Early management of mild ischaemic stroke: role of dual antiplatelet treatment

Early management of mild ischaemic stroke: role of DAPT. The algorithm summarizes antithrombotic treatment strategies in patients presenting with mild neurological deficits (defined as clinical stroke severity with a score of 0-5 on the NIHSS). It is based on existing guidelines of the European Stroke Organisation (default strategy), but integrates recently published clinical trial evidence and real-world data demonstrating safety and benefit of other antithrombotic strategies in non-cardioembolic (Non-CE) and cardioembolic (CE) stroke due to atrial fibrillation.6,13–15 Intravenous thrombolysis (IVT) is recommended if the clinical symptoms are considered ‘disabling' (i.e., ‘mild but disabling stroke') and no other formal contraindications exist. Following IVT, the default strategy is to delay treatment with antiplatelets for 24 h until clinically relevant IVT-related intracranial haemorrhage is ruled out. There are currently no strong data supporting treatment with antiplatelet agents earlier than 24 h after IVT (e.g. no benefit shown in the EAST trial9). Increasing evidence (including findings from the EAST trial) support safety of dual antiplatelet therapy (DAPT) started at 24 h after IVT. Thus, DAPT should be considered a reasonable alternative strategy in this setting, especially in patients with large-artery atherosclerosis or branch atheromatous disease, no significant haemorrhagic transformation and low extracerebral bleeding risk. In patients not eligible for IVT (i.e., with ‘non-disabling’ clinical deficits or presenting outside the IVT time-window), starting DAPT as soon as possible is the default strategy. Single antiplatelet therapy with aspirin is a reasonable alternative in patients presenting late (>72 h), in those without atherosclerosis, and in patients with high bleeding risk. Recent evidence strongly supports early initiation of DOAC (<4 days) in stroke patients with CE stroke due to atrial fibrillation and that initiation <48 h is reasonable in patients not treated with IVT. Consider prolonged DAPT duration for three months if the stroke is attributed to severe intracranial atherosclerosis.