2021 年 38 巻 5 号 p. 708-714
Among patients with emergent large vessel occlusion (LVO), mechanical thrombectomy (MT) is now become first–line therapy. It is unclear whether preceding alteplase is mandatory or not. DIRECT–MT study showed non–inferiority of MT alone in terms of achieving good clinical outcome compared to combined therapy with alteplase and MT. This clinical question will be answered when other ongoing similar trials' data become available.
New generation P2Y12 antagonists, ticagrelor and prasugrel, announced promising results in 2020. Dual antiplatelet therapy (DAPT) using ticagrelor reduced stroke or death in patients with minor ischemic stroke or high–risk TIA. Although overall benefit was cancelled by increase of severe bleeding. Prasugrel showed good safety profile among Japanese high risk patients (age ＞75y or weight ＜50kg) with lacunar and atherothrombotic stroke.
The concept of embolic stroke of undetermined source (ESUS) is now entered re–consideration phase. Japanese subgroup analysis of RE–SPECT ESUS disclosed that dabigatran significantly reduced the risk of recurrent stroke (HR 0.55, 95%CI 0.32–0.94). Furthermore, no difference was observed about the risk of major bleeding. Japanese subgroup was older and more CKD patients are enrolled. Prevalence of covert atrial fibrillation may be higher than the other.
Treat Stroke to Target (TST) trial investigated whether aggressive LDL lowering (＜70mg/dL) result in reduction of cardiovascular events among patients with recent ischemic stroke with atherosclerotic plaque. Indeed, lower–target group (LDL ＜70mg/dL) revealed 22% risk reduction compared to higher–target group (LDL 90–110mg/dL).
Finally, COVID–19 pandemic dramatically changed our stroke triage and emergency protocol. Top priority is the perfect defense of medical staff from COVID–19 infection. Making each hospital's own Protected Code Stroke is essential. COVID–19 itself seems to cause stroke. ESUS, LVO, young stroke, and hypercoagulable state are the key words of COVID–19 related stroke.
