Singapore medical journal最新文献

Introduction: We explored the efficacy and safety of dual antiplatelet therapy (DAPT) for individuals diagnosed with stroke or transient ischaemic attack (TIA), incorporating the latest insights from randomised controlled trials (RCTs). The emerging evidence surrounding DAPT in stroke and TIA plays a pivotal role in guiding clinical decisions.

Methods: Our study included five RCTs (INSPIRES, THALES, POINT, CHANCE, FASTER) on DAPT (aspirin + P2Y12 inhibitor) initiated within 72 hours of acute stroke or TIA, which evaluated DAPT efficacy and safety over 21-90 days, focusing on new strokes and major bleeding. Secondary outcomes included cardiovascular events and recurrent strokes. Pooled odds ratios (OR) were computed using a random effects model.

Results: The five RCTs involved 27,559 patients. Our analysis showed that DAPT significantly reduced stroke recurrence (OR 0.75; 95% confidence interval [CI] 0.68-0.82; P <0.001, I2 = 0%) but increased major bleeding risk (OR 2.20; 95% CI 1.38-3.51, P = 0.0009, I2 = 30%). It lowered major adverse cardiovascular events (OR 0.76; 95% CI 0.67-0.85, P < 0.001, I2 = 5%) and recurrent ischaemic events (OR 0.73; 95% CI 0.66-0.80, P < 0.001, I2 = 0%), but raised haemorrhagic stroke risk (OR 2.09; 95% CI 1.14-3.84, P = 0.02, I2 = 8%).

Conclusion: Dual antiplatelet therapy - a combination of aspirin with either ticagrelor or clopidogrel - initated within 72 hours of a high-risk TIA or mild moderate ischaemic stroke is superior to aspirin alone in reducing the risk of recurrent stroke. However, DAPT comes with a higher risk of major bleeding.

Introduction: Mechanical thrombectomy (MT) is the standard of care in anterior circulation large vessel occlusion. A vital modifiable factor is successful reperfusion. While multiple passes improve the rates of successful reperfusion, previous studies have reported progressively diminishing returns. This study aimed to investigate the relationship between number of passes and outcomes in basilar artery occlusion (BAO).

Methods: This multicentre retrospective cohort study included patients who were treated with MT for acute BAO from eight comprehensive stroke centres between 2015 and 2020. The primary outcome was favourable functional outcome (FFO) defined as modified Rankin Scale (mRS) 0-3 measured at 90 days. Secondary outcomes included spontaneous intracranial haemorrhage and mortality. Patients were stratified according to reperfusion status and the number of passes for further analysis.

Results: The adjusted odds ratio (OR) for FFO 90 days for each additional pass of a thrombectomy device was 0.56 (P = 0.003). When ≤3 passes of the thrombectomy device were made, achieving reperfusion led to higher rates of FFOs. However, when >3 passes of the thrombectomy device were made, achieving reperfusion no longer led to higher rates of FFOs (FFO = 0% in patients who did not achieve reperfusion vs. FFO = 14.5 in patients who achieved reperfusion; P = 0.200). Notably, increasing number of passes was associated with a non-significant trend towards higher rate of parenchymal haemorrhage (OR 1.55, P = 0.055).

Conclusion: Acute BAO patients treated with up to three passes of a thrombectomy device derived improved functional outcomes from reperfusion compared to those with more than three passes. Further prospective cohort studies are necessary to validate these findings.