Emergent Large Vessel Occlusion Stroke During New York City's COVID-19 Outbreak: Clinical Characteristics and Paraclinical Findings.

BACKGROUND AND PURPOSE: The 2019 novel coronavirus outbreak and its associated disease (coronavirus disease 2019 [COVID-19]) have created a worldwide pandemic. Early data suggest higher rate of ischemic stroke in severe COVID-19 infection. We evaluated whether a relationship exists between emergent large vessel occlusion (ELVO) and the ongoing COVID-19 outbreak. METHODS: This is a retrospective, observational case series. Data were collected from all patients who presented with ELVO to the Mount Sinai Health System Hospitals across New York City during the peak 3 weeks of hospitalization and death from COVID-19. Patients' demographic, comorbid conditions, cardiovascular risk factors, COVID-19 disease status, and clinical presentation were extracted from the electronic medical record. Comparison was made between COVID-19 positive and negative cohorts. The incidence of ELVO stroke was compared with the pre-COVID period. RESULTS: Forty-five consecutive ELVO patients presented during the observation period. Fifty-three percent of patients tested positive for COVID-19. Total patients' mean (±SD) age was 66 (±17). Patients with COVID-19 were significantly younger than patients without COVID-19, 59±13 versus 74±17 (odds ratio [95% CI], 0.94 [0.81-0.98]; P=0.004). Seventy-five percent of patients with COVID-19 were male compared with 43% of patients without COVID-19 (odds ratio [95% CI], 3.99 [1.12-14.17]; P=0.032). Patients with COVID-19 were less likely to be White (8% versus 38% [odds ratio (95% CI), 0.15 (0.04-0.81); P=0.027]). In comparison to a similar time duration before the COVID-19 outbreak, a 2-fold increase in the total number of ELVO was observed (estimate: 0.78 [95% CI, 0.47-1.08], P≤0.0001). CONCLUSIONS: More than half of the ELVO stroke patients during the peak time of the New York City's COVID-19 outbreak were COVID-19 positive, and those patients with COVID-19 were younger, more likely to be male, and less likely to be White. Our findings also suggest an increase in the incidence of ELVO stroke during the peak of the COVID-19 outbreak.

Cerebral Venous Sinus Thrombosis and Acute Myocardial Infarction in a Patient with PAI-1 4G/4G Homozygosity.

The plasminogen activator inhibitor-1 (PAI-1) 4G/4G homozygous genotype represents a genetic thrombophilia that has been associated with enhanced risk of arterial and venous thrombotic events. The optimal anticoagulation strategy for PAI-1 4G homozygous patients is unclear. Herein we present a case of a patient with PAI-1 4G/4G homozygosity who was placed on dabigatran after developing cerebral venous sinus thrombosis (CVST), but who then suffered an acute myocardial infarction several weeks later. We seek to highlight the relationship between the PAI-1 4G/4G genotype and risk of CVST, as well as discuss our management strategy in the aftermath of dabigatran failure.

Defining an Intraoperative Hypotension Threshold in Association with Stroke in Cardiac Surgery.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Stroke is a leading cause of morbidity, mortality, and disability in patients undergoing cardiac surgery. Identifying modifiable perioperative stroke risk factors may lead to improved patient outcomes. The association between the severity and duration of intraoperative hypotension and postoperative stroke in patients undergoing cardiac surgery was evaluated. METHODS: A retrospective cohort study was conducted of adult patients who underwent cardiac surgery requiring cardiopulmonary bypass at a tertiary center between November 1, 2009, and March 31, 2015. The primary outcome was postoperative ischemic stroke. Intraoperative hypotension was defined as the number of minutes spent within mean arterial pressure bands of less than 55, 55 to 64, and 65 to 74 mmHg before, during, and after cardiopulmonary bypass. The association between stroke and hypotension was examined by using logistic regression with propensity score adjustment. RESULTS: Among the 7,457 patients included in this analysis, 111 (1.5%) had a confirmed postoperative diagnosis of stroke. Stroke was strongly associated with sustained mean arterial pressure of less than 64 mmHg during cardiopulmonary bypass (adjusted odds ratio 1.13; 95% CI, 1.05 to 1.21 for every 10 min of mean arterial pressure between 55 and 64 mmHg; adjusted odds ratio 1.16; 95% CI, 1.08 to 1.23 for every 10 min of mean arterial pressure less than 55 mmHg). Other factors that were independently associated with stroke were older age, hypertension, combined coronary artery bypass graft/valve surgery, emergent operative status, prolonged cardiopulmonary bypass duration, and postoperative new-onset atrial fibrillation. CONCLUSIONS: Hypotension is a potentially modifiable risk factor for perioperative stroke. The study's findings suggest that mean arterial pressure may be an important intraoperative therapeutic hemodynamic target to reduce the incidence of stroke in patients undergoing cardiopulmonary bypass.

Utility of Carotid Ultrasonography in Management of an Atypical High Vascular-Risk Patient with Recurrent Calcified Cerebral Embolic Stroke.

OBJECTIVE: To describe a case of recurrent calcified cerebral emboli (CCE)-related acute ischemic stroke (AIS) and the diagnostic utility of plaque morphology characterization on carotid ultrasound. BACKGROUND: CCE are a rare cause of AIS. CCE-related AIS has been previously reported only in high vascular-risk patients such as those with severe carotid stenosis, widespread atheromatous disease, or cardiac valvular disease. CCE-related AIS from a carotid origin has not been reported in patients without carotid stenosis. CASE: A 69-year-old man with no known medical history presented with hemiparesis and aphasia was found to have a curvilinear calcification in the left sylvian fissure on brain imaging, consistent with CCE. Two months later, he developed a second episode of CCE-related AIS. Standard workup, as well as advanced imaging with digital subtraction angiography, revealed no carotid stenosis or valvular disease. Carotid ultrasound demonstrated normal flow velocities but a left carotid heterogeneous plaque with multiple ulcerative craters and lucencies, suggestive of an active thromboembolic source. CONCLUSION: To our knowledge, this is the first case reporting CCE-AIS from carotid origin in a patient with no carotid stenosis. Carotid ultrasound serves a diagnostic role in these patients.

Median nerve penetration by a persistent median artery and vein mimicking carpal tunnel syndrome.

INTRODUCTION: Carpal tunnel syndrome (CTS) is a common clinical syndrome seen in the outpatient setting that is easily confirmed by electrodiagnostic testing. METHODS: We describe the case of a patient who presented with the classic symptoms and neurological examination for CTS, but had a normal nerve conduction study and electromyogram. RESULTS: Neuromuscular ultrasound of the median nerve on the symptomatic side revealed penetration of the nerve by a persistent median artery and vein in the mid-forearm, with a positive sonographic Tinel sign over this spot. This finding is an anatomical variation that has been described sparingly in the literature, mostly in cadavers. It has not been reported previously to be a mimic of CTS. CONCLUSIONS: This case demonstrates the diagnostic utility of neuromuscular ultrasound and the importance of considering an anatomical variation involving the median nerve in the differential diagnosis of CTS.

Strategies for multivessel revascularization in patients with diabetes.

BACKGROUND: In some randomized trials comparing revascularization strategies for patients with diabetes, coronary-artery bypass grafting (CABG) has had a better outcome than percutaneous coronary intervention (PCI). We sought to discover whether aggressive medical therapy and the use of drug-eluting stents could alter the revascularization approach for patients with diabetes and multivessel coronary artery disease. METHODS: In this randomized trial, we assigned patients with diabetes and multivessel coronary artery disease to undergo either PCI with drug-eluting stents or CABG. The patients were followed for a minimum of 2 years (median among survivors, 3.8 years). All patients were prescribed currently recommended medical therapies for the control of low-density lipoprotein cholesterol, systolic blood pressure, and glycated hemoglobin. The primary outcome measure was a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke. RESULTS: From 2005 through 2010, we enrolled 1900 patients at 140 international centers. The patients' mean age was 63.1±9.1 years, 29% were women, and 83% had three-vessel disease. The primary outcome occurred more frequently in the PCI group (P=0.005), with 5-year rates of 26.6% in the PCI group and 18.7% in the CABG group. The benefit of CABG was driven by differences in rates of both myocardial infarction (P<0.001) and death from any cause (P=0.049). Stroke was more frequent in the CABG group, with 5-year rates of 2.4% in the PCI group and 5.2% in the CABG group (P=0.03). CONCLUSIONS: For patients with diabetes and advanced coronary artery disease, CABG was superior to PCI in that it significantly reduced rates of death and myocardial infarction, with a higher rate of stroke. (Funded by the National Heart, Lung, and Blood Institute and others; FREEDOM ClinicalTrials.gov number, NCT00086450.).

Internal Carotid Artery Stenosis and Ipsilateral Subretinal Drusenoid Deposits.

Purpose: Subretinal drusenoid deposits (SDDs) in age-related macular degeneration (AMD) are strongly associated with vasculopathies such as myocardial infarction and ischemic stroke. This study evaluates ischemic stroke subjects for SDDs to determine whether ocular hypoperfusion from internal carotid artery (ICA) stenosis is associated with ipsilateral SDDs. Methods: A cross-sectional study at Mount Sinai Hospital recruited 39 subjects with ischemic stroke (aged 52-90; 18 women, 21 men); 28 completed all study procedures. Computed tomography (CT) of the head and neck evaluated 54/56 ICAs for stenosis criteria: none (n = 33), mild (n = 12), moderate (n = 3), severe (n = 3), and complete (n = 3). Spectral-domain optical coherence tomography (SD-OCT) scans were read to consensus by two masked graders for soft drusen, SDDs and choroidal thickness (CTh; choroidal thinning = CTh < 250 µm). Univariate testing was done with Fisher's exact test. Multivariate logistic regression models tested age, gender, and ICA stenosis as covariates. Results: Moderate or more ICA stenosis (≥50%-69%) was significantly associated with ipsilateral choroidal thinning (P = 0.021) and ipsilateral SDDs (P = 0.005); the latter were present distal to six of nine stenosed ICAs versus five of 33 normal ICAs. Mild ICA stenosis (≥1%-49%) was not significantly associated with ipsilateral SDDs. Multivariate regression found that older age (P = 0.015) and moderate or more ICA stenosis (P = 0.011) remained significant independent risks for ipsilateral SDDs. Conclusions: At least moderate ICA stenosis (≥50%-69%) is strongly associated with ipsilateral SDDs and choroidal thinning, supporting downstream ophthalmic artery and choroidal hypoperfusion from ICA stenosis as the mechanism for SDD formation. SDDs may thus serve as sensitive biomarkers for ischemic stroke and other vascular diseases.

Multiple ischemic strokes after transcatheter arterial chemoembolization for hepatocellular carcinoma with a radiographic and pathological correlate.

INTRODUCTION: Transcatheter arterial chemoembolization (TACE) is a widely used form of therapy in advanced hepatocellular carcinoma. We report the first pathological data from an autopsy case of multiple cerebral emboli occurring during TACE. METHODS: A Medline search for previous cases of cerebral embolism and TACE revealed 11 other cases. FINDINGS: Multiple microscopic subacute infarcts were found in the cerebrum, midbrain, and cerebellum of our patient on autopsy, but no embolic material was seen. Embolic material was noted in dilated vessels throughout the fibrotic right diaphragm and in the upper lobe of the right lung. Combining the literature search with our patient, the mortality of cerebral embolism after TACE is 25% (n = 12). Intracardiac shunts were seen in 20% of the cases (n = 10). Hyperdense lesions were seen on head CT in 80% of the patients evaluated (n = 10). Chest imaging revealed infiltrate or consolidation in 60% of the cases (n = 5). Pulmonary emboli were reported in 100% of the cases (n = 8). CONCLUSIONS: Cerebral embolism after TACE is devastating. Brain pathology supports embolization of ethiodized oil rather than DC beads as the mechanism of cerebral injury. Further pathological studies are needed to better understand the pathophysiology of this condition. Lung pathology confirmed the presence of embolic material in the distal lung, suggestive of a hepatopulmonary shunt undetectable by current modalities. Evaluation for such shunts with emerging modalities such as TCD with emboli detection may be an area of future research.

Common carotid artery dissection: a case report and review of the literature.

Common carotid artery dissection (CCAD) is a rare and poorly characterized cause of ischemic stroke. We describe a case of multiple cerebral infarcts in a patient with CCAD initially detected by carotid duplex ultrasonography, and review the literature on CCAD. A Medline search from 1960 to the present for cases of CCAD yielded 46 cases. We extracted demographic data, anatomical location, symptoms, neurosonography, neuroradiology, pathological findings, treatment, and outcomes. The mean age of the patients was 48.8 ± 15.8 years (range, 19-89 years). With our patient, our search found 20 cases of spontaneous CCAD, 11 cases of traumatic CCAD, 4 cases of iatrogenic CCAD, and 12 cases of CCAD associated with aortic arch dissection. The most common presenting neurologic symptoms of CCAD were hemiparesis, decreased consciousness, headache/neck pain, aphasia, and monocular field deficit. The most frequently reported neurosonographic findings included a double lumen, mural thrombus, intraluminal hyperechoic/isoechoic lesion, and intimal flap. Most cases of CCAD were subsequently confirmed with conventional angiography, computed tomography angiography, or magnetic resonance angiography. Treatment differed based on etiology; anticoagulation was used most commonly for spontaneous CCAD, and surgical repair was most often done for traumatic and aortic dissection-associated CCAD. Prognosis was generally good; the majority of patients achieved complete clinical recovery, but 3 died. Our findings indicate that carotid Doppler is a widely accessible, rapid, and noninvasive technique for diagnosing CCAD. Our case and literature review further characterizes the diverse etiologies, clinical course, and radiographic features of CCAD.

Antiplatelet agents for stroke prevention following transient ischemic attack.

Regardless of extent or duration of acute effects, transient ischemic attack (TIA) is a marker for cerebrovascular ischemia and carries risk for secondary stroke comparable to that associated with ischemic stroke. Pharmacologic and nonpharmacologic interventions aimed at reducing risk of secondary stroke should be implemented as soon as possible after characterization of the initial event. Medical strategies for secondary prevention include modifying general cardiovascular risk factors but are centered on the specific reduction of stroke risk by antiplatelet agents. Aspirin and clopidogrel have each demonstrated efficacy in reducing secondary event risk; however, clopidogrel has not been shown specifically to prevent secondary events in patients who have had a TIA or stroke. Combination therapy using aspirin plus dipyridamole is the only combination approach to demonstrate additive benefit that is significantly greater than that conferred by aspirin. In contrast, the combination of clopidogrel plus aspirin has not demonstrated significant benefit over monotherapy with either agent and has been associated with increased risk of bleeding episodes.

Management of intracerebral hemorrhage.

Currently, intracerebral hemorrhage (ICH) has the highest mortality rate of all stroke subtypes (Counsell et al 1995; Qureshi et al 2005). Hematoma growth is a principal cause of early neurological deterioration. Prospective and retrospective studies indicate that up to 38% hematoma expansion is noted within three hours of ICH onset and that hematoma volume is an important predictor of 30-day mortality (Brott et al 1997; Qureshi et al 2005). This article will review current standard of care measures for ICH patients and new research directed at early hemostatic therapy and minimally invasive surgery.

Resolution of Occlusive Carotid Artery Thrombus Treated with Anticoagulation as Demonstrated on Duplex Ultrasonography.

BACKGROUND AND PURPOSE: While the majority of cerebral ischemic events due to carotid occlusive disease result from atherosclerotic plaque rupture, intraluminal carotid artery thrombus occasionally occurs in patients without preexisting carotid atherosclerosis. Identification of nonatherosclerotic thrombus as the cause of the carotid occlusive disease can obviate the need for an interventional procedure, and resolution of thrombus can be monitored with B-mode duplex ultrasonography. METHODS: We reviewed 3 patients treated on The Mount Sinai Hospital Stroke Unit with anticoagulation for nonatherosclerotic carotid thrombi and followed with serial Doppler ultrasonogrpahy for resolution of thrombus. RESULTS: Occlusive carotid thrombus was successfully treated in all 3 patients with systemic anticoagulation. B-mode duplex ultrasonography allowed for demonstration of resolving thrombus. CONCLUSION: Differentiation between a stenotic plaque and occlusive thrombus can be achieved by ultrasonographic analysis of thrombus morphology, attachment site potential, and characteristics of a resolving thrombus. Systemic anticoagulation can safely and effectively eliminate the risk for future embolization and complete occlusion of the carotid artery in patients who present with transient ischemic events or completed infarcts of small size.

Effects of aggressive versus conventional lipid-lowering therapy by simvastatin on human atherosclerotic lesions: a prospective, randomized, double-blind trial with high-resolution magnetic resonance imaging.

OBJECTIVES: This study sought to compare the effects of aggressive and conventional lipid lowering by two different dosages of the same statin on early human atherosclerotic lesions using serial noninvasive magnetic resonance imaging (MRI). BACKGROUND: Regression of atherosclerotic lesions by lipid-lowering therapy has been reported. METHODS: Using a double-blind design, newly diagnosed hypercholesterolemic patients (n = 51) with asymptomatic aortic and/or carotid atherosclerotic plaques were randomized to 20 mg/day (n = 29) or 80 mg/day (n = 22) simvastatin. Mean follow-up was 18.1 months. A total of 93 aortic and 57 carotid plaques were detected and sequentially followed up by MRI every six months after lipid-lowering initiation. The primary MRI end point was change in vessel wall area (VWA) as a surrogate for atherosclerotic burden. RESULTS: Both statin doses reduced significantly total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) versus baseline (p < 0.001). Total cholesterol decreased by 26% versus 33% and LDL-C by 36% versus 46% in the conventional (20 mg) versus aggressive (80 mg) simvastatin groups, respectively. Although the simvastatin 80-mg group had significantly higher baseline TC and LDL-C levels, both groups reached similar absolute values after treatment. A significant reduction in VWA was already observed by 12 months. No difference on vascular effects was detected between the randomized doses. Post-hoc analysis showed that patients reaching mean on-treatment LDL-C < or = 100 mg/dl had larger decreases in plaque size. CONCLUSIONS: Effective and protracted lipid-lowering therapy with simvastatin is associated with a significant regression of atherosclerotic lesions. No difference in vessel wall changes was seen between high and conventional doses of simvastatin. Changes in vessel wall parameters are more related to LDL-C reduction rather than to the dose of statin.

Correlation between coronary artery disease and aortic arch plaque thickness measured by non-invasive B-mode ultrasonography.

OBJECTIVE: Transesophageal echocardiography (TEE) has been used to visualize aortic arch plaques. TEE is moderately invasive. We employed a new non-invasive method for visualization of the aortic arch to assess the correlation of the extent of plaque in the aortic arch as visualized by non-invasive ultrasound with the prevalence of coronary artery disease (CAD). METHODS: The aortic arch was examined with B-mode sonography using a right supraclavicular approach in 517 consecutive patients referred for carotid duplex sonography. CAD was defined as previous myocardial infarction, previous coronary revascularization or typical angina pectoris requiring treatment. Cardiovascular risk factors were documented. RESULTS: The aortic arch could be visualized to measure intima-media thickness (IMT) in 97% of the 517 patients. The IMT was a strong predictor for the presence of CAD. Only 14% (37 out of 256) of patients with an IMT of <1.1 mm had overt CAD. The prevalence increased consistently with increase of IMT to 86% among the patients with IMT over 5 mm (chi2, p<0.0000001) (R=0.97, p<0.001). The average IMT increased also with age, diabetes mellitus, arterial hypertension, hypercholesterolemia and tobacco smoking. CONCLUSIONS: Aortic arch IMT can be measured in the majority of patients using the right supraclavicular window. The method is non-invasive, allowing sequential examinations applicable to prospective studies of the risk of CAD.

Evolving therapeutic approaches to treating acute ischemic stroke.

Stroke contributes significantly to death, disability, and healthcare costs; however, recombinant tissue plasminogen activator (rt-PA) is the only approved thrombolytic therapy for acute ischemic stroke. One area of development for new ischemic stroke treatment options is focused on neuroprotection of viable tissue in the ischemic vascular bed. The ischemic penumbra is recognizable on MRI by decreased perfusion, in contrast to the core area of ischemia, which includes diffusion and perfusion abnormalities. Understanding the mechanisms of neuronal death, including the role of excitotoxic neurotransmitters, free radical production, and apoptotic pathways, is important in developing new therapies for stroke. This article reviews these causes and results of stroke, as well as current and future neuroprotective treatment options. Several compounds have shown neuroprotective effects in animal studies, but have failed to be effective in human clinical trials. Several promising therapeutic areas include targeting of free radicals, modulation of glutamatergic transmission, and membrane stabilization via ion channels.

Lipid lowering by simvastatin induces regression of human atherosclerotic lesions: two years' follow-up by high-resolution noninvasive magnetic resonance imaging.

BACKGROUND: Statins are widely used to treat hypercholesterolemia and atherosclerotic disease. Noninvasive MRI allows serial monitoring of atherosclerotic plaque size changes. Our aim was to investigate the effects of lipid lowering with simvastatin on atherosclerotic lesions. METHODS AND RESULTS: A total of 44 aortic and 32 carotid artery plaques were detected in 21 asymptomatic hypercholesterolemic patients at baseline. The effects of statin on these atherosclerotic lesions were evaluated as changes versus baseline in lumen area (LA), vessel wall thickness (VWT), and vessel wall area (VWA) by MRI. Maximal reduction of plasma total and LDL cholesterol by simvastatin (23% and 38% respectively; P<0.01 versus baseline) was achieved after approximately 6 weeks of therapy and maintained thereafter throughout the study. Significant (P<0.01) reductions in maximal VWT and VWA at 12 months (10% and 11% for aortic and 8% and 11% for carotid plaques, respectively), without changes in LA, have been reported. Further decreases in VWT and VWA ranging from 12% to 20% were observed at 18 and 24 months. A slight but significant increase (ranging from 4% to 6%) in LA was seen in both carotid and aortic lesions at these later time points. CONCLUSION: The present study demonstrates that maintained lipid-lowering therapy with simvastatin is associated with significant regression of established atherosclerotic lesions in humans. Our observations indicate that lipid-lowering therapy is associated with sustained vascular remodeling and emphasize the need for longer-term treatment.

Thrombolytic therapy for acute stroke in late pregnancy with intra-arterial recombinant tissue plasminogen activator.

BACKGROUND AND PURPOSE: The most common presentation of ischemic stroke related to pregnancy is arterial occlusion, occurring during the third trimester or postpartum. The authors present the first successful administration of intra-arterial cerebral tissue plasminogen activator to treat an embolic cerebral vascular accident in a 37-week parturient resulting in complete recovery of neurological function. METHODS: The patient presented with left hemiplegia, left-sided neglect, and aphasia. Right internal carotid artery cerebral angiogram showed occlusion of the mid-M1 segment of the middle cerebral artery (MCA). After 15 mg of tissue plasminogen activator was administered via intra-arterial route, there was greatly improved retrograde flow through the posterior communication artery and the MCA territory. RESULTS: A reduction in size of the MCA occlusion was noted with improvement of antegrade flow through the MCA. Three days after the procedure, the patient was induced successfully and delivered a healthy infant vaginally. CONCLUSIONS: This report describes the use of intra-arterial tissue plasminogen activator in the setting of stroke in late pregnancy.

Adverse effects and drug interactions of antithrombotic agents used in prevention of ischaemic stroke.

Stroke is the third most common cause of death in the US. Primary prevention of stroke can be achieved by control of risk factors including hypertension, diabetes mellitus, elevated cholesterol levels and smoking. Approximately one-third of all ischaemic strokes occur in patients with a history of stroke or transient ischaemic attack (TIA). The mainstay of secondary prevention of ischaemic stroke is the addition of medical therapy with antithrombotic agents to control the risk factors for stroke. Antithrombotic therapy is associated with significant medical complications, particularly bleeding.Low-dose aspirin (acetylsalicylic acid) has been shown to be as effective as high-dose aspirin in the prevention of stroke, with fewer adverse bleeding events. Aspirin has been shown to be as effective as warfarin in the prevention of noncardioembolic ischaemic stroke, with significantly fewer bleeding complications. Ticlopidine may be more effective in preventing stroke than aspirin, but is associated with unacceptable haematological complications. Clopidogrel may have some benefit over aspirin in preventing myocardial infarction, but has not been shown to be superior to aspirin in the prevention of stroke. The combination of clopidogrel and aspirin may be more effective than aspirin alone in acute coronary syndromes, but the incidence of adverse bleeding is significantly higher. Furthermore, the combination of aspirin with clopidogrel has not been shown to be more effective for prevention of recurrent stroke than clopidogrel alone, while the rate of bleeding complications was significantly higher with combination therapy. The combination of aspirin and extended-release dipyridamole has been demonstrated to be more effective than aspirin alone, with the same rate of adverse bleeding complications as low-dose aspirin. When selecting the appropriate antithrombotic agent for secondary prevention of stroke, the adverse event profile of the drug must be taken into account when assessing the overall efficacy of the treatment plan.