This is apparent from research coordinated by Erasmus MC
Administration of the blood thinners acetylsalicylic acid or heparin during catheter treatment of a cerebral infarction leads to an increased risk of cerebral haemorrhage, without having a beneficial effect on recovery. This is apparent from research coordinated by Erasmus MC
In the so-called MR CLEAN-MED trial, a team led by Erasmus MC investigated the effectiveness and safety of the use of the blood thinners acetylsalicylic acid (aspirin) and heparin during the catheter treatment of a cerebral infarction. In such a treatment, the blood clot is removed from the artery with a catheter via the groin (see box). The additional blood thinners must also ensure that the smaller blood vessels open. Until now, however, it was unknown whether the potential benefits of these drugs outweigh the increased risk of brain haemorrhage.
brain haemorrhages
That now appears not to be the case. Patients who received acetylsalicylic acid or heparin by infusion were about two times more likely to have serious brain haemorrhages than patients who did not receive these medicines. This involved 14 percent of patients in the acetylsalicylic acid group and 13 percent in the heparin group, versus 7 percent of patients in the control group.
In addition, there was no evidence that patients recovered better when they were given acetylsalicylic acid or heparin. In total, the researchers enrolled 628 patients in the study before it was stopped early because of the findings.
The researchers report their findings in the renowned scientific journal The Lancet.
Catheter treatment cerebral infarction
During catheter treatment, a patient with a stroke is inserted into an artery through a puncture in the groin. The catheter is advanced into the occluded blood vessel in the brain. Then the blood clot is removed through the catheter. The catheter approach became the standard after the MR CLEAN study led by neurologist Prof. Dr. Diederik Dippel and radiologist Prof. Dr. Aad van der Lugt from Erasmus MC in 2015 showed that it leads to less brain damage and better recovery. Not all patients are eligible for catheter treatment. This concerns a subgroup of people with a serious cerebral infarction that is diagnosed quickly.
Rapid catheter treatment does not always lead to better outcomes. That’s because the clot that occludes a blood vessel in the brain often cannot be completely removed, and smaller blood vessels remain occluded. For this reason, blood thinners were often administered via an IV during the catheter treatment of a cerebral infarction.
The researchers expect that their results will change guidelines worldwide for the administration of blood-thinning medication during the catheter treatment of a stroke. ‘As a result, a large number of serious brain haemorrhages worldwide can be prevented,’ says neurologist in training and first author Wouter van der Steen.
At Erasmus MC, acetylsalicylic acid and heparin are no longer administered during the catheter treatment of a cerebral infarction.
Tissue fragile
The fact that the blood-thinning agents lead to more brain haemorrhages is probably because the brain tissue has been damaged by the infarction. ‘If a clot blocks a blood vessel, the brain tissue behind it dies. This makes it vulnerable and more prone to bleeding. Blood thinners then increase the risk of bleeding’, explains neurologist and coordinating researchers Dr Bob Roozenbeek.
‘Now it is clear that the advantages do not outweigh the disadvantages’
Roozenbeek is pleased that their study now provides information about the administration of acetylsalicylic acid and heparin during the catheter treatment of a cerebral infarction. “We knew we were dealing with the balance between the bleeding risk and the potential benefit of opening the small vessels. Now it is clear that the advantages do not outweigh the disadvantages.’
The researchers emphasize that their study is not about the blood thinners that patients are prescribed after a stroke to prevent another stroke. ‘It is safe and very important to keep using it,’ says Roozenbeek.
15 participating centers
15 centers in the Netherlands participated in the MR CLEAN MED study: Albert Schweitzer Hospital, Amphia Hospital, Amsterdam UMC, Catharina Hospital, Erasmus MC, Haaglanden Medical Center, Haga Hospital, Isala Klinieken, Maastricht University Medical Center, Sint Antonius Hospital, Elisabeth TweeSteden hospital, University Medical Center Groningen, Radboudumc, University Medical Center Utrecht, Rijnstate Hospital.
The research was led by Prof. Dr. Diederik Dippel and Prof. Aad van der Lugt of Erasmus MC and was made possible in part by the Heart and Brain Foundation, through the CONTRAST Consortium.
This study was funded by the CONTRAST consortium, which is financially supported by Cardiovascular Research Netherlands, an initiative of the Heart Foundation, (CVON2015-01: CONTRAST), and the Brain Foundation (HA2015.01.06). This collaborative project has also been financed by the Ministry of Economic Affairs, through the PPP Allowance, made available by the Top Sector Life Sciences & Health, with the aim of stimulating public-private collaboration (LSHM17016). The consortium also received unconditional funding from Stryker, Medtronic and Cerenovus for research.
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