Antithrombotic treatment of ischemic stroke among patients with occlusion or severe stenosis of the internal carotid artery: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST).
OBJECTIVE
To examine the responses to early IV administration of an anticoagulant or placebo started within 24 hours of stroke among persons with an ipsilateral occlusion or severe stenosis of the internal carotid artery (ICA) identified by carotid duplex imaging.


BACKGROUND
Patients with ischemic stroke of the cerebral hemisphere secondary to an ipsilateral occlusion or severe stenosis of the ICA generally have a poor prognosis. Early, accurate identification of these patients might permit improved treatment.


METHODS
Exploratory analysis of outcomes at 7 days and 3 months was performed among patients enrolled in the Trial of Org 10172 in Acute Stroke Treatment (TOAST) who had an ischemic stroke in the cerebral hemisphere ipsilateral to an occlusion or a stenosis >50% of the ICA identified by carotid duplex imaging.


RESULTS
Regardless of treatment, patients with duplex evidence of an occlusion of the ICA had more severe strokes and poorer outcomes at 7 days and 3 months than patients who had a stenosis. Favorable outcomes at 7 days were noted in 64 of 119 patients given danaparoid (53.8%) and 41 of 108 patients treated with placebo (38.0%; p = 0.023). By 3 months, favorable outcomes were noted in 82 patients given danaparoid (68.3%) and 58 patients administered placebo (53.2%; p = 0.021).


CONCLUSIONS
Early identification by duplex imaging of an occlusion or severe stenosis of the ICA ipsilateral to a hemispheric ischemic stroke might improve selection of patients who could be treated with emergent anticoagulation. Further testing of this approach is needed.
Department of Neurology, University of Iowa College of Medicine, Iowa City 52242, USA. harold-adams@uiowa.edu
H P
HP
Adams
B H
BH
Bendixen
E
E
Leira
K C
KC
Chang
P H
PH
Davis
R F
RF
Woolson
W R
WR
Clarke
M D
MD
Hansen
D000925:Anticoagulants / Q000627:therapeutic use*; D002545:Brain Ischemia / Q000150:complications* / Q000000981:diagnostic imaging / Q000188:drug therapy*; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging; D016893:Carotid Stenosis / Q000150:complications* / Q000000981:diagnostic imaging; D002809:Chondroitin Sulfates / Q000627:therapeutic use*; D003871:Dermatan Sulfate / Q000627:therapeutic use*; D004311:Double-Blind Method; D004338:Drug Combinations; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D007839:Functional Laterality; D015600:Glasgow Coma Scale; D006497:Heparan Sulfate / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D010919:Placebos; D013997:Time Factors; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex
D000925:Anticoagulants; D002809:Chondroitin Sulfates; D003871:Dermatan Sulfate; D004338:Drug Combinations; D005343:Fibrinolytic Agents; D006497:Heparan Sulfate; D010919:Placebos; C035838:danaparoid