Abstract DP176: Intravenous thrombolysis and antiplatelet therapy of acute minor stroke: a systematic review and pairwise and bayesian network meta-analysis of randomized controlled trials

Background: Although patients with mild ischemic stroke present with relatively minor symptoms, approximately one-third experience stroke progression or recurrence within 90 days, often resulting in substantial functional disability. The optimal treatment strategy for mild stroke remains uncertain. Objectives: To determine the most effective therapeutic approach for acute mild ischemic stroke. Methods: Eight randomized controlled trials (RCTs) involving a total of 7,770 patients with mild ischemic stroke were included. Both pairwise meta-analysis and Bayesian network meta-analysis were performed to compare the efficacy and safety of intravenous thrombolysis (IVT) versus standard antiplatelet therapy (SMT). Subgroup analyses ranked the effects of different antiplatelet regimens (e.g., dual antiplatelet therapy [DAPT], aspirin monotherapy) and thrombolytic agents (e.g., alteplase, tenecteplase) on 90-day functional outcomes, symptomatic intracranial hemorrhage (sICH), and all-cause mortality. Results: Pairwise meta-analysis revealed no significant difference between the IVT and SMT groups in achieving excellent functional outcomes at 90 days (modified Rankin Scale [mRS] 0–1: odds ratio [OR] 0.85, 95% confidence interval [CI] 0.72–1.00) or good functional outcomes (mRS 0–2: OR 0.81, 95% CI 0.65–1.01), whereas IVT was associated with a markedly increased risk of sICH (OR 5.17, 95% CI 1.97–13.55). The network meta-analysis suggested that DAPT provided the greatest likelihood of achieving excellent 90-day functional outcomes with a favorable safety profile. Conclusions: In patients with mild ischemic stroke within 12 hours of onset, SMT is noninferior to IVT and significantly reduces the risk of sICH. Among SMT regimens, dual antiplatelet therapy (DAPT) based on aspirin and clopidogrel may represent the optimal treatment option that balances both efficacy and safety, outperforming traditional and novel thrombolytic agents.