Antithrombotic treatment after stroke due to intracerebral haemorrhage

Observation of the Therapeutic Effect of Dual Antiplatelet Therapy with Aspirin and Clopidogrel on the Incidence, Characteristics, and Outcome in Acute Ischemic Stroke Patients with Cerebral Microbleeds at a Teaching Hospital, China

Background

Cerebral microbleeds (CMBs) are an important risk factor for stroke recurrence and prognosis. However, there is no consensus on the safety of antiplatelet therapy in patients with ischemic stroke and CMBs.

Objective

This study aimed to observe the effects of dual antiplatelet therapy with aspirin and clopidogrel on bleeding conversion in patients with different degrees of CMBs.

Materials and Methods

An observational retrospective study was conducted on 160 patients with acute mild ischemic stroke admitted to the Stroke Center, Affiliated Hospital of Beihua University between March 2021 and December 2022. Patients were divided into the CMBs and non-CMB groups. The CMB group was then divided into the low, medium and high-risk groups. In two groups, all patients were administered dual antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg orally once a day for 21 days according to the Chinese Stroke Guidelines of 2018), and no other anticoagulant or antiplatelet drugs were administered during the treatment period. Head CT, National Institutes of Health Stroke Scale(NIHSS) and modified Rankin Scale (mRS) score were re-checked, and the number of bleeding conversions was calculated at 21 days.

Results

Five patients in the CMB group had intracranial hemorrhage (5/116, 4.3%), while no intracranial hemorrhage was observed in the non-CMB group. There were no differences in the conversion rate of cerebral hemorrhage, NIHSS score, or mRS score between two groups after dual antiplatelet therapy (p>0.05). The conversion rate of cerebral hemorrhage in the high-risk group was higher than that in the non-CMB group (p<0.05), but the NIHSS and mRS score showed no difference between the high-risk and non-CMB groups (p>0.05).

Conclusion

Dual antiplatelet therapy with aspirin and clopidogrel does not significantly increase the risk of bleeding transformation; however, it improves neurological recovery or long-term prognosis in patients with acute ischemic cerebral stroke complicated by low-risk and middle-risk CMBs.

Long-Term Outcomes in Patients With Spontaneous Cerebellar Hemorrhage: An International Cohort Study

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) in the cerebellum has a poor short-term prognosis, whereas data on the long-term case fatality and recurrent vascular events are sparse. Herewith, we aimed to assess the long-term case fatality and recurrence rate of vascular events after a first cerebellar ICH.

METHODS

In this international cohort study, we included patients from 10 hospitals (the United States and Europe from 1997 to 2017) aged ≥18 years with a first spontaneous cerebellar ICH who were discharged alive. Data on long-term case fatality and recurrence of vascular events (recurrent ICH [supratentoria or infratentorial], ischemic stroke, myocardial infarction, or major vascular surgery) were collected for survival analysis and absolute event rate calculation.

RESULTS

We included 405 patients with cerebellar ICH (mean age [SD], 72 [13] years, 49% female). The median survival time was 67 months (interquartile range, 23-100 months), with a cumulative survival rate of 34% at 10-year follow-up (median follow-up time per center ranged: 15-80 months). In the 347 patients with data on vascular events 92 events occurred in 78 patients, after initial cerebellar ICH: 31 (8.9%) patients had a recurrent ICH (absolute event rate, 1.8 per 100 patient-years [95% CI, 1.2-2.6]), 39 (11%) had an ischemic stroke (absolute event rate, 2.3 [95% CI, 1.6-3.2]), 13 (3.7%) had a myocardial infarction (absolute event rate, 0.8 [95% CI, 0.4-1.3]), and 5 (1.4%) underwent major vascular surgery (absolute event rate, 0.3 [95% CI, 0.1-0.7]). The median time to a first vascular event during follow-up was 27 months (interquartile range, 8.7-50 months), with a cumulative hazard of 47% at 10 years.

CONCLUSIONS

The long-term prognosis of patients who survive a first spontaneous cerebellar ICH is poor and comparable to that of patients who survive a first supratentorial ICH. Further identification of patients at high risk of vascular events following the initial cerebellar ICH is needed. Including patients with cerebellar ICH in randomized controlled trials on secondary prevention of patients with ICH is warranted.

Practical guide on left atrial appendage closure for the non-implanting physician: an international consensus paper

A significant proportion of patients who suffer from atrial fibrillation (AF) and are in need of thromboembolic protection are not treated with oral anticoagulation or discontinue this treatment shortly after its initiation. This undertreatment has not improved sufficiently despite the availability of direct oral anticoagulants which are associated with less major bleeding than vitamin K antagonists. Multiple reasons account for this, including bleeding events or ischaemic strokes whilst on anticoagulation, a serious risk of bleeding events, poor treatment compliance despite best educational attempts, or aversion to drug therapy. An alternative interventional therapy, which is not associated with long-term bleeding and is as effective as vitamin K anticoagulation, was introduced over 20 years ago. Because of significant improvements in procedural safety over the years, left atrial appendage closure, predominantly achieved using a catheter-based, device implantation approach, is increasingly favoured for the prevention of thromboembolic events in patients who cannot achieve effective anticoagulation. This management strategy is well known to the interventional cardiologist/electrophysiologist but is not more widely appreciated within cardiology or internal medicine. This article introduces the devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. Almost all physicians who care for adult patients will have many with AF. This practical guide, written within guideline/guidance boundaries, is aimed at those non-implanting physicians who may need to refer patients for consideration of this new therapy, which is becoming increasingly popular.

Long-Term Risk of Arterial Thrombosis After Intracerebral Hemorrhage: MUCH-Italy

BACKGROUND

The identification of patients surviving an acute intracerebral hemorrhage who are at a long-term risk of arterial thrombosis is a poorly defined, crucial issue for clinicians.

METHODS

In the setting of the MUCH-Italy (Multicenter Study on Cerebral Haemorrhage in Italy) prospective observational cohort, we enrolled and followed up consecutive 30-day intracerebral hemorrhage survivors to assess the long-term incidence of arterial thrombotic events, to assess the impact of clinical and radiological variables on the risk of these events, and to develop a tool for estimating such a risk at the individual level. Primary end point was a composite of ischemic stroke, myocardial infarction, or other arterial thrombotic events. A point-scoring system was generated by the β-coefficients of the variables independently associated with the long-term risk of arterial thrombosis, and the predictive MUCH score was calculated as the sum of the weighted scores.

RESULTS

Overall, 1729 patients (median follow-up time, 43 months [25th to 75th percentile, 69.0]) qualified for inclusion. Arterial thrombotic events occurred in 169 (9.7%) patients. Male sex, diabetes, hypercholesterolemia, atrial fibrillation, and personal history of coronary artery disease were associated with increased long-term risk of arterial thrombosis, whereas the use of statins and antithrombotic medications after the acute intracerebral hemorrhage was associated with a reduced risk. The area under the receiver operating characteristic curve of the MUCH score predictive validity was 0.716 (95% CI, 0.56-0.81) for the 0- to 1-year score, 0.672 (95% CI, 0.58-0.73) for the 0- to 5-year score, and 0.744 (95% CI, 0.65-0.81) for the 0- to 10-year score. C statistic for the prediction of events that occur from 0 to 10 years was 0.69 (95% CI, 0.64-0.74).

CONCLUSIONS

Intracerebral hemorrhage survivors are at high long-term risk of arterial thrombosis. The MUCH score may serve as a simple tool for risk estimation.

Antiplatelet Agent Use After Stroke due to Intracerebral Hemorrhage

This focused update about antiplatelet agents to reduce the high risk of major adverse cardiovascular events after stroke due to spontaneous (nontraumatic) intracerebral hemorrhage (ICH) complements earlier updates about blood pressure-lowering, lipid-lowering, and oral anticoagulation or left atrial appendage occlusion for atrial fibrillation after ICH. When used for secondary prevention in people without ICH, antiplatelet agents reduce the risk of major adverse cardiovascular event (rate ratio, 0.81 [95% CI, 0.75-0.87]) and might increase the risk of ICH (rate ratio, 1.67 [95% CI, 0.97-2.90]). Before 2019, guidance for clinical decisions about antiplatelet agent use after ICH has focused on estimating patients' predicted absolute risks and severities of ischemic and hemorrhagic major adverse cardiovascular event and applying the known effects of these drugs in people without ICH to estimate whether individual ICH survivors in clinical practice might be helped or harmed by antiplatelet agents. In 2019, the main results of the RESTART (Restart or Stop Antithrombotics Randomized Trial) randomized controlled trial including 537 survivors of ICH associated with antithrombotic drug use showed, counterintuitively, that antiplatelet agents might not increase the risk of recurrent ICH compared to antiplatelet agent avoidance over 2 years of follow-up (12/268 [4%] versus 23/268 [9%]; adjusted hazard ratio, 0.51 [95% CI, 0.25-1.03]; P=0.060). Guidelines in the United States, Canada, China, and the United Kingdom and Ireland have classified the level of evidence as B and indicated that antiplatelet agents may be considered/reasonable after ICH associated with antithrombotic agent use. Three subsequent clinical trials have recruited another 174 participants with ICH, but they will not be sufficient to determine the effects of antiplatelet therapy on all major adverse cardiovascular events reliably when pooled with RESTART. Therefore, ASPIRING (Antiplatelet Secondary Prevention International Randomized Study After Intracerebral Hemorrhage) aims to recruit 4148 ICH survivors to determine the effects of antiplatelet agents after ICH definitively overall and in subgroups.

Poor Representation of Developing Countries in Editorial Boards of Leading Obstetrics and Gynaecology Journals

Evidence suggests a limited contribution to the total research output in leading obstetrics and gynaecology journals by researchers from the developing world. Editorial bias, quality of scientific research produced and language barriers have been attributed as possible causes for this phenomenon. The aim of this study was to understand the prevalence of editorial board members based out of low and lower-middle income countries in leading journals in the field of obstetrics and gynaecology. The top 21 journals in the field of obstetrics and gynaecology were selected based on their impact factor, SCImago ranking and literature search. The composition of the editorial boards of these journals was studied based on World Bank Income Criteria to understand the representation status of researchers from low and lower-middle income countries. A total of 1315 board members make up the editorial composition of leading obstetrics and gynaecology journals. The majority of these editors belong to high-income countries (n = 1148; 87.3%). Low (n = 6; 0.45%) and lower-middle income (n = 55; 4.18%) countries make up for a very minuscule proportion of editorial board members. Only a meagre 9 out of 21 journals have editorial board members from these countries (42.85%). Low and low-middle countries have poor representation in the editorial boards of leading obstetrics and gynaecology journals. Poor representation in research from these countries has grave consequences for a large proportion of the global population and multidisciplinary collaborative efforts must be taken to rapidly change this statistic with immediate effect.