2019 Volume 36 Issue 5 Pages 563-568
In 2018, a new treatment concept of tissue–based strategy was established. The two late time window thrombectomy trials, DAWN (6–24 hours) and DEFUSE3 (6–16 hours), showed dramatical improvement of outcome in patients with emergent large vessel occlusion (LVO). Both used RAPID software to select candidates who have small core with clinical–imaging mismatch or target mismatch. Revised AHA/ASA and Japanese guidelines now recommend mechanical thrombectomy as late as 16/24 hours after onset. In addition, patients with unknown onset time or wake–up stroke are now candidates for thrombolytic therapy using alteplase if diffusion–FLAIR mismatch is confirmed.
In patients with non–cardioembolic stroke, dual anti–platelet therapy (DAPT) using clopidogrel and aspirin is recommended up to 21 days. The POINT trial further evaluated intensive DAPT starting as early as <12 hours with higher loading dose and continued until 90 days. Though POINT disclosed better efficacy on preventing recurrence of stroke, but increased bleeding events denied clinical application of the intensive DAPT therapy.
NAVIGATE ESUS compared the efficacy and safety of rivaroxaban and aspirin in patients with embolic stroke of undetermined source (ESUS). This study was terminated prematurely because of the increased bleeding risk assigned to rivaroxaban treatment. Although efficacy was identical between the two groups. This ESUS concept was attracting and could offer better treatment option, however, it was not a case. It is time to consider refinement of ESUS concept or treatment strategy.
