Lit Matters 1: Lytics vs Dual Antiplatelets for Mild Stroke

Mild noncardioembolic ischemic stroke is not automatically low risk just because the NIHSS is low. In patients with NIHSS 3 or less, this study found no functional advantage for IV thrombolysis over early dual antiplatelet therapy, while thrombolysis carried more symptomatic intracranial hemorrhage and early neurologic deterioration.

Mild Stroke Reperfusion Decisions

• Low NIHSS uncertainty: A mild stroke score can hide disabling deficits, but in this registry of noncardioembolic ischemic stroke, IV thrombolysis did not outperform early dual antiplatelet therapy on functional recovery.
• Head-to-head treatment signal: Early DAPT with aspirin plus clopidogrel looked at least comparable to IV thrombolysis for NIHSS 3 or less, with the treatment-selection caveats and bedside implications we get into in the episode.
• Hemorrhage risk difference: Symptomatic intracranial hemorrhage was markedly more common after IV thrombolysis, about 1.4% versus 0.1%, a safety signal that persisted after propensity matching.
• Early deterioration warning: Early neurologic deterioration, defined as a 4-point NIHSS worsening within 24 to 48 hours, was also more frequent with IV thrombolysis than with DAPT.
• Functional outcome comparison: Modified Rankin outcomes at discharge and at 3 months were not significantly better with IV thrombolysis, despite the common assumption that lytics should help mild stroke patients.
• Lacunar infarct subgroup: A possible exception appeared in lacunar infarcts, where IV thrombolysis was associated with better outcomes, but the subgroup caveats matter and we walk through them in the chapter.