Edited by: Tianxiao Li, Henan Provincial People's Hospital, China
Reviewed by: Yingkun He, Henan Provincial People's Hospital, China
Zhi Mao, People's Liberation Army General Hospital, China
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Mechanical thrombectomy (MT) is one of the effective treatment methods for acute ischemic stroke (AIS), which requires a period of dual antiplatelet therapy (DAPT) after endovascular treatment. This study aimed to compare the efficacy and safety of 3-month DAPT and 1-month DAPT in AIS patients receiving MT through a retrospective study.
AIS patients who received MT from May 2018 to March 2023 were grouped into a 1-month group (1-M group) and a 3-month group (3-M group) according to the duration of DAPT after MT. The primary outcome was the mRS score at 90 days. Secondary outcomes included a good prognosis (mRS score of 0–2) at 90 days post-surgery, 6-month mortality, recurrence of cerebral infarction, Barthel's index, Montreal Cognitive Assessment (MoCA) score, and incidence of symptomatic intracranial hemorrhage (sICH) during hospitalization.
A total of 147 patients with AIS were included in the final analysis, with 78 patients in the 1-M group and 69 patients in the 3-M group. The baseline and neurological characteristics were comparable between both groups. At 3-month follow-up, a total of 61 patients had an mRS of 0–2 at 90 days, with an average mRS of 3.3 ± 0.9 for all patients. There was no statistically significant difference in the mRS between the two groups of patients at 90 days (P > 0.05). There was no statistically significant difference in the mortality rate and incidence of sICH between the two groups of patients during the 6-month follow-up period (P > 0.05), but the recurrence rate of AIS in the 3-M group was lower than that in the 1-M group (
For AIS patients undergoing mechanical thrombectomy, compared to 1-month DAPT, 3-month DAPT can reduce the recurrence rate of IS during a 6-month follow-up period, without increasing the mortality and risk of cerebral hemorrhage.
Stroke is one of the major diseases with a global burden, with acute ischemic stroke (AIS) being the predominant (
This study included AIS patients who were hospitalized from May 2018 to March 2023 for retrospective analysis. According to the duration of DAPT after MT, the patients were classified into a 1-month group (1-M group) and a 3-month group (3-M group). The inclusion criteria were as follows: age is ≥ 18 years; the diagnostic criteria for AIS is met (
After comprehensive evaluation on admission, the patient was immediately treated with MT. After sufficient local infiltration anesthesia with lidocaine, the Seldinger technique was used to puncture the right femoral artery, and then, an 8F arterial sheath was inserted, followed by aortic arch angiogram and cerebral angiography. After identifying the location of the thrombus, a thrombectomy was conducted. Stent thrombectomy: After passing through the occluded area and confirming the true lumen of the blood vessel, the microwire and microcatheter were inserted into the Solitaire FR stent (Medtronic Ltd, USA), and then, the thrombectomy device was retrieved under negative pressure. Thrombolysis: under the guidance of microwires, the Sofia aspiration catheter (MicroVention Ltd, USA) or ACE aspiration catheter (Penumbra Inc., USA) was inserted until it met the thrombus, and then, negative pressure was maintained and aspiration was performed for 90 s. After removing the thrombus, a repeated cerebral angiography was performed to evaluate the treatment effect and the presence of bleeding. If the residual stenosis rate in the local area was >70% or if a small thrombus escaped from the distal end, measures such as balloon angioplasty, stent implantation, and intra-arterial thrombolysis were used for remediation.
Patients in the 1-M group received 100 mg oral aspirin and 75 mg clopidogrel daily for 1 month after endovascular treatment. The 3-M group received DAPT treatment according to the same protocol, lasting for 3 months. After the completion of DAPT, aspirin was continued for at least 1 year. If patients have diabetes, hypertension, and coronary heart disease, they should be treated according to relevant guidelines. Specifically, both groups of patients received atorvastatin at a daily dose of 20–40 mg.
In this study, all patients underwent regular outpatient follow-up at 1 month, 3 months, and 6 months after surgery. The information of follow-up included the following: postoperative mRS score at 90 days and adverse events, mainly including death, recurrence of cerebral infarction, and symptomatic intracranial hemorrhage (sICH). The follow-up was conducted in an outpatient clinic, by telephone, or through WeChat.
All data were collected from the electronic medical record system. Baseline data include age, gender, smoking history, alcohol use, disease history, physical examination results, laboratory test results, and imaging results on admission. Information on in-hospital management and all follow-up outcomes was collected. The primary outcome was the mRS score at 90 days. The mRS score was assessed by physical examination in an outpatient clinic 90 days after onset. Secondary outcomes included a good prognosis (mRS score of 0–2) 90 days after the endovascular intervention, mortality, recurrence of cerebral infarction, Barthel's index, Montreal Cognitive Assessment (MoCA) score, and incidence of sICH at the 6-month follow-up. The prespecified adverse event was sICH defined by the National Institute of Neurological Disorders and Stroke (NINDS) criteria.
Statistical Package for the Social Sciences (SPSS, version 24.0, USA) was used to analyze data. Continuous data with normal distribution were presented as mean ± standard deviation and compared between two groups using a two-sample independent
According to the inclusion and exclusion criteria, a total of 147 patients with AIS were included in the final analysis. Among these patients, there were 108 (73.5%) patients with hypertension, 44 (29.9%) with type 2 diabetes, and 99 (67.3%) with hyperlipidemia. Seventy-eight patients received 1-month DAPT with 100 mg aspirin daily and 75 mg clopidogrel daily, and the remaining 69 patients were treated with DAPT for 3 months. A comparison between the 1-M group and the 3-M group showed no statistical difference regarding baseline characteristics (
Baseline characteristics.
| Age (years) | 63.1 ± 7.8 | 64.3 ± 9.1 | 0.861 | 0.391 |
| Male ( |
54 (69.2) | 51 (73.9) | 0.393 | 0.531 |
| Smoking ( |
24 (30.8) | 28 (40.6) | 1,541 | 0.214 |
| Alcohol use ( |
41 (52.6) | 30 (43.5) | 1.210 | 0.271 |
| Hypertension ( |
55 (70.5) | 53 (76.8) | 0.745 | 0.388 |
| Diabetes ( |
21 (26.9) | 23 (33.3) | 0.717 | 0.397 |
| Hyperlipidemia ( |
52 (66.7) | 47 (68.1) | 0.035 | 0.852 |
| BMI (kg/m2) | 25.3 ± 3.9 | 24.8 ± 4.0 | 0.766 | 0.445 |
| SBP (mmHg) | 154.6 ± 13.2 | 157.1 ± 14.9 | 1.079 | 0.282 |
| FG (mmol/L) | 7.3 ± 1.1 | 7.0 ± 1.2 | 1.581 | 0.116 |
| TC (mmol/L) | 5.9 ± 0.8 | 5.8 ± 1.0 | 0.673 | 0.502 |
| TG (mmol/L) | 2.8 ± 0.9 | 3.0 ± 0.8 | 1.416 | 0.159 |
| PT (s) | 12.5 ± 1.9 | 12.7 ± 2.0 | 0.621 | 0.535 |
| APTT (s) | 30.3 ± 4.5 | 29.6 ± 4.8 | 0.912 | 0.363 |
BMI, body mass index; SBP, systolic blood pressure; FG, fasting glucose; TC, total cholesterol; TG, triglyceride; PT, prothrombin time; APTT, activated partial thrombin time.
The time from onset to initiation of MT in patients is 3–14 h, with an average of 6.1 ± 1.5 h. A comparison of neurological characteristics between the 1-M group and the 3-M group also found no statistically significant difference (all
Neurological characteristics.
| Onset to MT time (h) | 5.9 ± 1.4 | 6.3 ± 1.7 | 1.564 | 0.120 |
| NIHSS score | 17.6 ± 3.1 | 18.2 ± 3.5 | 1.102 | 0.272 |
| Diameter of lesions (mm) | 3.5 ± 0.8 | 3.7 ± 0.9 | 1.426 | 0.156 |
| Culprit vessels ( |
0.237 | 0.626 | ||
| MCA | 49 (62.8) | 46 (66.7) | ||
| ICA | 29 (37.2) | 23 (33.3) | ||
| IDS ( |
4 (5.1) | 3 (4.3) | 0.028 | 0.868 |
MTG, mechanical thrombectomy group; CG, control group; MoCA, Montreal cognition assessment; TOAST, Trial of Org 10172 in Acute Stroke Treatment; IDS, intracranial decompression surgery.
The follow-up results (
Comparison of follow-up results between the two groups of patients.
| 90-d mRS | 3.4 ± 0.9 | 3.2 ± 1.0 | 1.276 | 0.204 |
| mRS 0-2 ( |
31 (39.7) | 30 (43.5) | 0.210 | 0.646 |
| Death ( |
5 (6.4) | 6 (8.7) | 0.276 | 0.599 |
| AIS recurrence ( |
9 (11.5) | 2 (2.9) | 3.948 | 0.047 |
| sICH ( |
1 (1.3) | 2 (2.9) | 0.011 | 0.914 |
| Barthel improvement | 37.6 ± 5.5 | 39.3 ± 5.7 | 1.839 | 0.068 |
| MoCA improvement | 8.9 ± 2.6 | 9.7 ± 2.9 | 1.764 | 0.080 |
sICH, symptomatic intracranial hemorrhage; MoCA, Montreal cognition assessment.
The preliminary results of this study indicate that 3-month DAPT after MT can significantly reduce the risk of AIS recurrence in AIS patients while not increasing the risk of death and sICH. Our study also found that 3-month DAPT showed a trend toward further improvement in patients' daily living conditions and cognitive abilities.
For AIS patients with non-cardiogenic embolism, the mechanism of culprit vessel occlusion is similar to that of acute myocardial infarction, which is the formation of a thrombus caused by the rupture of an unstable atherosclerotic plaque, leading to vascular occlusion. These AIS patients are often known to have hypertension, diabetes, and hyperlipidemia. In this study, patients with hypertension, diabetes, and hyperlipidemia accounted for 73.5%, 29.9%, and 67.3%, respectively. Moreover, this study excluded AIS caused by cardiogenic thrombus, so the pathogenesis of AIS patients in this study may be atherosclerosis. In the treatment of unstable atherosclerotic plaque, antiplatelet drugs are mainly used to prevent thrombosis, while intensive statin therapy is used to stabilize plaque (
Antiplatelet therapy is one of the main treatment measures for patients with acute ischemic stroke. In the CHANCE study, Wang et al. compared the efficacy and safety of DAPT with those of aspirin alone in the treatment of acute minor stroke or transient ischemic attack in a randomized controlled trial. The results showed that, compared with aspirin alone, DAPT significantly reduced the risk of stroke within 90 days after the attack, while it did not increase the risk of cerebral hemorrhage (
The antiplatelet mechanisms of aspirin and clopidogrel are different, and the combination of the two drugs can have a stronger effect than when using a single drug. Administering DAPT during the acute phase of AIS can effectively prevent thrombus formation at the target lesion site after MT. After a certain period of comprehensive treatment, including antihypertensives, hypoglycemics, and statin drugs, the blood vessels at the target lesion site can be repaired and endothelial function can be restored. However, the exact duration required for endothelial function recovery is currently unclear. Previous studies have focused more on the use of antiplatelet drugs in patients with cerebrovascular disease after stent placement. In the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study, patients received DAPT with 75 mg/day of clopidogrel and 325 mg/day of aspirin for 3 months. At an average follow-up of 11.9 months, safety evaluations indicated that the incidence of sICH in the stent implantation group compared to that in the intensified drug group was 3.6% (8 cases) vs. 0.4% (1 case) (
Our research findings also suggest that, compared to 1-month DAPT, 3-month DAPT has a trend toward further improvement in patients' daily living and cognitive abilities, which was suggested by slight improvement in Barthel index and MoCA scores. The relatively small sample size of the present study and short follow-up duration might be the reasons for no statistical significance. This finding may be related to the more effective preventive effect of longer DAPT on ischemic stroke, especially in the prevention of minor ischemic stroke or transient ischemic attack. However, currently, there is a lack of evidence to support it.
There are some limitations in this study. First, this study is a single-center study with a small sample size. Second, this study is a retrospective study, and some patients were excluded due to incomplete data, which may lead to case selection bias. Third, there is insufficient information on the retrospective data to assess the presence of asymptomatic mild cerebral hemorrhage. In the future, multicenter, large-sample randomized controlled studies with long-term follow-up are needed to further evaluate the efficacy and safety of 3-month DAPT in AIS patients undergoing mechanical thrombectomy.
The results of this study indicate that a 3-month DAPT can safely and effectively reduce the risk of IS in AIS patients undergoing mechanical thrombectomy during a 6-month follow-up period.
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.
The studies involving humans were approved by the Ethics Committee of Bethune International Peace Hospital. The studies were conducted in accordance with the local legislation and institutional requirements. The Ethics Committee/institutional review board waived the requirement of written informed consent for participation from the participants or the participants' legal guardians/next of kin due to the retrospective nature of the study.
LL: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Writing – original draft, Writing – review & editing. ZL: Data curation, Formal analysis, Investigation, Writing – original draft. CL: Data curation, Formal analysis, Investigation, Writing – original draft. BC: Data curation, Resources, Software, Validation, Writing – original draft. QJ: Investigation, Methodology, Writing – original draft.
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.