الفهرس 
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Abstract
While current therapies such as tissue plasminogen activator (rTPA) and revascularization are effective in the acute management of ischemic stroke and transient ischemic attack (TIA), the majority of patients are ineligible to receive them. As it must be administered within 4.5 hours of symptom onset. This small treatment window effectively eliminates the majority of patients, such as those who do not know that they are having a stroke, those who cannot articulate because they are having a stroke, those who live in remote areas, and those who live alone or if patient can’t afford or it is not available.
So the aim of this study is to find an alternative therapy that is available most of the time with cheaper price and extended time window to 9 hours. So we studied using clopidogrel in two doses (900 mg and 600 mg) and aspirin 300 mg as loading oral dose (guidelines recommendations).
This study prospectively recruited 179 patients, 65 in group 1 (900 mg clopidogrel), 58 patients from group 2 (600 mg clopidogrel) and 56 patients in group 3 (300 mg aspirin). The study was double blinded and randomized, carried out in EL Demerdash hospital, AIN Shams specialized hospital and EL Mataria hospital.
Patients with first ever stroke presenting within the first 9 hours of onset received 12 tablets from a numbered box (randomized according to the group). Each patient had NIHSS on admission, day 2 and on day 7 (or discharge which first) and MRS after 3 months was assessed to detect prognosis. Patients as well did routine CT brain before receiving the treatment, MRI brain on day 2 and follow up CT brain on day 5. Besides routine work up for stroke patients (lipid profile, sugar profile, carotid duplex, Echocardiography and CT angiography if needed).
The results of this study showed the mean NIHSS difference for group 1 was (4.49) while for group 2 is (4.84). Meanwhile the mean for group 3 is 2.69 (p < 0.05). There was significant improvement of NIHSS for group 1 (41/63) (65.1%) and in group 2 (40/57) (71.4%) in comparison to group 3 (14/55) (25.5%) (p = 0.000).
As regard bleeding complication, one patient from group 1 (1/65) (1.5%) and one patient from group 2 (1/57) (1.8%) had asymptomatic intracranial hemorrhage, while no patient in group 3 developed bleeding complication, yet this is not statistically significant (p = 0.625).
MRS analysis showed no statistical difference between the three groups, so MRS 2 was taken as cut off point to detect the difference between the 3 groups. This showed statistical difference between MRS < 2 in group 2 (28/55) versus (14/46) in group 3 (p = 0.039), while between group 1 (31/65) and group 3 (14/46) the p= 0.07 (p > 0.05). Meanwhile the comparison between group 1 and 2 was not statistically significant (p = 0.725).
This results highlighted the role of loading clopidogrel in acute ischemic stroke compared to standard loading aspirin, the results showed no difference between the dose 900 mg and 600 mg clopidogrel, so we recommend using the safest lower dose (600 mg clopidogrel) for patients presented within the first 9 hours.
However, the mechanism by which clopidogrel improve the acute thrombus needs further studies with CT angiography before and after giving the drug. Further studies is needed to reinforce our results and to compare clopidogrel with other therapies.