Abstract TP005: Early Intravenous Antiplatelet Therapy Combined with Intravenous Thrombolysis for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis of Randomized Trials

Background: Intravenous thrombolysis (IVT) with alteplase is the standard approved pharmacologic reperfusion therapy for acute ischemic stroke (AIS). Despite its proven efficacy, early administration of intravenous antiplatelet therapy (APT) remains controversial regarding its potential improvement in recanalization durability and functional recovery. Our objective was to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of early antiplatelet therapy following IVT in patients with AIS. Methods: We systematically searched PubMed, Embase, and the Cochrane CENTRAL for RCTs of patients with AIS treated with IVT and APT. The outcomes of interest were symptomatic intracranial hemorrhage (sICH), asymptomatic intracranial hemorrhage, mortality and functional outcome (mRs 0-2). Statistical analyses were performed using RStudio. Pooled relative risks (RR) with 95% confidence intervals (CI) were calculated using random-effects models and heterogeneity was assessed using I 2 statistics. Results: Four RCTs comprising 1,840 patients were included. There was no difference between groups for sICH (RR 1.20; 95% CI 0.18–8.06; p= 0.855; I 2 = 73.2%). After excluding the CLEAR trial, the risk of sICH was higher with APT (RR 3.18; 95% CI 1.20–8.43; I 2 = 0%). No differences were found in mortality (RR 1.14; 95% CI 0.80–1.62; p=0.463; I 2 = 0%) or functional independence (RR 1.10; 95% CI 0.93–1.29; p=0.274; I 2 = 72.1%). Exploratory analyses restricted to the subgroup of patients who received intravenous APT within 2 hours of IVT showed no significant impact on sICH, asymptomatic ICH or functional outcomes. Conclusion: Our findings suggest that early antiplatelet therapy after intravenous thrombolysis in AIS does not improve functional independence or survival and may increase the risk of sICH. Further large-scale RCTs are required to better define its role in clinical practice.