New Insights on Stroke: Atypical Antipsychotics and Other Considerations

December 21, 2017

Clinical implications of three new studies on treatments that may increase risk of-or mitigate harm from-stroke in older patients.

The highlights of 3 new clinical studies involving stroke include older adults who take atypical antipsychotics have an increased risk of major cardiovascular events, particularly stroke; thrombectomy may be effective up to 24 hours after stroke onset; and elderly adults can safely undergo endovascular therapy to treat acute ischemic stroke.

Study 1: Antipsychotics Lead to Higher Incidence of Stroke

Long-term use of atypical antipsychotics may lead to major cardiovascular events, including stroke, in older patients.

A retrospective cohort study included 1008 patients, mean age 72.4 years, who were followed for a median of 36.5 months to evaluate the effect of antipsychotic medications categorized by their metabolic side effect profiles as low, intermediate, or high risk on major cardiovascular events. The primary outcome measure was the time to the composite of acute myocardial infarction, acute coronary syndrome, ischemic stroke, peripheral artery disease, or a new revascularization procedure.

Those taking second-generation antipsychotics who experienced a high level or an intermediate level of metabolic changes had an almost threefold increased risk of experiencing a cardiovascular event, in particular, stroke, as compared to those taking medications associated with a lower risk for metabolic changes.

Clinical Implications

“Older adult patients under antipsychotic regimens with high or intermediate risk of metabolic side effects may face a higher incidence of major cardiovascular events than those under a low-risk regimen during long-term follow-up,” stated the researchers. The higher risk for major cardiovascular events among those taking intermediate-risk or high-risk agents appears to be mostly driven by the higher risk of stroke, which may be due to high prevalence of patients with dementia or related to potential direct or indirect effects of antipsychotics.

Szmulewicz AG, et al. Long-Term Antipsychotic Use and Major Cardiovascular Events: A Retrospective Cohort Study. J Clin Psychiatry 2017;78(8):e905–e912.  10.4088/JCP.16m10976

Study 2 on the next page >

Study 2: Stroke Patients May Benefit from Thrombectomy Up to 24 Hours After Onset

Time alone should not disqualify stroke patients for thrombectomy-patients from 6 to 24 hours from symptom onset may benefit from treatment.

A study enrolled 206 patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery who had last been known to be well 6 to 24 hours earlier and who had a mismatch between the severity of the clinical deficit and the infarct volume; 107 patients were assigned to the thrombectomy group and 99 to the control group.

At 90 days, the rate of functional independence was 49% in the thrombectomy group as compared with 13% in the control group. The rate of symptomatic intracranial hemorrhage did not differ significantly between the two groups.

Clinical Implications:

The findings suggest that physiological criteria as well as time from symptom onset should be considered for endovascular therapy. “Among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone,” stated the researchers.

Nogueria RG, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. New Eng J Med November 11, 2017DOI: 10.1056/NEJMoa1706442

Study 3 on the next page >

Study 3: Mechanical Thrombectomy Safe and Effective for Elderly Stroke Patients

Endovascular treatment appears to be safe and effective in elderly adults with large-vessel occlusion stroke.

A retrospective cohort study of 219 elderly adults treated for acute ischemic stroke divided the patients into two groups based on age-62 patients were age 80 years or older and 157 patients were under age 80. Safety outcomes, such as intracranial hemorrhage (ICH) and mortality, and efficacy outcomes, such as successful reperfusion and 3-month good clinical outcome, were compared in the two groups.

In patients aged 80 and older, intravenous thrombolysis was more frequent (67.7%) and onset to reperfusion time was shorter (318.7) than in younger patients (52.8% and 282, respectively), but no between-group differences were found in terms of successful reperfusion, good clinical outcome, any or symptomatic ICH, or mortality.

A multivariable analysis found that onset National Institute of Health Stroke Scale (NIHSS) score and 24-hour clinical improvement were independent predictors of 3-month functional independence in the older group.

Clinical Implications:

Paying particular attention to onset NIHSS score could speed endovascular procedures and help achieve reperfusion and good clinical outcomes. “For elderly adults showing remarkable clinical improvement in the early period after the procedure, all efforts should be made to prevent or treat post-stroke complications, which are known to strongly affect short-term, intermediate-term, and long-term morbidity and mortality,” stated the researchers.

Sallustio F, et al. Efficacy and Safety of Mechanical Thrombectomy in Older Adults With Acute Ischemic Stoke. J Am Geriatr Soc. 2017 Aug;65(8):1816-1820. doi: 10.1111/jgs.14909.