treatment

Wayneho Kam, MD

Wu C, Sun C, Wang L, Lian Y, Xie N, Huang S, et al. Low-Dose Tirofiban Treatment Improves Neurological Deterioration Outcome After Intravenous Thrombolysis. Stroke. 2019.

The current standard of practice is to avoid the use of antithrombotic agents within the first 24 hours after receiving intravenous thrombolytics. This is due to concern that the concurrent use of antiplatelets or anticoagulants with recent thrombolytic administration may increase the risk for bleeding events. The concern may be unfounded, however, particularly given the relatively short half-life of alteplase.

There are instances, of course, when use of such medications within 24 hours of alteplase administration may be warranted, such as with concomitant endovascular therapy with stent placement or acute myocardial infarction.

What if early neurological deterioration occurs in patients after they received tPA, in the absence of a clear explanation, such as hemorrhagic conversion or cerebral edema? Will these patients benefit from early initiation of antiplatelet therapy?

Adeola Olowu, MD

Lambert EA, Esler MD, Schlaich MP, Dixon J, Eikelis N, Lambert GW. Obesity-Associated Organ Damage and Sympathetic Nervous Activity: A Target for Treatment? Hypertension. 2019;73:1150–1159.

The authors of this review focused on obesity and a potential target for treatment. Obesity and increased body mass index are risk factors for diseases such as stroke, cardiovascular disease, and other medical conditions. This brief review focused on cardiovascular studies, studies demonstrating an association between weight gain with blood pressure, cardiovascular abnormalities, renal function, and endothelial dysfunction and its relationship with biochemical sympathetic nervous activity.

Being overweight or obese is a growing medical condition worldwide. Obesity is unique to other cerebrovascular risk factors because it may be the sole risk factor an individual may have for quite some time. However, the lack of other cerebrovascular risk factors such as hypertension and diabetes does not make being overweight or obese harmless. The studies reviewed showed hypertension prevalence to be at least 16% higher in the obese population compared to the normal-weight population in the United States. Pre-hypertension was found in approximately 40% of obese men and 30% in obese women in China. Observational studies demonstrated elevated plasma norepinephrine and increased MSNA with weight gain.

Elena Zapata-Arriaza, MD
@ElenaZaps

García-Tornel A, Requena M, Rubiera M, Muchada M, Pagola J, Rodriguez-Luna D, et al. When to Stop: Detrimental Effect of Device Passes in Acute Ischemic Stroke Secondary to Large Vessel Occlusion. Stroke. 2019;50:1781–1788

The achievement of mTICI 3 after one pass, known as first pass effect, is clearly associated with better functional outcome, as compared with those patients with more passes needed to obtain full recanalization. But how many passes should we attempt before stop procedure? Or maybe we should pursue a good (TICI 2B) but not perfect recanalization, instead of seeking TICI 3, because such recanalization is more than enough for patient outcome?

These are some of the aims of this study, in addition to finding the relation between number of passes and recanalization degree and clinical outcome.

Alan C. Cameron, MB ChB, BSc (Hons), MRCP

Hackam DG, Spence JD. Antiplatelet Therapy in Ischaemic Stroke and Transient Ischaemic Attack. Stroke. 2019; 50:773–778.

Antiplatelet therapy reduces the burden of recurrent vascular events in patients with non-cardioembolic ischaemic stroke or TIA and the authors present an overview of major trials.  The IST and CAST studies, conducted over 20 years ago, highlight the benefits of aspirin in the acute setting and the benefits of aspirin in the longer term are demonstrated by the Antithrombotic Trialists’ Collaboration.  It was later shown that aspirin and dipyridamole in combination is more effective than aspirin alone, with most data coming from the ESPS-2 and ESPRIT studies, although dipyridamole requires twice daily dosing and many patients develop headache.  The PRoFESS trial shows rates of recurrent stroke are similar with clopidogrel compared to aspirin and dipyridamole, although clopidogrel has once-daily dosing and fewer patients develop headache.

The landmark CHANCE and POINT trials demonstrate that DAPT with clopidogrel and aspirin reduces the risk of stroke and vascular events in patients with high-risk TIA or minor stroke compared to aspirin alone and the benefit is confined to the early period.  This may explain why longer-term trials of DAPT (MATCH, SPS3 and CHARISMA) found no benefit. The SOCRATES trial found that DAPT with ticagrelor and aspirin is not superior to aspirin in reducing vascular events, although ticagrelor shows a strong trend toward reduced stroke in the acute setting and is more efficacious in patients with large artery disease or patients already taking aspirin.  The THALES trial is studying ticagrelor in this context and will help to better define the role of ticagrelor in acute stroke. Importantly, we can reduce the risk of haemorrhage associated with antiplatelet therapy by effectively managing bleeding risk factors, including blood pressure control, treatment of Helicobacter pylori infection and proton pump inhibitors for high risk patients.

Robert W. Regenhardt, MD, PhD
@rwregen

Jadhav AP, Zaidat OO, Liebeskind DS, Yavagal DR, Haussen DC, Hellinger FR, et al. Emergent Management of Tandem Lesions in Acute Ischemic Stroke: Analysis of the STRATIS Registry. Stroke. 2018;50:428–433.

With the 2015 trials irrefutably showing the superiority of endovascular thrombectomy (ET) over intravenous tPA alone for the treatment of stroke secondary to large vessel occlusion (LVO), and the 2018 trials showing it may be effective for up to 24 hours from symptom onset, current research efforts focus on expanding the number of patients who may be eligible for this highly effective treatment (e.g., larger core, more distal occlusions) and optimizing protocols for more complex cases. The latter is exemplified by questions that remain about the best approach to treating tandem lesions, which involve both the cervical internal carotid artery (ICA) and an intracranial artery. The most common etiology is cervical ICA atherosclerosis, but tandem lesions can also result from cervical ICA dissection.

Perhaps the biggest conundrum in the management of tandem lesions is whether or not to stent the cervical ICA in the acute setting. Given the risk of dual antiplatelet therapy, especially in patients who received tPA and have larger cores, some interventionalists choose to defer in the acute setting and offer stenting versus endarterectomy later. If stenting is offered in the acute setting, it is unclear whether cervical ICA stenting should be done before or after intracranial ET. Furthermore, the role of angioplasty and the optimum antithrombotic regimen have yet to be determined. There is limited data available to help guide these decisions. While many of the ET trials included patients with tandem lesions, the management was highly variable. Tandem lesions were present in 32% of MR CLEAN, 18% of REVASCAT, and 17% of ESCAPE, while they were excluded from SWIFT PRIME and EXTEND IA. An analysis of the 30 patients with tandem lesions that were treated with ET in ESCAPE showed 17 underwent cervical ICA stenting, 10 before and 7 after intracranial ET. Of the 13 for which stenting was deferred in the acute setting, only 4 underwent ICA revascularization later.