Introduction: When antiplatelets are used alongside thrombolytics in acute ischemic stroke (AIS), they may increase the risk of hemorrhagic conversion. Guidelines recommend delaying antiplatelet initiation for 24 hours post-thrombolysis, yet patients undergoing stenting during thrombectomy commonly require dual antiplatelet therapy (DAPT) immediately after stent placement, irrespective of thrombolytic use. The objective of this study was to compare the safety and efficacy of DAPT plus intracranial or carotid stenting versus single antiplatelet therapy (SAPT) post-thrombolytic administration in AIS patients undergoing thrombectomy.
Methods: This retrospective, single-center cohort study evaluated hemorrhagic conversion rates in AIS patients post-thrombolysis and thrombectomy who received either aspirin alone or stenting plus DAPT. Data were collected from Health Data Compass for patients aged 18–89 treated at University of Colorado Hospital between September 2019 and September 2024. Exclusion criteria included prior DAPT use, history of intracranial/carotid stents, and brain malignancies. The primary outcome was symptomatic hemorrhagic conversion rates as defined by a ≥4-point increase in NIH Stroke Scale (NIHSS) score within 48 hours of thrombolytic with concomitant hemorrhage on brain imaging.
Results: Among 142 patients, 124 received aspirin and 18 received stenting plus DAPT. Baseline characteristics for stenting with DAPT versus aspirin, respectively, included: median age 64.7 vs 63 years old, male sex 51.6% vs 61.1%, and baseline Modified Rankin Scale (mRS) 0.48 vs 0.28. There was not a statistically significant difference between symptomatic hemorrhagic conversion rates of 0% aspirin vs 5.6% DAPT/stent (p = 0.34) within 48 hours of fibrinolytic. There was a statistically significant difference in symptomatic intracranial hemorrhage at 14 days (0% vs 11.1%, p = 0.02).
Conclusions: The study found no significant increase in symptomatic hemorrhagic rates with stenting plus DAPT versus aspirin alone within 48 hours of thrombolysis, suggesting the need for further research into optimal antiplatelet timing post-thrombolysis in AIS.
