Alyssa Sykuta, BCCCP, PharmD,
Critical Care Pharmacist
Riverside Methodist Hospital
Columbus, Ohio
Disclosure information not submitted.
Amber King, BCPS, PharmD
Associate Professor, Department of Pharmacy Practice
Thomas Jefferson University, United States
Disclosure information not submitted.
Title: Evaluation of Antiplatelet Timing in Ischemic Stroke Post-tPA and Mechanical Thrombectomy
Introduction: For management of acute ischemic stroke (AIS), tissue plasminogen activator (tPA) and mechanical thrombectomy (MT) with or without carotid artery stenting (CAS) are utilized to restore cerebral blood flow. Patients who meet criteria for pharmacologic and surgical intervention are recommended to receive both. Long-term, patients require antiplatelets (AP) to prevent recurrent AIS and thrombosis of CAS if placed. As both tPA and MT are associated with risk of hemorrhage, AP is commonly deferred for 24 hours post-tPA. However, select MT patients may be at a higher risk of reocclusion from incomplete revascularization or underlying atherosclerosis. Early initiation of AP within 24 hours of tPA may decrease the risk of further ischemia in these patients. There is a lack of data regarding the safety of early AP in patients who undergo MT after receiving tPA. Two retrospective studies of 56 patients have supported the safety of this practice; neither found an impact of early AP on bleed risk. More data is needed to determine the frequency and safety of this practice. Therefore, the primary objective of this study was to identify the incidence of early AP administration, defined as AP given within 24 hours of tPA. Secondary outcomes were median time to AP administration and risk of bleeding with early AP.
Methods: This was a single-center, retrospective study of patients admitted between 2017 and 2019 with a diagnosis of AIS. A total of 76 patients who received both tPA and MT were included in statistical analysis.
Results: Of 69 patients who received AP, 13 were started within 24 hours of tPA (18.8%). Most patients who underwent CAS received early AP (71.4%). The median time to administration of AP was 29 hours (range 2 to 360 hours). Five of the 76 patients analyzed experienced bleeding subsequent to tPA and MT. None of the early AP patients experienced bleeds.
Conclusion: Nearly 20% of patients who received tPA and MT also received early AP. Despite this incidence, none of the patients in the early AP cohort experienced hemorrhage. This retrospective study lays groundwork for prospective studies to evaluate the true impact of early AP initiation in patients at high risk of thrombosis post-tPA and MT.