In Brief | Neurology | Radiology
Apixaban vs. Aspirin for Preventing Covert Infarcts in Cryptogenic Stroke: Insights from the ARCADIA-MRI Study
Time to read: 03:16
Time to listen: 06:11
Originally Published: 27 January 2025
Source: JAMA Neurology
Type of article: In Brief
MedED Catalogue Reference: MNIB010
Category: Neurology
Cross Reference: Radiology, Gerontology
Keywords: cryptogenic stroke, ARCADIA, apixaban, aspirin, stroke
Apixaban was more effective than aspirin in reducing nonlacunar covert infarcts among patients with a recent cryptogenic stroke and atrial cardiopathy. Due to the limitations of the study, the researchers indicate that further research is required to validate their findings.
This article is a review of recent studies originally published in the JAMA Neurology, 27 January 2025. This article does not represent the original research, nor is it intended to replace the original research. Access the full Disclaimer Information.
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Covert brain infarcts (CBI) are small ischemic cerebral lesions detected on MRI without noticeable clinical stroke symptoms.1
They are prevalent in both stroke patients and healthy aging populations. Initially termed "silent infarcts," this label has been reconsidered as subtle clinical effects have been observed. CBI accumulation contributes to cognitive and motor decline, particularly in small vessel disease. Several studies, the most notable of which is the Rotterdam Scan Study, have found that patients with baseline covert infarcts have more than double dementia risk, accelerated cognitive decline, and a two-fold increased risk of future stroke risk, highlighting their impact on long-term neurological health. 2
The ARCADIA study, a large multicenter, randomized, double-blind trial, compared apixaban and aspirin in patients with a recent cryptogenic stroke and atrial cardiopathy. 3
It found no difference in recurrent stroke rates between the two groups – an annualized recurrence rate of 4.4% in both (HR, 1.00; 95% CI, 0.64-1.55) - indicating no clear benefit of apixaban over aspirin in preventing recurrent strokes.
However, it remained unclear whether apixaban could reduce the incidence of covert infarcts, which are common in older adults and those with cardiovascular risk factors.
Given the significant association between covert infarcts, dementia, and future stroke risk, the researchers of this study sought to evaluate anticoagulation as a preventive strategy was essential.
Study Purpose
Study Methodology
Participants received either apixaban (n=79) or aspirin (n=95) and were followed for a median of 27 months.
Findings
Given the known association between covert infarcts and cognitive decline, this could have important implications for long-term patient outcomes.
It is important to note that the ARCADIA-MRI study had several limitations. Firstly, only 30% of ARCADIA participants were enrolled, with 56% of those having adequate baseline and follow-up scans. Furthermore, the small sample size led to wide confidence intervals, making the results less definitive. Additionally, while baseline characteristics were mostly balanced, nominal differences between treatment groups may have influenced the outcomes.
Conclusion
Apixaban was associated with a lower risk of nonlacunar covert infarcts compared to aspirin in patients with cryptogenic stroke and atrial cardiopathy. These findings highlight a potential benefit of anticoagulation beyond stroke prevention and warrant further investigation, particularly regarding its role in reducing long-term cognitive decline and improving overall neurological outcomes.
Importance of this study for South Africa
Stroke is a leading cause of mortality and morbidity in South Africa. Given the high crude stroke mortality rate in rural areas (127/100,000 in people >35 years), investigating silent strokes is crucial for early detection and intervention.4 Preventative therapy, such as Apixaban, could help reduce the risk of stroke and may improve long-term outcomes, refine screening strategies, and ease the burden on South Africa’s healthcare system.
Additional References
1. Chabriat H. (2020). Covert Brain Infarcts: Look at Extra and Intracranial Vessels. Stroke, 51(1), 2–3. https://doi.org/10.1161/STROKEAHA.119.027445
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