Dual antiplatelet therapy in acute ischemic stroke

Efficacy and safety of clopidogrel and/or aspirin for ischemic stroke/transient ischemic attack: An overview of systematic reviews and meta-analysis

OBJECTIVE

Patients experiencing acute ischemic stroke or transient ischemic attack are commonly treated with clopidogrel and/or aspirin (mono- and dual-antiplatelet therapy) to minimize the risk for recurrent stroke. Updated data from systematic studies can be used to guide practice. The present study aimed to compare findings from systematic reviews and meta-analyses addressing the efficacy and safety of clopidogrel or aspirin - alone or in combination - in patients experiencing acute ischemic stroke or transient ischemic attack.

METHODS

The Cochrane Library, PubMed, Ovid, Scopus, EBSCO, and CINAHL databases were searched for relevant studies published from inception to 2020. Data from each study were extracted independently using a predefined data abstraction form. The Risk of Bias in Systematic Reviews tool and A Measurement Tool to Assess Systematic Reviews 2 were used to evaluate risk of bias and the quality of the included studies.

RESULTS

Seven studies, published between 2010 and 2020, were eligible for analysis. The included studies evaluated a wide range of outcomes, including recurrent stroke, myocardial infarction, recurrent ischemic stroke, vascular mortality and vascular events, bleeding events, all-cause mortality, functional disability, and quality of life. The risk of bias and methodological validity of the included studies ranged from low to high according to ROBIS and AMSTAR 2 parameters. Results revealed that clopidogrel plus aspirin was more effective than aspirin alone in reducing the risk for recurrent stroke (ischemic or hemorrhagic), with high-quality evidence. However, compared with aspirin, dual treatment increased major bleeding events (intracranial bleeding and extracranial bleeding), supported by high-quality evidence.

CONCLUSIONS

High-quality evidence suggested that clopidogrel plus aspirin was more efficient than monotherapy, although the risk for hemorrhagic stroke was relatively higher in combined therapy regimens lasting >1 month.

Potential Drug-drug Interactions in Acute Ischemic Stroke Patients at the Neurological Intensive Care Unit

Background

Clinically relevant potential drug-drug interactions are considered preventable adverse drug reactions.

Objective

The aim of this study was to ascertain the frequency of potential drug-drug interactions in acute ischemic stroke patients and to explore factors associated with occurrence of potentially contraindicated drug-drug interactions.

Methods

This observational retrospective cohort and nested case-control study was carried out among patients treated for acute ischemic stroke at the Neurological Intensive Care Unit in the Clinical Centre Kragujevac, Serbia. The potentially drug-drug interactions for each day of hospitalization were identifi ed using Micromedex® soft ware. Based on the existence or absence of potentially contraindicated drug-drug interactions, the participants were divided into a group of cases (n=111) and the control group (n=444).

Results

A total of 696 patients were analysed. All patients had a minimum of one potential drug-drug interaction during hospitalization. The most common drugs involved in potential drug-drug interactions were aspirin (8.02%), diclofenac (7.49%) and warfarin (7.14%). The number of medications prescribed for simultaneous use during hospitalisation and the use of antipsychotics in therapy signifi cantly increased the likelihood of potentially contraindicated drug-drug interactions aft er adjustment by means of logistic regression for 1.2 and 3 times, respectively.

Conclusions

This study suggests that patients with acute ischemic stroke are frequently exposed to potential drug-drug interactions. It is essential to identify potentially drug-drug interactions in these patients as early as possible in order to prevent adverse drug reactions and ensure safe recovery. Besides, full attention should be paid when adding each new medication in therapy, particularly when a neurologist decides to prescribe antipsychotics, such as risperidone.

Neuroprotective effect of total flavonoids from Ilex pubescens against focal cerebral ischemia/reperfusion injury in rats

Ilex pubescens is commonly used in traditional Chinese medicine to treat cardiovascular and cerebrovascular diseases, such as coronary artery disease and stroke. However, the underlying mechanisms remain to be fully elucidated. The aim of the present study was to investigate the effects of Ilex pubescens total flavonoids (IPTF) on neuroprotection and the potential mechanisms in a rat model of focal cerebral ischemia/reperfusion (I/R) injury. Rats were pretreated with intragastric administration of IPTF at doses of 200 and 100 mg/kg for 5 days; middle cerebral artery occlusion surgery was then performed to induce cerebral I/R injury. Neurological deficits were determined using the 5‑point neurological function score evaluation system, brain infarct sizes were determined by 2,3,5‑triphenyltetrazolium chloride staining and alterations in brain histology were determined by hematoxylin and eosin staining. The neurological deficit score, the infarcted area and the brain tissue pathological injury were significantly reduced when the rats were pretreated with IPTF. In addition, inflammatory mediators and neurotrophic factors in the brain were investigated. IPTF pretreatment decreased the activities of total nitric oxide synthase (TNOS), induced NOS (iNOS) and constitutive NOS (cNOS), and the levels of nitric oxide (NO), interleukin‑1β (IL‑1β) and tumor necrosis factor‑α (TNF‑α), however, it increased the levels of IL‑10 in brain tissues. Furthermore, pretreatment with IPTF also increased the protein expressions of brain‑derived neurotrophic factor, glial cell‑derived neurotrophic factor and vascular endothelial growth factor, when compared with the model group. In conclusion, the results of the present study demonstrated that IPTF has a neuroprotective effect against focal cerebral I/R injury in rats. The mechanism may be associated with the decreased production of certain proinflammatory cytokines including NO, IL‑1β, TNF‑α, TNOS, iNOS and cNOS, the increased production of the anti‑inflammatory cytokine IL‑10 and the increased secretion of neurotrophic factors.

Lumbar puncture in patients using anticoagulants and antiplatelet agents

The use of anticoagulants and antiplatelet agents has largely increased. Diagnostic lumbar puncture in patients taking these drugs represents a challenge considering the opposing risks of bleeding and thrombotic complications. To date there are no controlled trials, specific guidelines, nor clear recommendations in this area. In the present review we make some recommendations about lumbar puncture in patients using these drugs. Our recommendations take into consideration the pharmacology of these drugs, the thrombotic risk according to the underlying disease, and the urgency in cerebrospinal fluid analysis. Evaluating such information and a rigorous monitoring of neurological symptoms after lumbar puncture are crucial to minimize the risk of hemorrhage associated neurological deficits. An individualized patient decision-making and an effective communication between the assistant physician and the responsible for conducting the lumbar puncture are essential to minimize potential risks.