Dual Antiplatelet Therapy Improves Functional Outcome in Patients With Progressive Lacunar Strokes

Anne Berberich, MD; Christine Schneider, MD; Tilman Reiff, MD; Christoph Gumbinger, MD; Peter Arthur Ringleb, MD


Stroke. 2019;50(4):1007-1009. 

In This Article


The article adheres to the American Heart Association journals' implementation of TOP guidelines. Because of the data protection law, detailed data supporting the findings of this study are only available from the corresponding author upon reasonable request.

We performed a retrospective observational cohort study in patients with lacunar strokes based on a single stroke center hospital database, analyzing data from January 1, 2010, to December 31, 2017.

Detection of neuroimaging evidence of lacunar infarction was mandatory for inclusion in this study. This evidence comprised a subcortical region of hypointensity on computed tomographic (CT) scans or hyperintensity on diffusion-weighted sequences on magnetic resonance imaging (MRI), with largest diameter of ischemic lesion ≤20 mm and corresponding with the clinical deficit. Patients also required clinical deficits consistent with lacunar ischemia lasting for ≥24 hours. We excluded patients with imaging evidence of extracranial or intracranial carotid stenosis, proximal vessel occlusion, clot retrieval, evidence of cardioembolism, anticoagulant treatments, or with contraindications to DAPT. Evidence of cardioembolism was defined as detection of atrial fibrillation, intraventricular thrombus, or patent foramen ovale. All patients received in-hospital ECG monitoring for ≥24 hours and transthoracic echocardiography; patients ≤65 years of age received transesophageal echocardiography. Arterial imaging with ultrasound, CT, or MRI was performed at the discretion of treating physicians. Symptomatic bleeding complications were defined as evidence of blood on CT or in susceptibility-weighted MRI sequences at time point of clinical deterioration. As neuroimaging was not routinely performed after the end of DAPT, only symptomatic bleeding complications were detected within this study.

Included patients were retrospectively screened for occurrence of END within 5 days after stroke onset, which was characterized by worsening of existing clinical symptoms and particularly defined by deterioration of ≥3 total NIHSS points, deterioration of ≥2 NIHSS points for limb paresis, or description of fluctuating clinical symptoms in medical reports. Follow-up neuroimaging was performed after END to exclude new ischemic lesions and cerebral hemorrhage.

Patients with END were divided into patients with initiation of DAPT (aspirin and clopidogrel) after END occurred and in patients with single antiplatelet therapy only. DAPT was initiated as off-label therapy and mostly continued for 5 to 7 days based on individual decisions and institutional standards according to which DAPT is allowed but not mandatory.

For analysis of efficacy of DAPT in patients with END, the NIHSS score at discharge was compared with the score at admission as primary end point which was fulfilled if NIHSS score at discharge improved after END at least to the score at admission. Secondary end points were fulfilled if (1) Rankin Scale score at discharge was improved or stable after END compared with score at admission, (2) no further clinical fluctuation occurred, and (3) symptomatic hemorrhage was absent.

Patients' characteristics and clinical outcomes were retrieved from electronic medical reports and NIHSS documentation. NIHSS score was performed at admission and at least every 6 hours mostly for ≥72 hours or until patients' discharge in routine clinical work-up.

Statistical significance was assessed by fisher exact test using StatsDirect Version 3.1.14. P values of 0.05 were considered to show significant differences. As no adjustment for multiplicity was applied, P values should be interpreted descriptively.

Ethical approval (S-109/2018) was obtained from the local ethics committee in Heidelberg; written informed consent was waived because of the retrospective analysis.