Treatment of acute ischaemic stroke with thrombolysis or thrombectomy in patients receiving anti-thrombotic treatment

Summary Systemic thrombolysis with alteplase is the only approved medical treatment for patients with acute ischaemic stroke. Thrombectomy is also increasingly used to treat proximal occlusions of the cerebral arteries, but has not shown superiority over systemic thrombolysis with alteplase. Many pa...

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Bibliographic Details
Published in:Lancet neurology 2013-07, Vol.12 (7), p.677-688
Main Authors: Diener, Hans-Christoph, Prof, Foerch, Christian, MD, Riess, Hanno, Prof, Röther, Joachim, Prof, Schroth, Gerhard, Prof, Weber, Ralph, MD
Format: Article
Language:English
Subjects:
Animals
Anticoagulants
Anticoagulants - therapeutic use
Aspirin
Brain Ischemia - complications
Brain Ischemia - drug therapy
Cerebral Hemorrhage - etiology
Clinical outcomes
Drug dosages
Fibrinolytic Agents - therapeutic use
Hemorrhage
Humans
Ischemia
Mortality
Neurology
Observational studies
Plasminogen Activators - adverse effects
Plasminogen Activators - therapeutic use
Platelet Aggregation Inhibitors - therapeutic use
Randomized Controlled Trials as Topic
Stroke
Stroke - drug therapy
Stroke - etiology
Thrombectomy - adverse effects
Thrombectomy - methods
Thrombolytic Therapy - adverse effects
Thrombolytic Therapy - methods
Tissue Plasminogen Activator - adverse effects
Tissue Plasminogen Activator - therapeutic use
Warfarin - therapeutic use
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Summary:Summary Systemic thrombolysis with alteplase is the only approved medical treatment for patients with acute ischaemic stroke. Thrombectomy is also increasingly used to treat proximal occlusions of the cerebral arteries, but has not shown superiority over systemic thrombolysis with alteplase. Many patients with acute ischaemic stroke are pretreated with antiplatelet or anticoagulant drugs, which can increase the bleeding risk of thrombolysis or thrombectomy. Pretreatment with aspirin monotherapy increases the bleeding risk of alteplase in both observational and randomised trials with no effect on clinical outcome, and the risk of intracerebral haemorrhage is increased with the combination of aspirin and clopidogrel. Antiplatelet drugs should not be given in the first 24 h after alteplase treatment. Data from pooled randomised trials and a large observational study show that thrombolysis can probably be done safely in patients given vitamin-K antagonists if the international normalised ratio is less than 1·7, although bleeding risk is slightly raised. Almost no data are available for the safety of alteplase in patients with atrial fibrillation who have been given novel oral anticoagulants (NOAC) for stroke prevention. Some coagulation parameters could help to identify patients treated with NOAC who might be eligible for thrombolysis. Thrombectomy can be done in patients given antiplatelets and probably in those given anticoagulants; however, conclusions about anticoagulants are based on findings from observational studies with small patient numbers.
ISSN:1474-4422
1474-4465
DOI:10.1016/S1474-4422(13)70101-7