From the Guidelines
Aspirin should not be given to a patient experiencing a stroke with MELAS (Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like episodes). MELAS is a mitochondrial disorder where stroke-like episodes are not caused by typical blood clots but rather by metabolic abnormalities and cellular energy failure. Unlike ischemic strokes, where aspirin helps by preventing further clot formation, in MELAS the stroke-like episodes are due to metabolic dysfunction. Giving aspirin could potentially worsen the situation by increasing the risk of bleeding without providing benefit.
Key Considerations
- The provided guidelines 1 focus on the management of acute ischemic stroke and do not specifically address MELAS.
- The most recent and highest quality study relevant to stroke management is from 2023 1, but none of these studies address the use of aspirin in MELAS specifically.
- Management of MELAS should focus on supportive care, treating the underlying metabolic crisis with intravenous fluids, glucose if needed, and addressing any seizure activity.
- Patients with MELAS experiencing stroke-like episodes should be evaluated by specialists familiar with mitochondrial disorders, as they may benefit from specific treatments like L-arginine or coenzyme Q10.
Clinical Decision
Based on the pathophysiology of MELAS and the lack of evidence supporting the use of aspirin in this condition, the use of aspirin is not recommended. Instead, management should prioritize supportive care and addressing the underlying metabolic abnormalities. The distinction between conventional strokes and MELAS stroke-like episodes is crucial for appropriate management and avoiding potentially harmful treatments.
From the Research
Treatment of MELAS
- The use of aspirin is not mentioned in the provided studies as a treatment for MELAS.
- Instead, the studies suggest the use of arginine as a potential treatment for MELAS, with evidence showing its effectiveness in improving symptoms during acute attacks and preventing further stroke-like episodes 2, 3, 4, 5.
- The timing of arginine administration is crucial, with studies suggesting that it is most effective when started within 4 hours of the onset of neurological symptoms 5.
- Other treatments, such as corticosteroids, have also been explored, with some evidence suggesting their potential benefit in individual cases 6.
Arginine Therapy
- Arginine has been shown to be effective in improving symptoms during acute attacks of MELAS, and in preventing further stroke-like episodes 2, 3, 4.
- The optimal dosing and timing of arginine therapy are still being studied, but maintaining plasma arginine concentration at least 168 μmol/l may be beneficial 3.
- Arginine is thought to work by normalizing endothelial function and improving nitric oxide-dependent vasodilation, which is impaired in MELAS patients 3, 5.