Reperfusion Therapy Brings Apixaban Administration Forward in Patients with Nonvalvular Arterial Fibrillation with Anterior Circulation Large Vessel Occlusion or Stenosis.

OBJECTIVE: The initiation of anticoagulant administration after large vessel occlusion (LVO) or stenosis with nonvalvular arterial fibrillation (NAVF) is controversial. We evaluate the timing of anticoagulation and its relationship with clinical factors. METHODS: We enrolled 595 anterior circulation LVO or stenosis with NAVF cases from 38 stroke centers. Laboratory data; activities of daily living; the Alberta Stroke Program Early CT Score (ASPECTS); the National Institutes of Health Stroke Scale (NIHSS) score; occluded artery; treatment methods; date of the initiation of apixaban administration and outcome were recorded. Multivariate analyses were performed after univariate analysis. RESULTS: The median start of apixaban administration after the stroke was 2 days (interquartile range, 1-5; range, 0-14). Multivariate analysis of variance showed that non-internal carotid artery occlusion (F value 4.60), reperfusion therapy (31.1), high ASPECTS (6.27) before anticoagulant intake, and absence of intracranial hemorrhage (12.9) were significantly correlated with early apixaban administration. Multiple logistic regression analysis for independent living at 90 days after the stroke showed significant factors: aging (odds, 0.94; 95% confidence interval [CI], 0.91-0.97); male (odds, 0.46; 95% CI, 0.26-0.79); prestroke independence (odds, 20.7; 95% CI, 6.48-93.9); number of white blood cells (odds, 0.99; 95% CI, 0.97-1.00); non-internal carotid artery occlusion; NIHSS score at 72 hours after the stroke (odds 0.92; 95% CI, 0.89-0.96); ASPECTS before apixaban intake (odds, 1.15; 95% CI, 1.00-1.31) and initiation of apixaban (odds, 0.91; 95% CI, 0.83-0.99). CONCLUSIONS: Early administration of apixaban is induced by nonsevere infarction, reperfusion therapy or none of intracranial hemorrhage and it correlates with an independent long-term outcome.

Effect of prior antiplatelet therapy on large vessel occlusion in patients with non-valvular atrial fibrillation newly initiated on apixaban.

INTRODUCTION: We evaluated the effect of prior antiplatelet therapy on large vessel occlusion (LVO) in patients with non-valvular atrial fibrillation (NVAF) newly initiated on apixaban. METHODS: Patients with acute LVO with acute stroke due to NVAF or stenosis with NVAF started on apixaban within 14 days of onset were enrolled. We compared incidence of major bleeding, cerebral hemorrhage, ischemic events, cerebral infarction, and all-cause mortality between patients with and without prior antiplatelet therapy for acute LVO. We also compared these events between patients who continued antiplatelet therapy after onset (continued group) and those who discontinued it (discontinued group). Hazard ratios were estimated after adjusting for confounders; interaction was evaluated considering intravenous thrombolysis (IVT) or endovascular treatment (EVT) according to major bleeding. RESULTS: The study comprised 686 eligible patients (excluded [n = 194]; enrolled [n = 492]). The antiplatelet group consisted of older patients (mean: 79 vs. 76 years; p = 0.006) and had a higher cumulative incidence of major bleeding (7.3% vs. 2.9%, p = 0.003). The incidence of ischemic events and all-cause mortality was similar between the groups. Among the 109 patients in the antiplatelet group, the cumulative incidence of major bleeding, ischemic events, and all-cause mortality was comparable between continued group (n = 26) and discontinued group (n = 83). There were no significant differences between groups with and without IVT/EVT. However, major bleeding occured more frequently in the antiplatelet group without IVT. CONCLUSION: Prior antiplatelet therapy for LVO in patients with NVAF newly initiated on apixaban was associated with major bleeding, which was more frequent in the antiplatelet group without IVT.

Safety and Effectiveness of Drip, Ship, and Retrieve Paradigm for Acute Ischemic Stroke: a Single Center Experience.

This study analyzed the efficacy and safety of the "drip, ship, and retrieve (DSR)" approach used to improve patient access to thrombectomy for acute stroke. METHODS: The study participants were 45 patients who underwent thrombectomy following intravenous tissue plasminogen activator between September 2013 and August 2015. Patients were divided into two groups according to whether they were transferred from another hospital (DSR group; n = 33) or were brought in directly (Direct group; n = 12). The two groups were compared based on their baseline characteristics, time from stroke onset to reperfusion, outcome, and adverse events. RESULTS: There were no significant differences in baseline characteristics. Time from onset until admission to our facility was significantly shorter in the Direct group (56.9 min) than in the DSR group (163.5 min) (P <0.0001). Conversely, time from arrival at the hospital to arterial puncture was significantly shorter in the DSR group (25.0 min) than in the Direct group (109.5 min) (P <0.0001). Time from onset to reperfusion did not differ significantly between the groups. There was no significant difference in patient outcomes, with a modified Rankin scale score of 0-2 (44.8% in DSR group versus 48.7% in Direct group). Moreover, there was no difference in the incidence of adverse events. DISCUSSION: Despite the time required to transfer patients in the DSR group between hospitals, reducing the time from arrival until commencement of endovascular therapy meant that the time from onset to reperfusion was approximately equivalent to that of the Direct group. CONCLUSION: Time-saving measures need to be taken by both the transferring and receiving hospitals in DSR paradigm.

Acute Embolic Cerebral Infarction and Coronary Artery Embolism in a Patient with Atrial Fibrillation Caused by Similar Thrombi.

Although atrial fibrillation (AF) is one of the most frequent causes of ischemic stroke, coronary artery embolism (CE) from AF is rare, and 2.9% of all myocardial infarctions are caused by CE. We present a case of an 87-year-old female patient who suffered ischemic stroke and myocardial infarction at the same time and received intracranial and coronary thrombectomy. Pathological investigation revealed that thrombi were similar and both infarctions were considered as cardioembolism.