Prior antiplatelet therapy in patients undergoing endovascular treatment for acute ischemic stroke: Results from the MR CLEAN Registry.

Rob A Van De Graaf,Aad Van Der Lugt,Adriaan Cgm Van Es,Diederik Wj Dippel,Sanne M Zinkstok,Hester F Lingsma,Robert-Jan B Goldhoorn,Vicky Chalos,Bob Roozenbeek,Robert J Van Oostenbrugge,Yvo Bwem Roos,Charles Blm Majoie

doi:10.1177/1747493020946975

Abstract

BackgroundAntiplatelet therapy may increase the risk of symptomatic intracranial hemorrhage after endovascular treatment for ischemic stroke but may also have a beneficial effect on functional outcome. The aim of this study is to compare safety and efficacy outcomes after endovascular treatment in patients with and without prior antiplatelet therapy.MethodsWe analyzed patients registered in the MR CLEAN Registry between March 2014 and November 2017, for whom data on antiplatelet therapy were available. We used propensity score nearest-neighbor matching with replacement to balance the probability of receiving prior antiplatelet therapy between the prior antiplatelet therapy and no prior antiplatelet therapy group and adjusted for baseline prognostic factors to compare these groups. Primary outcome was symptomatic intracranial hemorrhage. Secondary outcomes were 90-day functional outcome (modified Rankin Scale), successful reperfusion (extended thrombolysis in cerebral infarction score ≥2B) and 90-day mortality.ResultsThirty percent (n = 937) of the 3154 patients were on prior antiplatelet therapy, who were matched to 477 patients not on prior antiplatelet therapy. Symptomatic intracranial hemorrhage occurred in 74/937 (7.9%) patients on prior antiplatelet therapy and in 27/477 (5.6%) patients without prior antiplatelet therapy adjusted odds ratio 1.47, 95% confidence interval 0.86–2.49. No associations were found between prior antiplatelet therapy and functional outcome (adjusted common odds ratio 0.87, 95% confidence interval 0.65–1.16), successful reperfusion (adjusted odds ratio 1.23, 95% confidence interval 0.77–1.97), or 90-day mortality (adjusted odds ratio 1.15, 95% confidence interval 0.86–1.54).ConclusionWe found no evidence of an association of prior antiplatelet therapy with the risk of symptomatic intracranial hemorrhage after endovascular treatment, nor on functional outcome, reperfusion, or mortality. A substantial beneficial or detrimental effect of antiplatelet therapy on clinical outcome cannot be excluded. A randomized clinical trial comparing antiplatelet therapy versus no antiplatelet therapy is needed.

Highlights

50% of patients with ischemic stroke do not recover to functional independence after endovascular treatment (EVT).[1]
March 2014 and November 2017 and adhered to the following criteria: age 18 years or older; treatment in a center that participated in the MR CLEAN trial; presence of a proximal intracranial occlusion in the anterior circulation confirmed on computed tomography angiography (CTA) (intracranial carotid artery (ICA), intracranial carotid artery terminus (ICA-T), middle cerebral artery (M1/M2), or anterior cerebral artery (A1/A2)); and groin puncture within 6.5 h after symptom onset and known data on prior antiplatelet therapy
We reported occurrence of stroke progression and new ischemic stroke, which showed a non-significant trend toward lower occurrence in patients who were on prior antiplatelet therapy

Summary

Introduction

50% of patients with ischemic stroke do not recover to functional independence after endovascular treatment (EVT).[1]. The formation of microthrombi might be promoted by vessel wall damage caused by EVT.[2,3] Use of antiplatelet drugs could potentially reduce periprocedural formation of microthrombi by inhibiting platelet aggregation and inflammation of the vessel wall, which could improve microvascular reperfusion.[3] On the other hand, one randomized trial showed that antiplatelet therapy increases the risk of symptomatic intracranial hemorrhage (sICH) when administered early—within 90 min—after intravenous treatment with alteplase.[4] this trial did not focus on the subpopulation of patients with ischemic stroke caused by a large vessel occlusion undergoing EVT. The aim of this study is to compare safety and efficacy outcomes after endovascular treatment in patients with and without prior antiplatelet therapy

Objectives

Methods

Results

Conclusion