Interview Conducted by Chirantan Banerjee, MD
Dr. Butcher:The key findings are that acute treatment with the Direct Oral Anticoagulant (DOAC) dabigatran within 24 hours of an acute ischemic stroke is feasible. Given the small sample size, we have not definitively proven safety of course, but the lack of symptomatic hemorrhagic transformation, and indeed the paucity of even sub–clinical HT on susceptibility weighted MRI, is encouraging. Certainly we saw no safety signal that would preclude pursuing this approach in a larger study, as we are currently.
Dr. Butcher: It is now recognized that early recurrent stroke after TIA/minor stroke is a frequent problem and new treatment target. Efforts to date have focused on anti-platelet approaches (CHANCE, POINT, SOCRATES). However, it has also been shown that occult paroxysmal AF is common in this population (CRYSTAL AF and EMBRACE). Thus, many patients with acute minor stroke/TIA will not benefit from anti-platelet approaches.
Dr. Butcher: There were really three:
1. The first was actually convincing some of our colleagues that hyper acute DOAC use was a reasonable concept. There was initially some trepidation on the part of some of our colleagues. 2. All patients needed an MRI scan before treatment, all within 24 hours. Even in a research center such as ours, this was a challenge. 3. Finally, there were competing trials that made enrollment a challenge (POINT and SOCRATES).
Dr. Butcher: The implications are that it may be reasonable to protect all patients with minor stroke, using dabigatran. Of course, this needs to be tested in a larger RCT. This is what we are doing now, with DATAS II, which randomizes 300 patients to ASA or dabigatran for 30 days.
Dr. Butcher: We are currently conducting DATAS II, as described above.
Dr. Butcher: I spend time with my kids. We all like to ski in the winter (cross country and downhill). I also play hockey (badly) and enjoy triathlon when time permits.