The effect of dual antiplatelet therapy for improvement of extracranial and intracranial artery stenosis evaluated by digital subtraction angiography

Fritz S. Usman; Rony Parlindungan Sinaga; Karina Dewi; Nilamsari; Daril Al Rasyid; Merlin P. Kastilong

doi:10.18203/2320-6012.ijrms20240201

Authors

Fritz S. Usman Department of Neurovascular Intervention, Pelni Hospital, West Jakarta, DKI Jakarta, Indonesia
Rony Parlindungan Sinaga Department of Neurovascular Intervention, Pelni Hospital, West Jakarta, DKI Jakarta, Indonesia
Karina Dewi Department of Neurovascular Intervention, Pelni Hospital, West Jakarta, DKI Jakarta, Indonesia
Nilamsari Department of Neurovascular Intervention, Pelni Hospital, West Jakarta, DKI Jakarta, Indonesia
Daril Al Rasyid Department of Neurovascular Intervention, Pelni Hospital, West Jakarta, DKI Jakarta, Indonesia
Merlin P. Kastilong Department of Neurovascular Intervention, Pelni Hospital, West Jakarta, DKI Jakarta, Indonesia

DOI:

https://doi.org/10.18203/2320-6012.ijrms20240201

Keywords:

Carotid artery stenosis, Degree of stenosis, Dual antiplatelet, Intracranial artery stenosis, vertebral artery stenosis

Abstract

Background: Stroke involving extracranial carotid (ECAS), vertebral (EVAS), and intracranial arteries (IAS) contributed to an annual stroke rate of 0.1-3.3%. Even though endarterectomy and/or angioplasty and stenting had revolutionized its’ management, best medical treatment (BMT) is still the mainstay of therapy to prevent secondary stroke/transient ischemic attack. This study aimed to evaluate the effect of BMT to reduce the degree of stenosis by using six-months double antiplatelet therapy (DAPT).

Methods: A retrospective cohort study was conducted in a secondary private hospital in Indonesia, in January-December 2022. Adults ≥18 years old with ECAS, EVAS, or IAS detected using digital subtraction angiography (DSA), receiving DAPT for at least six months, and those who had second DSA evaluation were included. Any subjects with other brain pathologies or recorded incompliance to DAPT were excluded. Age, gender, stenosis degree, stenosis location, and conversion of stenosis degree were recorded and compared between pre-DAPT and post-DAPT group.

Results: Of 30 subjects, there were insignificant changes (46.5±24.3% to 50.8±22.9%, p=0.09) of ECAS, EVAS, and IAS. There were 14 cases with constant stenosis (51.4±17.5%), 8 cases with decreasing stenosis (46.9±28.2% to 40.1±32.8%, p=0.012), and 12 cases with increasing stenosis (40.4±29.9% to 57.1±21.0%, p=0.002). No significant association were found among those groups related to traditional vascular risk factors.

Conclusions: There was no difference in respect to the degree of stenosis following six months of DAPT in either ECAS, EVAS, or IAS. Routine evaluation as well as recognizing features of high-risk stroke/TIA are important to help decide individual who may be candidates of endovascular procedures earlier.

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References

Chang RW, Tucker LY, Rothenberg KA, Lancaster E, Faruqi RM, Kuang HC, et al. Incidence of ischemic stroke in patients with asymptomatic severe carotid stenosis without surgical intervention. JAMA. 2022;327(20):1974-82.

Elhfnawy AM, Volkmann J, Schliesser M, Fluri F. Symptomatic versus asymptomatic 20-40% internal carotid artery stenosis: does the plaque size matter? Front Neurol. 2019;10(October):1-7.

Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, et al. European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. 2023;65(1):7-111.

Dong J, Wang F, Sundararajan S. Use of dual antiplatelet therapy following ischemic stroke. Stroke. 2020;E78-80.

Howard DPJ, Gaziano L, Rothwell PM. Risk of stroke in relation to degree of asymptomatic carotid stenosis: a population-based cohort study, systematic review, and meta-analysis. Lancet Neurol. 2021;20(3):193-202.

Yaghi S, de Havenon A, Rostanski S, Kvernland A, Mac Grory B, Furie KL, et al. Carotid stenosis and recurrent ischemic stroke: a post-hoc analysis of the POINT trial. Stroke. 2021;52(7):2414-7.

Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, et al. Successful implementation of best medical treatment for patients with asymptomatic carotid artery stenosis within a randomized controlled trial (SPACE-2). Neurol Res Pract. 2021;3(1).

Karlsson L, Kangefjärd E, Hermansson S, Strömberg S, Österberg K, Nordanstig A, et al. Risk of recurrent stroke in patients with symptomatic mild (20-49% NASCET) carotid artery stenosis. Eur J Vasc Endovasc Surg. 2016;52(3):287-94.

Das PJ, Handique SK, Saharia B. A study on first ischemic stroke patients for prevalence of extracranial carotid artery stenosis and risk factors: our experience in northeast India and review of literature. J Diagn Med Sonograph. 2021;37(2):133-43.

Indonesian Ministry of Health. National Riskesdas Report 2018. 2018;44(8):181–222. Available from: http://www.yankes.kemkes.go.id/assets/downloads/PMKNo.57Tahun2013tentangPTRM.pdf. Accessed on 20 August 2023.

Di Chiara T, Del Cuore A, Daidone M, Scaglione S, Norrito RL, Puleo MG, et al. Pathogenetic mechanisms of hypertension-brain-induced complications: focus on molecular mediators. Int J Mol Sci. 2022;23(5).

Park JH, Ovbiagele B, Hong KS, Kwon SU. Association of systolic blood pressure with progression of symptomatic intracranial atherosclerotic stenosis. J Stroke. 2017;19(3):304-11.

Kim HW, Regenhardt RW, D’Amato SA, Nahhas MI, Dmytriw AA, Hirsch JA, et al. Asymptomatic carotid artery stenosis: A summary of current state of evidence for revascularization and emerging high-risk features. J NeuroIntervent Surg. 2022;15(7).

Messas E, Goudot G, Halliday A, Sitruk J, Mirault T, Khider L, et al. Management of carotid stenosis for primary and secondary prevention of stroke: State-of-the-art 2020: a critical review. Eur Heart J Suppl. 2020;22:M35-42B.