The edition · Neurology
Factor XIa inhibition cut recurrent stroke by a quarter without a significant rise in bleeding
A meta-analysis of three trials (14,239 patients) found adding a factor XIa inhibitor to antiplatelets after non-cardioembolic stroke or TIA reduced stroke recurrence. Also: lamotrigine levels fall by two-thirds in pregnancy, lecanemab's plasma biomarker signature, AI for LVO on plain CT, and atogepant against topiramate.
The edition in brief
A meta-analysis of three placebo-controlled trials with 14,239 patients, dominated by one phase 3 trial of 12,327, found adding a factor XIa inhibitor to antiplatelet therapy after acute non-cardioembolic ischaemic stroke or TIA reduced any stroke (RR 0.75, 95% CI 0.66–0.84) without a significant rise in major bleeding (RR 1.12, 0.87–1.44) or intracranial haemorrhage. A Chinese prospective cohort of 947 women with epilepsy found lamotrigine concentration-to-dose ratios fell by up to 65.8% at 32 weeks of pregnancy, with levetiracetam and oxcarbazepine also falling, supporting therapeutic drug monitoring. A cohort of 197 lecanemab-treated patients found plasma p-tau217 and GFAP moved towards normal while TREM2 and synaptic markers moved away from it. A diagnostic network meta-analysis of retrospective studies found AI on non-contrast CT detected large vessel occlusion with 78% sensitivity versus 62% for expert readers. TEMPLE, a head-to-head trial in 545 adults with migraine, found atogepant was stopped for adverse events less often than topiramate (12% vs 30%) and more often halved migraine days (64% vs 39%).
Adding a factor XIa inhibitor after non-cardioembolic stroke reduced recurrence without more bleeding
Continue guideline antiplatelet therapy now, but expect factor XIa inhibitors to become an add-on option after non-cardioembolic stroke.
Lamotrigine levels fall by up to two-thirds in pregnancy; levetiracetam and oxcarbazepine fall too
Check lamotrigine, levetiracetam and oxcarbazepine levels against the woman's own pre-pregnancy baseline through pregnancy and adjust the dose.
Lecanemab normalises plasma p-tau217 but pushes inflammatory and synaptic markers the other way
Treat plasma biomarker changes on lecanemab as research findings, not a tool for treatment decisions, for now.
AI on non-contrast CT flagged large vessel occlusion more often than expert readers
Use AI on non-contrast CT only as a prompt to prioritise CTA or transfer, never to rule out large vessel occlusion.
Write down the pre-pregnancy seizure-free drug level
Record a seizure-free baseline level before pregnancy and use it as the target throughout.
Atogepant was better tolerated and more effective than topiramate for migraine prevention
Offer atogepant as a preventive when topiramate is not tolerated or ineffective, and where cost allows, consider it first.
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