these issues, future studies should implement comprehensive longitudinal vascular, thrombus, and perfusion imaging, as well as intensive/continuous monitoring of heart rate, blood pressure, oxygen saturation and blood glucose, to detect potentially untoward events and collaterals mapping as a potential risk factor for END. …”

Relevance of Blood–Brain Barrier Disruption After Endovascular Treatment of Ischemic Stroke

“…9 However, in the early post-ET period, this distinction is not feasible using conventional post-treatment CT. [2][3][4][5]10 Dual-energy CT (DE-CT) is a relatively new technique that allows for a reliable differentiation between tissue high attenuation areas related to iodine contrast material extravasation and parenchymal hemorrhage.11-13 The technique is based on the different attenuation effects of normal brain tissue, iodine, and blood at different irradiation energy levels. In patients receiving ET, DE-CT has shown a good accuracy for early differentiation between hemorrhage and contrast extravasation, but these studies did not address specifically the prognostic implications of this segregation.…”

“…9 However, in the early post-ET period, this distinction is not feasible using conventional post-treatment CT. [2][3][4][5]10 Dual-energy CT (DE-CT) is a relatively new technique that allows for a reliable differentiation between tissue high attenuation areas related to iodine contrast material extravasation and parenchymal hemorrhage.…”