Department of Neurosurgery, UTHealth McGovern Medical School, 6400 Fannin ST, Houston, TX 77030, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
J Stroke Cerebrovasc Dis. 2022 May;31(5):106396. doi: 10.1016/j.jstrokecerebrovasdis.2022.106396. Epub 2022 Feb 24.
Early recurrence of cerebral ischemia in acutely symptomatic carotid artery stenosis can precede revascularization. The optimal antithrombotic regimen for this high-risk population is not well established. Although antiplatelet agents are commonly used, there is limited evidence for the use of anticoagulants. We sought to understand the safety and efficacy of short-term preoperative anticoagulants in secondary prevention of recurrent cerebral ischemic events from acutely symptomatic carotid stenosis in patients awaiting carotid endarterectomy (CEA).
A retrospective query of a prospective single institution registry of carotid revascularization was performed. Patients who presented with acute ischemic stroke or transient ischemic attack (TIA) attributable to an ipsilateral internal carotid artery stenosis (ICA) were included. Antiplatelet (AP) only and anticoagulation (AC) treatment arms were compared. The primary outcome was a composite of preoperative recurrent ischemic stroke or TIA. The primary safety outcome was symptomatic intracranial hemorrhage.
Out of 443 CEA patients, 342 were in the AC group and 101 in the AP group. Baseline characteristics between groups (AC vs AP) were similar apart from age (71±10.5 vs 73±9.5, p=0.04), premorbid modified Rankin scale (mRS) score (1.0±1.2 vs 1.4±1.3, p=0.03) and stroke as presenting symptom (65.8 vs 53.5%, p=0.02). Patients in the AC group had a lower incidence of recurrent stroke/TIA (3.8 vs 10.9%, p=0.006). One patient had symptomatic intracranial hemorrhage in the AC group, and none in the AP group. In multivariate analysis controlling for age, premorbid mRS, stroke severity, degree of stenosis, presence of intraluminal thrombus (ILT) and time to surgery, AC was protective (OR 0.30, p=0.007). This effect persisted in the cohort exclusively without ILT (OR 0.23, p=0.002).
Short term preoperative anticoagulation in patients with acutely symptomatic carotid stenosis appears safe and effective compared to antiplatelet agents alone in the prevention of recurrent cerebral ischemic events while awaiting CEA.
急性症状性颈动脉狭窄患者的脑缺血早期复发可能先于血运重建。对于这种高危人群，最佳的抗血栓形成方案尚未确定。尽管抗血小板药物通常被使用，但抗凝剂的使用证据有限。我们试图了解在等待颈动脉内膜切除术（CEA）期间，短期术前抗凝剂在预防急性症状性颈动脉狭窄复发性脑缺血事件中的安全性和有效性。
对颈动脉血运重建的前瞻性单机构登记处进行了回顾性查询。纳入了因同侧颈内动脉狭窄（ICA）而出现急性缺血性卒中和短暂性脑缺血发作（TIA）的患者。比较了抗血小板（AP）组和抗凝（AC）治疗组。主要结局是术前复发性缺血性卒中和 TIA 的复合结局。主要安全性结局是症状性颅内出血。
在 443 例 CEA 患者中，342 例患者在 AC 组，101 例患者在 AP 组。组间（AC 与 AP）的基线特征除年龄（71±10.5 与 73±9.5，p=0.04）、发病前改良Rankin 量表评分（mRS）（1.0±1.2 与 1.4±1.3，p=0.03）和以卒中为首发症状（65.8%与 53.5%，p=0.02）外，其他均相似。AC 组患者的复发性卒中和 TIA 发生率较低（3.8%与 10.9%，p=0.006）。AC 组中有 1 例患者出现症状性颅内出血，AP 组中则无。在多变量分析中，控制年龄、发病前 mRS、卒中严重程度、狭窄程度、管腔内血栓形成（ILT）和手术时间后，AC 具有保护作用（OR 0.30，p=0.007）。在不伴有 ILT 的队列中，这种效果仍然存在（OR 0.23，p=0.002）。
与单独使用抗血小板药物相比，急性症状性颈动脉狭窄患者术前短期抗凝治疗在等待 CEA 期间预防复发性脑缺血事件似乎更安全、更有效。
