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ABSTRACT: Dabigatran etexilate is an oral, reversible direct thrombin inhibitor and has been recently approved for the prevention of stroke in patients with non-valvular atrial fibrillation. This review describes the incidence and management of stroke and related complications in patients on dabigatran etexilate. Dabigatran is a rapidly acting, and highly selective and reversible inhibitor of thrombin. It also has a potent inhibitory effect on thrombin-induced platelet aggregation, making it effective in preventing both venous and arterial thrombosis. The activated partial thromboplastin time, ecarin clotting time and thrombin time are sensitive tests to evaluate the anticoagulant effects of dabigatran. The rate of ischemic stroke is significantly lower in patients on 150 mg of dabigatran etexilate as compared to 110-mg dose or warfarin (9.2, 13.4, 12 per 1,000 patients, respectively). As there is no standard coagulation test for dabigatran; treatment of acute stroke in such patients is debatable. Careful clinical consideration is required before administering thrombolytic therapy in this patient population. The rate of hemorrhagic stroke was 1.2 and 1.0 per 1,000 patients treated on 110 and 150 mg of dabigatran, respectively. As there is no specific antidote, the only treatment option is discontinuation of the drug and supportive management. Other treatment options, though not clinically proven, include specific reversal agents, which can be individualized according to the severity of the hemorrhage. Dabigatran should be discontinued before invasive procedures depending on the degree of renal impairment and risk of bleeding.
Neurocritical Care 07/2011; 16(1):203-9. · 2.47 Impact Factor
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ABSTRACT: Several studies have reported variable rates of perioperative risk of stroke in individuals with tandem stenoses after carotid endarterectomy. Endovascular treatment of extracranial lesions associated with tandem lesions is limited to case reports and small case series.
We retrospectively reviewed clinical records and angiographic findings of 132 symptomatic patients with extracranial atherosclerotic disease who underwent elective stent placement at three tertiary care centers. Tandem stenosis was defined as any lesion with intracranial stenosis ≥50% in the same (but not contiguous) vascular distribution distal to primary extracranial stenosis. The study end point was a composite of any stroke or death within 24 hours, at 1- and 6-month postprocedure. The rates of primary end points were compared between patients with or without secondary tandem stenosis.
Out of 132 patients (134 procedures), 27 patients were identified with a tandem stenosis. The stroke and/or death rates at 24 hours were (11.1% vs 7.5%, P = . 69) for patients with tandem stenosis and single stenosis, respectively. The cumulative stroke and/or death rate at 1-month postprocedure (15.0% vs 7.5%, P = .10) and at 6-month postprocedure (26.6% vs 12.8%, P = .08) appeared to be higher among those with tandem stenoses without reaching statistical significance.
The high risk of postprocedural stroke and/or death observed in this series requires careful assessment of the risk/benefit ratio of endovascular procedures in patients with tandem stenosis.
Journal of neuroimaging: official journal of the American Society of Neuroimaging 06/2011; 22(3):243-8. · 1.72 Impact Factor
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ABSTRACT: Intracranial hemorrhage is the third most common cause of stroke and involves the accumulation of blood within brain parenchyma or the surrounding meningeal spaces. Accurate identification of acute hemorrhage and correct characterization of the underlying pathology, such as tumor, vascular malformation, or infarction, is a critical step in planning appropriate therapy. Neuroimaging studies are required not only for diagnosis, but they also provide important information on the type of hemorrhage, etiology, and the pathophysiological process. Historically, computed tomography (CT) scan has been the diagnostic imaging study of choice; however, there is growing evidence suggesting that magnetic resonance imaging (MRI) is at least as sensitive as CT to detect intraparenchymal hemorrhages in the hyperacute setting, and actually superior to CT in the subacute and chronic settings. Unique MRI and CT characteristics differentiate secondary causes of hemorrhage from the more common hypertensive hemorrhage. Baseline and serial studies can be used to identify patients who might benefit from acute interventions. In addition, new imaging modalities, (such as magnetic resonance spectroscopy, diffusion tensor imaging, and 320-row CT) are promising research techniques that have the potential to enhance our understanding of the tissue injury and recovery after intracranial hemorrhages.
Journal of the American Society for Experimental NeuroTherapeutics 01/2011; 8(1):28-38. · 5.38 Impact Factor
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ABSTRACT: Warfarin is the only oral anticoagulant recommended for the prevention of ischemic stroke in atrial fibrillation. A newer and safer anticoagulant is needed because of increased hemorrhagic risks with warfarin, difficult-to-maintain therapeutic levels, and higher drug to drug and food interactions.
Dabigatran etexilate is a new, effective, reversible, rapid-acting, oral direct inhibitor of thrombin. This review focuses on the results of major Phase II and III trials conducted to evaluate the use of dabigatran in prevention of stroke in atrial fibrillation.
The objective of this paper is to discuss the use of dabigatran for prevention of stroke in patients with atrial fibrillation and to review its major advantages and disadvantages over warfarin.
After the recent publication of Phase III trial RE-LY (randomized evaluation of long-term anticoagulation therapy), the use of dabigatran in atrial fibrillation is more clearly defined. A higher dose of dabigatran may be beneficial in patients who have recurrent ischemic events, despite therapeutic levels of warfarin. A lower dose is potentially safer than warfarin because of fewer hemorrhagic complications. Disadvantages include twice-daily dosing, dyspepsia and higher cost.
Expert Opinion on Pharmacotherapy 06/2010; 11(8):1403-11. · 3.20 Impact Factor
