Rachel Forman, MD
Kim BJ, Kwon SU, Park J-H, Kim Y-J, Hong K-S, Wong LKS, et al. Cilostazol Versus Aspirin in Ischemic Stroke Patients With High-Risk Cerebral Hemorrhage: Subgroup Analysis of the PICASSO Trial. Stroke. 2019.
One of the most common discussions on any given stroke service involves the balance of preventing ischemic strokes (IS) and preventing intracranial hemorrhage (ICH). Whether it is about resuming anticoagulation in a hemorrhage patient or resuming aspirin in a patient with cerebral amyloid angiopathy there is always much debate on timing and decisions. The decision to resume aspirin in a patient with an MRI full of cerebral microbleeds (CMBs) is often difficult. This paper looks into an alternative agent, cilostazol, for reducing hemorrhage risk in patients who warrant anti-platelet therapy. The background of the study is that cilostazol has shown to have less hemorrhagic events than aspirin among patients with ischemic stroke.
The PICASSO trial (Prevention of Cardiovascular Events in Asian Ischemic Stroke Patients with High Risk of Cerebral Hemorrhage) was an Asian trial that aimed to determine which antiplatelet agent is more effective and safe in patients with prior hemorrhagic stroke or multiple CMBs. Cilostazol is an antiplatelet agent with additional vasodilatory effects. The trial, published in 2018, showed that cilostazol was noninferior to aspirin in preventing a composite of major vascular events; however, it failed to reduce ICH. This paper reviews the subgroup analysis to identify patients who would show greater benefit with cilostazol.