Early cerebral infarction on CT is a rare but devastating complication of acute SAH. The observed associations with coma, global cerebral edema, intraventricular hemorrhage, and loss of consciousness at onset suggest that intracranial circulatory arrest may play a role in the pathogenesis of this disorder.

Background Continued dual antiplatelet therapy and optimal medical therapy (OMT) improve outcomes in selected patient populations with established coronary heart disease, but whether OMT modifies the treatment effect of dual antiplatelet therapy is unknown. Methods The Dual Antiplatelet Therapy Study, a double-blind trial, randomized 11,648 patients who had undergone coronary stenting and completed 1 year of dual antiplatelet therapy without major bleeding or ischemic events to an additional 18 months of continued thienopyridine or placebo. OMT was defined as a combination of statin, beta blocker and angiotensin converting enzyme inhibitor/angiotensin receptor blocker use in patients with an ACC/AHA class I indication for each medication. Per protocol, all patients were treated with aspirin 75–325 mg daily. Endpoints included myocardial infarction (MI), major adverse cardiovascular and cerebrovascular events (MACCE) and GUSTO moderate or severe bleeding events. Results Of 11,643 randomized patients with complete medication data, 63% were on OMT. Between 12 and 30 months, continued thienopyridine reduced MI compared with placebo in both groups (on OMT 2.1% vs 3.3%, HR 0.64, CI 0.48–0.86, p=0.003; off OMT 2.2% vs 5.2%, HR 0.41, CI 0.29–0.58, p <0.001; interaction p=0.103). Comparing continued thienopyridine vs placebo, rates of MACCE were 4.2% vs 5.0% among patients on OMT (HR 0.82, CI 0.66–1.02, p=0.077) and 4.5% vs 7.0% among those off OMT (HR 0.63, CI 0.49–0.82, p<0.001; interaction p=0.250); rates of bleeding for thienopyridine vs placebo in patients on OMT were 2.2% vs 1.0% (HR 2.13, CI 1.43–3.17, p<0.001) and in patients off OMT were 2.8% vs 2.2% (HR 1.30, CI 0.88–1.92, p=0.189; interaction p=0.073). Overall, patients on OMT had lower rates of MI (2.7% vs 3.7%, p=0.003), MACCE (4.6% vs 5.7%, p=0.007) and bleeding (1.6% vs 2.5%, p<0.001) compared with patients off OMT. Rates of stent thrombosis (0.8% vs 1.0%, p=0.171) and death (1.6% vs 1.9%, p=0.155) did not differ. Conclusions Continued thienopyridine therapy reduced the rate of MI regardless of OMT status and had consistent effects on reduction in MACCE and increased bleeding. Trial Registration https://clinicaltrials.gov, #NCT00977938