Clinical Question
Minor non-disabling stroke. Alteplase, DAPT, or aspirin?
Synthesises 5 trialsthe trade-off between thrombolysis benefit, DAPT noninferiority, and aspirin baseline in mild stroke
What does the guideline say? (2 sections)
- §4.6.1 Thrombolysis Decision-Making· 2026
In adult patients with AIS with disabling deficits (regardless of NIHSS score) and eligible for IVT, faster treatment improves functional outcomes (COR 1, LOE A). In adult patients with AIS eligible for IVT within 4.5 hours of symptom onset, treatment should be initiated as quickly as possible, avoiding potential delays associated with additional multimodal neuroimaging such as CTA/MRA and CT/MR perfusion imaging (COR 1, LOE B-NR). In eligible adult patients with AIS presenting with mild non-disabling stroke deficits within 4.5 hours, IVT should not be used routinely as it has not shown superiority in improving functional outcomes compared to dual antiplatelet treatment (COR 3 No Benefit, LOE B-R).
Source: 2026 AHA/ASA Guideline — §4.6.1 (Thrombolysis Decision-Making)
- §4.8 Antiplatelet TreatmentLOE A· 2026
In patients with minor (NIHSS score ≤3) noncardioembolic AIS or high-risk TIA (ABCD² score ≥4) who did not receive IVT, DAPT (aspirin and clopidogrel with loading dose of clopidogrel) should be initiated early (within 24 hours after symptom onset) and continued for 21 days, followed by single antiplatelet therapy (SAPT) to reduce the 90-day risk of recurrent ischemic stroke.
The trials cited in the guideline's supportive text appear below.
Trials in this question· 5
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