Abstract TP12: Safety of Antiplatelet Agents within 24 hours of Intra-arterial Thrombolytic Administration in Acute Ischemic Stroke Patients

Abstract

Background: Current American Heart Association guidelines recommend withholding all antiplatelet use within 24 hours of thrombolytic use because of concerns regarding an increased risk of intracerebral hemorrhage (ICH). The increased use of emergent thrombectomy, angioplasty, and stent placement in endovascular treatment of acute stroke has prompted a reconsideration of antiplatelet use within 24-hour period. Objective: To determine if there is an increased rate of poor outcomes and ICH in acute ischemic stroke patients that undergo intra-arterial thrombolysis (IAT) and are started on antiplatelets within 24 hours of thrombolytics. Methods: All IAT treated acute ischemic stroke patients identified through a prospective database maintained from two comprehensive stroke centers over a 6-year period. Patients’ clinical characteristics, timing of antiplatelet agents, rates of poor outcome at discharge (modified Rankin score [mRS] of >3) and ICH were obtained and analyzed. Results: Among the total 115 patients that underwent IAT, 65 patients (mean age 60 ± 16.4; 60% men) were started on antiplatelet agents within 24 hours. 43 (66%) patients were started on single antiplatelet, 19 (29%) on dual antiplatelet, and 3 (4.7%) on triple antiplatelet agents within 24 hours of IAT. The proportion of patients with admission NIHSS score>20 was similar in patients who received antiplatelet agents within 24 hours versus those who received them after 24 hours (22% versus 24%, p=0.8) Compared with patients in whom antiplatelets were started after 24 hours, there was no significant difference in the rates of post-procedure ICH (20% versus 9%, p=0.09) and in-hospital mortality (12% versus 12%, p=0.9) in patients started on antiplatelets within 24 hours. There was no significant difference in the rates of poor outcomes (64% versus 71%, p=0.5) between the two groups. Conclusions: Despite the existing recommendation advising against the initiation of antiplatelet agents within 24 hours of thrombolysis, there seems to be no significant risk of increased ICH or mortality with such a practice in IAT cases. Larger prospective studies are needed to identify the benefit of early initiation of antiplatelet agents before broad use is implemented.