Stroke is an important cause of death, disability, and memory problems in adults. The build-up of plaque in arteries inside the brain is known as "intracranial atherosclerotic disease" or "ICAD" for short, and can reduce blood flow in the brain. Clopidogrel is a medicine used to prevent strokes because it stops blood from clotting. However, there are some people who do not get as much benefit from Clopidogrel because of differences in their genes; they have a variation in a certain gene and their body is not able to properly process Clopidogrel. Another medication called Ticagrelor can benefit people who have this genetic variation. The study investigators will randomize patients who have had a stroke due to ICAD to receive genetic testing, or standard of care. The standard-of-care group will take Clopidogrel for 90 days. The genetic testing group will complete a genetic test to see if they can properly process Clopidogrel. Depending on the results of the genetic test, patients will either take Clopidogrel or Ticagrelor for 90 days. All patients will have a brain scan at baseline and 90 days to see if they had any new strokes. Patients will also complete tests and questionnaires about function and memory at baseline and 90 days. This study will be one of the first to see if it is feasible and safe to use genetic testing to help choose medications for patients who have had a stroke. This will help the study investigators design a larger study that can test if genetic testing in stroke patients reduces future stroke risk and improves health outcomes.
Age ≥ 40 years old, male and female.
TIA or ischemic stroke secondary to symptomatic atherosclerotic stenosis of 30- 99% involving the intracranial ICA or MCA or posterior circulation arteries as evidenced by CT or MR angiography.
Index TIA or ischemic stroke event occurred within past 30 days.
Clinical indication for DAPT for at least 3 months.
Any contraindication to DAPT.
Any contraindication to use of clopidogrel (Plavix) or ticagrelor (Brilinta), such as pregnancy. A pregnancy test will be performed on all women of child-bearing age prior to enrollment in the study.
Indication for chronic anticoagulation based on guideline recommendations or investigator's judgment (e.g., atrial fibrillation, mechanical heart valve, intracardiac clot, dilated cardiomyopathy, ejection fraction <30%, etc.).
Intracranial arterial occlusion (i.e. 100% stenosis) responsible for the acute brain ischemia.
Parallel
Point-of-Care CYP2C19 Testing
GeneticGenetic testing with the Genomadix cube to determine P2Y12 inhibitor
ticagrelor + aspirin
DrugIf patients are poor or intermediate metabolizers of clopidogrel, they will receive ticagrelor (90 mg PO BID) + aspirin (81 mg PO daily)
clopidogrel + aspirin
DrugNormal, rapid, and ultra-rapid metabolizers of clopidogrel will receive 75 mg PO daily of clopidogrel and 81 mg PO daily of aspirin.
Rate of recruitment
The number of patients who provide informed consent, or are deemed ineligible after screening.
Rate of study completion
The number of patients who complete the entire study protocol
Rate of protocol deviations
The number of patients who encounter at least one protocol deviation during the study
Proportion of patients with Symptomatic intracerebral hemorrhage (ICH)
New symptomatic ICH OR worsening existing ICH with a ≥33% increase in hematoma volume AND NIHSS score increase of ≥4 points AND clinical change is thought to be attributable to ICH
Proportion of patients who have Microembolic Signals on Transcranial Doppler Ultrasound
Change in volume of ischemic strokes and white matter hyperintensities (optional)
Change in number of ischemic strokes and white matter hyperintensities
Number of patients with ischemic stroke, myocardial infarction, or death
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