Antiplatelet therapy in ischemic stroke and transient ischemic attack
Keywords:
ischemic stroke, TIA, antiplateletAbstract
Stroke is a leading cause of serious long-term disability and mortality worldwide. In Thailand, the prevalence of stroke is estimated to be 2.7% among elders (aged more than 65 years old). Antiplatelet therapy has been used as a key component in management of non-cardioembolic stroke and transient ischemic attack (TIA). There are various types of antiplatelet agents that had been studied including monotherapy and combination-therapy. The aim of this topic is to summarize the clinical evidences of five antiplatelet agents including aspirin, aspirin-dipyridamole, clopidogrel, ticagrelor, and cilostazol that are the most mentioned in current practice guidelines and in stroke congress.
References
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3. Hall R, Mazer CDJA, Analgesia. Antiplatelet drugs: a review of their pharmacology and management in the perioperative period. 2011;112(2):292-318.
4. Awtry EH, Loscalzo J. Aspirin. Circulation. 2000;101(10):1206-18.
5. The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet. 1997;349(9065):1569-81.
6. CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. CAST (Chinese Acute Stroke Trial) Collaborative Group. Lancet. 1997;349(9066):1641-9.
7. Chen ZM, Sandercock P, Pan HC, Counsell C, Collins R, Liu LS, et al. Indications for early aspirin use in acute ischemic stroke : A combined analysis of 40 000 randomized patients from the chinese acute stroke trial and the international stroke trial. On behalf of the CAST and IST collaborative groups. Stroke. 2000;31(6):1240-9.
8. Warner JJ, Harrington RA, Sacco RL, Elkind MSV. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke. 2019:Strokeaha119027708.
9. Baigent C, Blackwell L, Collins R, Emberson J, Godwin J, Peto R, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;373(9678):1849-60.
10. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. Bmj. 2002;324(7329):71-86.
11. Hackam DG, Spence JD. Antiplatelet Therapy in Ischemic Stroke and Transient Ischemic Attack. Stroke. 2019;50(3):773-8.
12. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-236.
13. Harker LA, Kadatz RA. Mechanism of action of dipyridamole. Thromb Res Suppl. 1983;4:39-46.
14. Diener HC, Cunha L, Forbes C, Sivenius J, Smets P, Lowenthal A. European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci. 1996;143(1-2):1-13.
15. Halkes PH, van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A. Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): randomised controlled trial. Lancet. 2006;367(9523):1665-73.
16. Halkes PH, Gray LJ, Bath PM, Diener HC, Guiraud-Chaumeil B, Yatsu FM, et al. Dipyridamole plus aspirin versus aspirin alone in secondary prevention after TIA or stroke: a meta-analysis by risk. Journal of neurology, neurosurgery, and psychiatry. 2008;79(11):1218-23.
17. Sacco RL, Diener H-C, Yusuf S, Cotton D, Ôunpuu S, Lawton WA, et al. Aspirin and Extended-Release Dipyridamole versus Clopidogrel for Recurrent Stroke. New England Journal of Medicine. 2008;359(12):1238-51.
18. Powers William J, Rabinstein Alejandro A, Ackerson T, Adeoye Opeolu M, Bambakidis Nicholas C, Becker K, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46-e99.
19. Gachet C, Stierle A, Cazenave JP, Ohlmann P, Lanza F, Bouloux C, et al. The thienopyridine PCR 4099 selectively inhibits ADP-induced platelet aggregation and fibrinogen binding without modifying the membrane glycoprotein IIb-IIIa complex in rat and in man. Biochem Pharmacol. 1990;40(2):229-38.
20. Meyer DM, Albright KC, Allison TA, Grotta JC. LOAD: a pilot study of the safety of loading of aspirin and clopidogrel in acute ischemic stroke and transient ischemic attack. J Stroke Cerebrovasc Dis. 2008;17(1):26-9.
21. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet. 1996;348(9038):1329-39.
22. Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet. 2004;364(9431):331-7.
23. Bhatt DL, Fox KA, Hacke W, Berger PB, Black HR, Boden WE, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med. 2006;354(16):1706-17.
24. Effects of Clopidogrel Added to Aspirin in Patients with Recent Lacunar Stroke. New England Journal of Medicine. 2012;367(9):817-25.
25. Markus HS, Droste DW, Kaps M, Larrue V, Lees KR, Siebler M, et al. Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation. 2005;111(17):2233-40.
26. Wong KS, Chen C, Fu J, Chang HM, Suwanwela NC, Huang YN, et al. Clopidogrel plus aspirin versus aspirin alone for reducing embolisation in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR study): a randomised, open-label, blinded-endpoint trial. Lancet Neurol. 2010;9(5):489-97.
27. Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, et al. Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis. New England Journal of Medicine. 2011;365(11):993-1003.
28. Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C, et al. Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack. New England Journal of Medicine. 2013;369(1):11-9.
29. Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, et al. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. New England Journal of Medicine. 2018;379(3):215-25.
30. Johnston SC, Elm JJ, Easton JD, Farrant M, Barsan WG, Kim AS, et al. Time Course for Benefit and Risk of Clopidogrel and Aspirin After Acute Transient Ischemic Attack and Minor Ischemic Stroke. Circulation. 2019;140(8):658-64.
31. Bath PM, Woodhouse LJ, Appleton JP, Beridze M, Christensen H, Dineen RA, et al. Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial. Lancet. 2018;391(10123):850-9.
32. Tantry US, Bliden KP, Gurbel PA. AZD6140. Expert opinion on investigational drugs. 2007;16(2):225-9.
33. Husted S, Emanuelsson H, Heptinstall S, Sandset PM, Wickens M, Peters G. Pharmacodynamics, pharmacokinetics, and safety of the oral reversible P2Y12 antagonist AZD6140 with aspirin in patients with atherosclerosis: a double-blind comparison to clopidogrel with aspirin. European heart journal. 2006;27(9):1038-47.
34. Wong KSL, Amarenco P, Albers GW, Denison H, Easton JD, Evans SR, et al. Efficacy and Safety of Ticagrelor in Relation to Aspirin Use Within the Week Before Randomization in the SOCRATES Trial. Stroke. 2018;49(7):1678-85.
35. Goto S. Cilostazol: potential mechanism of action for antithrombotic effects accompanied by a low rate of bleeding. Atherosclerosis Supplements. 2005;6(4):3-11.
36. Kim JS, Kwon SU, Uchiyama S. Cilostazol research in Asia: can it be applied to European and American patients? International journal of stroke : official journal of the International Stroke Society. 2015;10 Suppl 1:1-9.
37. An SJ, Kim TJ, Yoon BW. Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update. Journal of stroke. 2017;19(1):3-10.
38. Lee YS, Bae HJ, Kang DW, Lee SH, Yu K, Park JM, et al. Cilostazol in Acute Ischemic Stroke Treatment (CAIST Trial): a randomized double-blind non-inferiority trial. Cerebrovasc Dis. 2011;32(1):65-71.
39. Gotoh F, Tohgi H, Hirai S, Terashi A, Fukuuchi Y, Otomo E, et al. Cilostazol stroke prevention study: A placebo-controlled double-blind trial for secondary prevention of cerebral infarction. J Stroke Cerebrovasc Dis. 2000;9(4):147-57.
40. Shinohara Y, Katayama Y, Uchiyama S, Yamaguchi T, Handa S, Matsuoka K, et al. Cilostazol for prevention of secondary stroke (CSPS 2): an aspirin-controlled, double-blind, randomised non-inferiority trial. Lancet Neurol. 2010;9(10):959-68.
41. Kwon SU, Cho YJ, Koo JS, Bae HJ, Lee YS, Hong KS, et al. Cilostazol prevents the progression of the symptomatic intracranial arterial stenosis: the multicenter double-blind placebo-controlled trial of cilostazol in symptomatic intracranial arterial stenosis. Stroke. 2005;36(4):782-6.
42. Kwon Sun U, Hong K-S, Kang D-W, Park J-M, Lee J-H, Cho Y-J, et al. Efficacy and Safety of Combination Antiplatelet Therapies in Patients With Symptomatic Intracranial Atherosclerotic Stenosis. Stroke. 2011;42(10):2883-90.
43. Kim BJ, Lee EJ, Kwon SU, Park JH, Kim YJ, Hong KS, et al. Prevention of cardiovascular events in Asian patients with ischaemic stroke at high risk of cerebral haemorrhage (PICASSO): a multicentre, randomised controlled trial. Lancet Neurol. 2018;17(6):509-18.
44. Toyoda K, Uchiyama S, Yamaguchi T, Easton JD, Kimura K, Hoshino H, et al. Dual antiplatelet therapy using cilostazol for secondary prevention in patients with high-risk ischaemic stroke in Japan: a multicentre, open-label, randomised controlled trial. Lancet Neurol. 2019;18(6):539-48.
45. Gent M, Blakely JA, Easton JD, Ellis DJ, Hachinski VC, Harbison JW, et al. The Canadian American Ticlopidine Study (CATS) in thromboembolic stroke. Lancet. 1989;1(8649):1215-20.
46. Love BB, Biller J, Gent MJDS. Adverse Haematological Effects of Ticlopidine. 1998;19(2):89-98.
47. Lee M, Saver JL, Hong KS, Rao NM, Wu YL, Ovbiagele B. Antiplatelet Regimen for Patients With Breakthrough Strokes While on Aspirin: A Systematic Review and Meta-Analysis. Stroke. 2017;48(9):2610-3.
2. Adams HP, Jr., Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35-41.
3. Hall R, Mazer CDJA, Analgesia. Antiplatelet drugs: a review of their pharmacology and management in the perioperative period. 2011;112(2):292-318.
4. Awtry EH, Loscalzo J. Aspirin. Circulation. 2000;101(10):1206-18.
5. The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet. 1997;349(9065):1569-81.
6. CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. CAST (Chinese Acute Stroke Trial) Collaborative Group. Lancet. 1997;349(9066):1641-9.
7. Chen ZM, Sandercock P, Pan HC, Counsell C, Collins R, Liu LS, et al. Indications for early aspirin use in acute ischemic stroke : A combined analysis of 40 000 randomized patients from the chinese acute stroke trial and the international stroke trial. On behalf of the CAST and IST collaborative groups. Stroke. 2000;31(6):1240-9.
8. Warner JJ, Harrington RA, Sacco RL, Elkind MSV. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke. 2019:Strokeaha119027708.
9. Baigent C, Blackwell L, Collins R, Emberson J, Godwin J, Peto R, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;373(9678):1849-60.
10. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. Bmj. 2002;324(7329):71-86.
11. Hackam DG, Spence JD. Antiplatelet Therapy in Ischemic Stroke and Transient Ischemic Attack. Stroke. 2019;50(3):773-8.
12. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-236.
13. Harker LA, Kadatz RA. Mechanism of action of dipyridamole. Thromb Res Suppl. 1983;4:39-46.
14. Diener HC, Cunha L, Forbes C, Sivenius J, Smets P, Lowenthal A. European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci. 1996;143(1-2):1-13.
15. Halkes PH, van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A. Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): randomised controlled trial. Lancet. 2006;367(9523):1665-73.
16. Halkes PH, Gray LJ, Bath PM, Diener HC, Guiraud-Chaumeil B, Yatsu FM, et al. Dipyridamole plus aspirin versus aspirin alone in secondary prevention after TIA or stroke: a meta-analysis by risk. Journal of neurology, neurosurgery, and psychiatry. 2008;79(11):1218-23.
17. Sacco RL, Diener H-C, Yusuf S, Cotton D, Ôunpuu S, Lawton WA, et al. Aspirin and Extended-Release Dipyridamole versus Clopidogrel for Recurrent Stroke. New England Journal of Medicine. 2008;359(12):1238-51.
18. Powers William J, Rabinstein Alejandro A, Ackerson T, Adeoye Opeolu M, Bambakidis Nicholas C, Becker K, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46-e99.
19. Gachet C, Stierle A, Cazenave JP, Ohlmann P, Lanza F, Bouloux C, et al. The thienopyridine PCR 4099 selectively inhibits ADP-induced platelet aggregation and fibrinogen binding without modifying the membrane glycoprotein IIb-IIIa complex in rat and in man. Biochem Pharmacol. 1990;40(2):229-38.
20. Meyer DM, Albright KC, Allison TA, Grotta JC. LOAD: a pilot study of the safety of loading of aspirin and clopidogrel in acute ischemic stroke and transient ischemic attack. J Stroke Cerebrovasc Dis. 2008;17(1):26-9.
21. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet. 1996;348(9038):1329-39.
22. Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet. 2004;364(9431):331-7.
23. Bhatt DL, Fox KA, Hacke W, Berger PB, Black HR, Boden WE, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med. 2006;354(16):1706-17.
24. Effects of Clopidogrel Added to Aspirin in Patients with Recent Lacunar Stroke. New England Journal of Medicine. 2012;367(9):817-25.
25. Markus HS, Droste DW, Kaps M, Larrue V, Lees KR, Siebler M, et al. Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation. 2005;111(17):2233-40.
26. Wong KS, Chen C, Fu J, Chang HM, Suwanwela NC, Huang YN, et al. Clopidogrel plus aspirin versus aspirin alone for reducing embolisation in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR study): a randomised, open-label, blinded-endpoint trial. Lancet Neurol. 2010;9(5):489-97.
27. Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, et al. Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis. New England Journal of Medicine. 2011;365(11):993-1003.
28. Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C, et al. Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack. New England Journal of Medicine. 2013;369(1):11-9.
29. Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, et al. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. New England Journal of Medicine. 2018;379(3):215-25.
30. Johnston SC, Elm JJ, Easton JD, Farrant M, Barsan WG, Kim AS, et al. Time Course for Benefit and Risk of Clopidogrel and Aspirin After Acute Transient Ischemic Attack and Minor Ischemic Stroke. Circulation. 2019;140(8):658-64.
31. Bath PM, Woodhouse LJ, Appleton JP, Beridze M, Christensen H, Dineen RA, et al. Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial. Lancet. 2018;391(10123):850-9.
32. Tantry US, Bliden KP, Gurbel PA. AZD6140. Expert opinion on investigational drugs. 2007;16(2):225-9.
33. Husted S, Emanuelsson H, Heptinstall S, Sandset PM, Wickens M, Peters G. Pharmacodynamics, pharmacokinetics, and safety of the oral reversible P2Y12 antagonist AZD6140 with aspirin in patients with atherosclerosis: a double-blind comparison to clopidogrel with aspirin. European heart journal. 2006;27(9):1038-47.
34. Wong KSL, Amarenco P, Albers GW, Denison H, Easton JD, Evans SR, et al. Efficacy and Safety of Ticagrelor in Relation to Aspirin Use Within the Week Before Randomization in the SOCRATES Trial. Stroke. 2018;49(7):1678-85.
35. Goto S. Cilostazol: potential mechanism of action for antithrombotic effects accompanied by a low rate of bleeding. Atherosclerosis Supplements. 2005;6(4):3-11.
36. Kim JS, Kwon SU, Uchiyama S. Cilostazol research in Asia: can it be applied to European and American patients? International journal of stroke : official journal of the International Stroke Society. 2015;10 Suppl 1:1-9.
37. An SJ, Kim TJ, Yoon BW. Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update. Journal of stroke. 2017;19(1):3-10.
38. Lee YS, Bae HJ, Kang DW, Lee SH, Yu K, Park JM, et al. Cilostazol in Acute Ischemic Stroke Treatment (CAIST Trial): a randomized double-blind non-inferiority trial. Cerebrovasc Dis. 2011;32(1):65-71.
39. Gotoh F, Tohgi H, Hirai S, Terashi A, Fukuuchi Y, Otomo E, et al. Cilostazol stroke prevention study: A placebo-controlled double-blind trial for secondary prevention of cerebral infarction. J Stroke Cerebrovasc Dis. 2000;9(4):147-57.
40. Shinohara Y, Katayama Y, Uchiyama S, Yamaguchi T, Handa S, Matsuoka K, et al. Cilostazol for prevention of secondary stroke (CSPS 2): an aspirin-controlled, double-blind, randomised non-inferiority trial. Lancet Neurol. 2010;9(10):959-68.
41. Kwon SU, Cho YJ, Koo JS, Bae HJ, Lee YS, Hong KS, et al. Cilostazol prevents the progression of the symptomatic intracranial arterial stenosis: the multicenter double-blind placebo-controlled trial of cilostazol in symptomatic intracranial arterial stenosis. Stroke. 2005;36(4):782-6.
42. Kwon Sun U, Hong K-S, Kang D-W, Park J-M, Lee J-H, Cho Y-J, et al. Efficacy and Safety of Combination Antiplatelet Therapies in Patients With Symptomatic Intracranial Atherosclerotic Stenosis. Stroke. 2011;42(10):2883-90.
43. Kim BJ, Lee EJ, Kwon SU, Park JH, Kim YJ, Hong KS, et al. Prevention of cardiovascular events in Asian patients with ischaemic stroke at high risk of cerebral haemorrhage (PICASSO): a multicentre, randomised controlled trial. Lancet Neurol. 2018;17(6):509-18.
44. Toyoda K, Uchiyama S, Yamaguchi T, Easton JD, Kimura K, Hoshino H, et al. Dual antiplatelet therapy using cilostazol for secondary prevention in patients with high-risk ischaemic stroke in Japan: a multicentre, open-label, randomised controlled trial. Lancet Neurol. 2019;18(6):539-48.
45. Gent M, Blakely JA, Easton JD, Ellis DJ, Hachinski VC, Harbison JW, et al. The Canadian American Ticlopidine Study (CATS) in thromboembolic stroke. Lancet. 1989;1(8649):1215-20.
46. Love BB, Biller J, Gent MJDS. Adverse Haematological Effects of Ticlopidine. 1998;19(2):89-98.
47. Lee M, Saver JL, Hong KS, Rao NM, Wu YL, Ovbiagele B. Antiplatelet Regimen for Patients With Breakthrough Strokes While on Aspirin: A Systematic Review and Meta-Analysis. Stroke. 2017;48(9):2610-3.
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2020-08-25
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Maytharakcheep S, Worakijthamrongchai T. Antiplatelet therapy in ischemic stroke and transient ischemic attack. J Thai Stroke Soc [Internet]. 2020 Aug. 25 [cited 2024 Nov. 13];19(2):31. Available from: https://he01.tci-thaijo.org/index.php/jtss/article/view/244233
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ข้อความภายในบทความที่ตีพิมพ์ในวารสารสมาคมโรคหลอดเลือดสมองไทยเล่มนี้ ตลอดจนความรับผิดชอบด้านเนื้อหาและการตรวจร่างบทความเป็นของผู้นิพนธ์ ไม่เกี่ยวข้องกับกองบรรณาธิการแต่อย่างใด การนำเนื้อหา ข้อความหรือข้อคิดเห็นของบทความไปเผยแพร่ ต้องได้รับอนุญาตจากกองบรรณาธิการอย่างเป็นลายลักษณ์อักษร ผลงานที่ได้รับการตีพิมพ์ในวารสารเล่มนี้ถือเป็นลิขสิทธิ์ของวารสาร
