BALTIMORE – The presence of cerebral microbleeds was not associated with a higher frequency of hemorrhagic transformation among patients who received a loading dose of the antiplatelet drug, compared with patients who had no evidence of microbleeds, in a retrospective study of 1,060 patients who presented with acute ischemic stroke.
“Clopidogrel seems like it can be a safe treatment for patients who are not eligible for tissue plasminogen activator, even if the stroke severity is higher than is being tested in recent clinical trials (CHANCE and POINT, for example),” Melisa Valmoria said at the annual meeting of the American Neurological Association.
Ms. Melisa Valmoria
Ms. Valmoria, a clinical research assistant at the Tulane University stroke research program, New Orleans, presented a retrospective study of 1,060 patients who presented with acute ischemic stroke. Of 1,060 patients in the study, 324 received a loading dose of at least 300 mg clopidogrel within 6 hours of admission, in addition to aspirin. A total of 51 of those patients had evidence of prior cerebral microbleeds on imaging.
The patients were similar in age (average, 63.5 years). Those with microbleeds were more likely to have had a prior stroke (63% vs. 49%; P = .05). The median NIH Stroke Scale (NIHSS) score was also higher among those patients (6 vs. 4).
There were no significant between-group differences in stroke events, including rates of inpatient complications (33% with microbleeds vs. 28% without), hemorrhagic transformation (6% vs. 8%), and recurrent thrombotic events (16% vs. 14%). Neurologic worsening, defined as an increase of at least 2 points in the NIHSS score over any 24-hour period, was not significantly different between the groups (39% vs. 27%). None of the patients with microbleeds developed a symptomatic hemorrhage.
Patients with microbleeds started off with a higher NIHSS score, but did not have significantly worse discharge outcomes. Poor functional outcome (a modified Rankin Scale score of more than 2) occurred in 59% of those with microbleeds and 47% of those without. An unfavorable discharge disposition (discharge to anywhere except the patient’s home or to inpatient rehabilitation) occurred in 16% of those with microbleeds and 10% of those without, which was not a significant difference.
A subanalysis of patients with more than 10 microbleeds showed that clopidogrel did not increase their risk of hemorrhagic transformation or poor functional outcomes, compared with patients who did not have microbleeds.
“Some trials (MATCH and CHARISMA) have raised concern about bleeding risk, specifically brain bleeding, in patients who receive dual antiplatelets, including clopidogrel, after stroke,” Ms. Valmoria said. “This risk may be higher among patients who have evidence of prior brain bleeding, such as microbleeds. Fortunately, our study did not find support for increased short-term bleeding in patients with ischemic stroke who were treated with a loading dose of clopidogrel with aspirin. Our study included many patients with moderatetosevere strokes, as measured by the NIHSS score who are not wellrepresented in modern clinical trials examining the safety and efficacy of clopidogrel loading, raising the question of whether enrollment criteria could be safely loosened.”
She said she had no relevant financial disclosures.
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