Editors' Note: IV Thrombolysis vs Early Dual Antiplatelet Therapy in Patients With Mild Noncardioembolic Ischemic Stroke

While intravenous thrombolysis is effective for most causes of acute cerebral infarction, recent trials (PRISM, ARAMIS) have not found the benefits of thrombolysis exceed the risks in patients with mild stroke symptoms. In their recent analysis of the prospectively maintained Austrian Stroke Registry, Dr. Sykora et al. corroborate the results of the ARAMIS trial and report no difference in the rate of excellent outcome (modified Rankin Scale [mRS] 0-1) at 90 days with thrombolysis vs dual antiplatelet therapy in mild non-cardioembolic stroke. However, the risk of symptomatic intracerebral hemorrhage was ten-fold higher with thrombolysis (adjusted odds ratio 10.3, 95% CI 2.7-39). In response, Dr. Pensato and colleagues remark that ultra-early dual antiplatelet therapy may be effective at preventing neurologic deterioration by plaque stabilization. Although this analysis supports the potential role of dual antiplatelet therapy in preventing neurologic deterioration using a conservative definition (worsening of 4 points in the NIH Stroke Scale), it may fail to identify patients who worsen by a smaller margin. Furthermore, Pensato notes that mRS may be an insensitive measure for functional outcomes when there is minimal or no baseline disability related to stroke. The authors agree with the limitations noted by Pensato; however, they used these end points and definitions to permit comparability of their analysis with prior studies.