IV Thrombolysis vs Early Dual Antiplatelet Therapy in Patients With Mild Noncardioembolic Ischemic Stroke

• Published in: Neurology Vol. 101; no. 9; p. e933
• Main Authors: Sykora, Marek, Krebs, Stefan, Miksova, Dominika, Badic, Ines, Gattringer, Thomas, Fandler-Höfler, Simon, Marko, Martha, Greisenegger, Stefan, Knoflach, Michael, Lang, Wilfried, Ferrari, Julia
• Format: Journal Article
• Language: English
• Published: United States 29.08.2023
• Subjects: Brain Ischemia - complications; Brain Ischemia - drug therapy; Cerebral Hemorrhage - etiology; Fibrinolytic Agents - therapeutic use; Humans; Ischemic Stroke - drug therapy; Platelet Aggregation Inhibitors - therapeutic use; Stroke - therapy; Thrombolytic Therapy - adverse effects; Treatment Outcome
• ISSN: 1526-632X
• DOI: 10.1212/WNL.0000000000207538

It is unclear whether IV thrombolysis (IVT) outperforms early dual antiplatelet therapy (DAPT) in the acute setting of mild ischemic stroke. The aim of this study was to compare the early safety and efficacy of IVT with that of DAPT. Data of mild noncardioembolic stroke patients with admission NIH Stroke Scale (NIHSS) score ≤3 who received IVT or early DAPT in the period 2018-2021 were extracted from a nationwide, prospective stroke unit registry. Study endpoints included symptomatic intracerebral hemorrhage (sICH), early neurologic deterioration ≥4 NIHSS points (END), and 3-month functional outcome by modified Rankin scale (mRS). A total of 1,195 mild stroke patients treated with IVT and 2,625 patients treated with DAPT were included. IVT patients were younger (68.1 vs 70.8 years), had less hypertension (72.8% vs 83.5%), diabetes (19% vs 28.8%), and a history of myocardial infarction (7.6% vs 9.2%), and slightly higher admission NIHSS scores (median 2 vs median 1) when compared with DAPT patients. After propensity score matching and multivariable adjustment, IVT was associated with sICH (4 [1.2%] vs 0) and END (adjusted odds ratio [aOR] 2.8, 95% CI 1.1-7.5), and there was no difference in mRS 0-1 at 3 months (aOR 1.3, 95% CI 0.7-2.6). This analysis from a prospective nationwide stroke unit network indicates that IVT is not superior to DAPT in the setting of mild noncardioembolic stroke and may eventually be associated with harm. Further research focusing on acute therapy of mild stroke is highly warranted. This study provides Class III evidence that IVT is not superior to DAPT in patients with acute mild (NIHSS score ≤3) noncardioembolic stroke. The study lacks the statistical precision to exclude clinically important superiority of either therapy.