Aspirin and/or Heparin During Endovascular Stroke Treatment

Mar 11, 2022
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Authors:
van der Steen W, van de Graaf RA, Chalos V, et al., on behalf of the MR CLEAN-MED Investigators.
Citation:
Safety and Efficacy of Aspirin, Unfractionated Heparin, Both, or Neither During Endovascular Stroke Treatment (MR CLEAN-MED): An Open-Label, Multicentre, Randomized Controlled Trial. Lancet 2022;399:1059-1069.
Summary By:
Mollie McDermott, MD, MS

Quick Takes

  • Stroke guidelines are quiet on the safety and efficacy of periprocedural antithrombotics in large vessel occlusion (LVO) stroke patients treated with endovascular therapy, and large practice variation exists.
  • This randomized trial of LVO stroke patients treated with endovascular therapy found no benefit in post-stroke functional outcome—and found an increased risk of symptomatic intracranial hemorrhage—in patients treated periprocedurally with IV aspirin and/or IV heparin.
  • The results of this trial should significantly raise the threshold of neurointerventionalists to use these agents periprocedurally in LVO stroke patients.

Study Questions:

What is the safety and efficacy of intravenous (IV) aspirin, IV heparin, or both started during endovascular treatment in large vessel occlusion (LVO) stroke patients?

Methods:

MR CLEAN-MED is an open-label, blinded-outcome trial of adult patients with ischemic stroke due to an intracranial anterior circulation LVO in whom endovascular treatment could be initiated within 6 hours from last known normal. Receipt of IV tissue plasminogen activator (tPA) was permitted if there were no contraindications. Patients were randomly assigned 1:1 to receive periprocedural IV aspirin or no aspirin and randomly assigned 1:1:1 to receive moderate-dose IV heparin, low-dose IV heparin, or no heparin. All study treatments were started directly after groin puncture or, if relevant, after completion of IV tPA. The primary efficacy outcome was 90-day functional outcome as measured by the modified Rankin Scale (mRS). The primary safety outcome was symptomatic intracranial hemorrhage (sICH).

Results:

The study population consisted of 628 patients, three-fourths of whom received IV tPA. No benefit was observed for patients treated with aspirin or low-dose heparin in 90-day functional outcome. Patients who received moderate-dose heparin showed an unfavorable shift in their 90-day mRS compared to the control group (adjusted odds ratio [aOR], 0.42; 95% confidence interval [CI], 0.18-0.99). No interaction between aspirin and heparin on the primary efficacy outcome was observed. Patients who received aspirin were more likely than the control group to have symptomatic ICH (aOR, 1.95; 95% CI, 1.13-3.35) as were patients who received heparin (aOR, 1.98; 95% CI, 1.14-3.46). No interaction between aspirin and heparin on sICH was observed.

Conclusions:

Periprocedural IV aspirin and/or IV heparin in LVO stroke patients treated with endovascular therapy are both associated with an increased risk of sICH without providing a benefit in functional outcomes.

Perspective:

These data support the avoidance of periprocedural aspirin and/or heparin in LVO stroke patients treated with endovascular therapy. The results of this trial are very likely to change clinical practice as they should lead to a significantly higher threshold for neurointerventionalists to use these agents periprocedurally in LVO stroke patients.

Clinical Topics: Anticoagulation Management, Dyslipidemia, Prevention, Vascular Medicine, Lipid Metabolism

Keywords: Anticoagulants, Aspirin, Brain Ischemia, Endovascular Procedures, Fibrinolytic Agents, Heparin, Intracranial Hemorrhages, Ischemic Stroke, Secondary Prevention, Stroke, Tissue Plasminogen Activator, Vascular Diseases


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