Brain Behav. 2026 Oct;16(10):e71813. doi: 10.1002/brb3.71813.
ABSTRACT
BACKGROUND: Dual antiplatelet therapy (DAPT) was noninferior to alteplase in nondisabling minor stroke (NIHSS 0 to 5). Given potential benefit of DAPT in minor stroke with large artery atherosclerosis (LAA) and of alteplase in stroke with NIHSS 4-5, we hypothesize that neurological deficit and LAA may affect efficacy of DAPT versus alteplase in minor stroke.
METHODS: This analysis included patients from the ARAMIS trial with minor stroke who underwent vessel imaging assessment. Participants were stratified into NIHSS 0-3 with LAA, NIHSS 0-3 with Non-LAA, NIHSS 4-5 with LAA, and NIHSS 4-5 with Non-LAA. Outcomes were compared between those receiving DAPT versus alteplase. Primary outcome was an excellent functional outcome (mRS 0 to 1) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and bleeding events. Primary analysis employed adjusted models, with sensitivity analysis conducted using inverse probability of treatment weighting.
RESULTS: Among 478 included patients, including 388 in NIHSS 0-3 group and 90 in NIHSS 4-5 group. In NIHSS 0-3 group, a numerically higher rates of excellent functional outcome was found in patients with LAA who received DAPT versus alteplase (97.3% vs. 85.1%; adjusted OR, 6.45 [0.68 to 60.81]; p = 0.10), which was obviously attenuated in patients with Non-LAA (96.5% vs. 94.4%; adjusted OR, 1.67 [0.50 to 5.59]; p = 0.41). This phenomenon was not observed in NIHSS 4-5 group, and the test for interaction was not statistically significant (p-interaction = 0.36). Notably, sensitivity analysis revealed that DAPT significantly increased the likelihood of excellent functional outcome in the NIHSS 0-3 with LAA subgroup (adjusted OR, 6.49 [1.54 to 27.39]; p = 0.01), but not in NIHSS 0-3 with Non-LAA subgroup (adjusted OR, 2.51 [0.58 to 10.90]; p = 0.22). Safety outcomes were comparable across treatments.
CONCLUSIONS: Neurological deficit and LAA may affect efficacy of DAPT versus alteplase in acute minor nondisabling stroke. In patients with NIHSS scores of 0 to 3 due to LAA, DAPT may be associated with numerically higher odds of 90-day functional outcomes compared to alteplase. Given the exploratory nature of this subgroup analysis and no formal adjustment for multiple comparisons was applied, these results should be interpreted as hypothesis-generating and require confirmation.
PMID:42834522 | DOI:10.1002/brb3.71813