Zeng Jing, Xin Wenli, Tang Shuang, Xiang Chengwei, Zeng Chun
Department of Neurosurgery, Suining Central Hospital, Suining, Sichuan, China.
Department of Cerebrovascular Disease, Suining Central Hospital, Suining, Sichuan, China.
Clin Neurol Neurosurg. 2024 Mar;238:108176. doi: 10.1016/j.clineuro.2024.108176. Epub 2024 Feb 15.
Intravenous thrombolysis (IVT) has been shown to effectively decrease both the disability rate and mortality associated with acute ischemic stroke, however, there is also a risk of vascular re-occlusion. Antiplatelet therapy can mitigate this risk. Nevertheless, there are no relevant guidelines recommending whether the administration of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel can be performed following thrombolysis. The aim of this study was to conduct a meta-analysis utilizing multiple studies in order to assess the effectiveness and safety of DAPT after IVT in cases of acute mild ischemic stroke (AMIS).
A comprehensive search on English literature published was performed on databases including PubMed, Embase, Web of Science, and Cochrane up until September 1, 2023. All cases were ischemic stroke patients who underwent IVT within a 4.5-hour timeframe and had a National Institutes of Health Stroke Scale (NIHSS) score of ≤5 (or 3) upon admission. The primary efficacy endpoint is the 90-day Modified Rankin Scale (mRS) Score (MRS score 0-1), while the primary safety endpoint encompassed the occurrence of symptomatic intracranial hemorrhage (SICH) and 90-day mortality. The study's secondary objective is the recurrence of any type of stroke (hemorrhagic and ischemic) within a 90-day period. The included studies underwent an evaluation of bias risk using the Newcastle Ottawa scale. Risk ratios (RRs) and CIs were calculated using a random effects model, and the findings and heterogeneity among the included studies were visually presented on a forest plot. (There was a protocol registration (PROSPERO):).
Out of the 1081 studies that were obtained, only 3 met the criteria and were included in the meta-analysis (657 patients in total). The findings indicate that, there was a significant difference in the mRS of 0-1 between single antiplatelet therapy (SAPT) with only aspirin or clopidogrel and DAPT with aspirin and clopidogrel ((RR,1.11[95%CI,0.99-1.24];P=0.07;I=55%), and no significant difference in stroke recurrence after 90 days or 1 year ((RR,0.94[95%CI,0.41-2.16];P=0.89;I=30%); Regarding safety evaluation, the results showed no significant difference in the SICH (RR,0.65[95%CI,0.11-3.97];P=0.64;I2=0%) and the incidence of mortality (RR,0.97[95%CI,0.19-4.96];P=0.97;I2=0%) between the two groups.
For patients with acute mild ischemic stroke (AMIS), in conjunction with DAPT after IVT can improve the 90-day prognosis, without increasing the risk of intracranial hemorrhage and 90-day mortality. However, it cannot reduce the risk of stroke recurrence.
静脉溶栓（IVT）已被证明能有效降低急性缺血性卒中的致残率和死亡率，然而，也存在血管再闭塞的风险。抗血小板治疗可减轻此风险。尽管如此，尚无相关指南推荐在溶栓后是否可使用阿司匹林和氯吡格雷进行双联抗血小板治疗（DAPT）。本研究的目的是利用多项研究进行荟萃分析，以评估急性轻度缺血性卒中（AMIS）患者静脉溶栓后双联抗血小板治疗的有效性和安全性。
截至2023年9月1日，在包括PubMed、Embase、Web of Science和Cochrane在内的数据库中对已发表的英文文献进行全面检索。所有病例均为在4.5小时时间范围内接受静脉溶栓且入院时美国国立卫生研究院卒中量表（NIHSS）评分≤5（或3）的缺血性卒中患者。主要疗效终点是90天改良Rankin量表（mRS）评分（MRS评分0 - 1），而主要安全终点包括症状性颅内出血（SICH）的发生和90天死亡率。该研究的次要目标是90天内任何类型卒中（出血性和缺血性）的复发。使用纽卡斯尔渥太华量表对纳入的研究进行偏倚风险评估。采用随机效应模型计算风险比（RRs）和可信区间（CIs），并在森林图上直观呈现纳入研究的结果和异质性。（有一项方案注册（PROSPERO）：）
在获取的1081项研究中，仅有3项符合标准并纳入荟萃分析（共657例患者）。结果表明，仅使用阿司匹林或氯吡格雷的单联抗血小板治疗（SAPT）与阿司匹林和氯吡格雷的双联抗血小板治疗在mRS的0 - 1方面存在显著差异（（RR，1.11[9,5%CI，0.99 - 1.24]；P = 0.07；I² = 55%），90天或1年后卒中复发无显著差异（（RR，0.94[95%CI，0.41 - 2.16]；P = 0.89；I² = 30%）；关于安全性评估，结果显示两组在SICH（RR，0.65[95%CI，0.11 - 3.97]；P = 0.64；I² = 0%）和死亡率发生率（RR，0.97[95%CI，0.19 - 4.96]；P = 0.97；I² = 0%）方面无显著差异。
对于急性轻度缺血性卒中（AMIS）患者，静脉溶栓后联合双联抗血小板治疗可改善90天预后，且不增加颅内出血风险和90天死亡率。然而，它不能降低卒中复发风险。
