The risk of intracerebral hematoma was lower than with conventional oral antiplatelets, a single-center study has found.
Despite concerns about the safety of using abciximab in the setting of acute ischemic stroke, a group of Spanish researchers have demonstrated the safety and benefits of using an abciximab-based intravenous antiplatelet protocol during endovascular interventions involving stent placement. Their findings were published online August 28, 2018, ahead of print in the Journal of NeuroInterventional Surgery.
However, use of abciximab in this setting is somewhat controversial. recommend against administration of abciximab in patients with acute ischemic stroke based on a Cochrane review demonstrating an increased risk of intracerebral hematoma (ICH), note the investigators, led by Fernando Delgado, MD (Hospital Reina Sofía, Córdoba, Spain).
Nevertheless, Delgado and colleagues use a protocol at their center consisting of half-dose intravenous abciximab (0.125 mg/kg), as a single bolus without a maintenance dose, with the addition of next-day oral aspirin 150-300 mg and clopidogrel 75 mg daily.
“Our assumption was that in the setting of endovascular treatment, we must find a balance between the antiplatelet effect of the drug and safety,” they write. “The use of oral antiplatelets can result in an insufficient antiplatelet effect due to delayed intestinal resorption. For that reason, we believe that an intravenous antiplatelet regimen is a better option.”
To determine the rate of symptomatic ICH associated with their protocol, the investigators conducted a retrospective database review of 99 patients treated with endovascular management of large acute vessel occlusion between January 2015 and March 2018. All patients received a half bolus of abciximab at the time of the stenting procedure, with oral aspirin (150 mg) and clopidogrel (75 mg) added the day after CT demonstrated no significant hematoma.
There were no cases of symptomatic ICH. Based on the European Cooperative Acute Stroke Study Scale, there were eight cases of hemorrhagic infarction 1; five cases of hemorrhagic infarction 2; four cases of parenchymal hemorrhage 1; and no cases of parenchymal hemorrhage 2.
Safer Than Conventional Doses
A review of the literature of the use of conventional antiplatelet doses of abciximab (0.25 mg/kg plus maintenance doses consisting of a 0.125 mg/kg/min infusion for 12 hours) revealed 31 cases of symptomatic ICH in 604 patients. In comparison, the risk of symptomatic ICH seen using this protocol was statistically lower (P = 0.015).
There were six acute stent occlusions, with two carotid cervical stenting occlusions occurring because distal recanalization was not possible. Four of the six occlusions occurred when stents were used as a rescue method following stent retriever failure. “We speculate that in some patients there is no possibility of effective recanalization because there is no recoverable distal cerebral tissue, although a malignant cascade of the coagulation cannot be excluded,” write the authors.
At 3 months of follow-up, 18 patients had died (11 of malignant strokes, five of respiratory infections, and two of cardiac pathologies). The remaining 81 patients underwent patency testing. Of these, 72 had a patent vessel, four had an occluded stent, and five had no control.
The authors conclude that “if an antiplatelet drug is considered necessary in the setting of endovascular treatment of acute ischemic stroke,” their protocol is “safe and effective.”
Delgado F, Oteros R, Jimenez-Gomez E, et al. . J NeuroIntervent Surg. 2018;Epub ahead of print.
Delgado reports no relevant conflicts of interest.