To compare the safety and efficacy of antiplatelet therapy and alteplase in the treatment of minor ischemic stroke.

Minor ischemic strokes with a National Institutes of Health Stroke Scale (NIHSS) score ≤ 5 present unique challenges in determining the optimal treatment strategy.

We systematically searched the literature for related primary studies published up to September 2023. A network meta-analysis, comprising five studies involving 6466 participants, was conducted using the R language, comparing three treatment arms: intravenous alteplase (IV alteplase), Dual Antiplatelet Therapy (DAPT) with aspirin and clopidogrel, and aspirin alone.

Compared to IV alteplase, DAPT was significantly associated with a decreased risk of symptomatic intracranial hemorrhage (sICH) (RR, 0.11; 95% CI, 0.04-0.32, p< 0.01), while aspirin was associated with a non-significant difference (RR, 0.09; 95% CI, 0.01-1.62, p= 0.10).

 However, there were no significant differences observed for both DAPT and aspirin regarding modified Rankin Score (mRS) 0-1 [(RR, 1.08; 95% CI, 0.99-1.19, p= 0.08), (RR, 0.98; 95% CI, 0.87-1.12, p= 0.79), respectively], mRS 0-2 [(RR, 1.04; 95% CI, 0.98-1.10, p= 0.23), (RR, 1.00; 95% CI, 0.93-1.08, p= 0.97), respectively], recurrent stroke [(RR, 0.88; 95% CI, 0.55-1.40, p= 0.58), (RR, 0.89; 95% CI, 0.54-1.46, p= 0.64), respectively], any intracranial hemorrhage [(RR, 0.23; 95% CI, 0.05-1.09, p= 0.06), (RR, 0.45; 95% CI, 0.16-1.27, p= 0.13), respectively], and mortality [(RR, 0.65; 95% CI, 0.16-2.67, p= 0.55), (RR, 2.41; 95% CI, 0.53-11.004, p= 0.25), respectively].

On the Surface Under the Cumulative Ranking (SUCRA), DAPT was ranked highest for mRS 0-1 (93%), mRS 0-2 (86%), Any ICH (87%), mortality (84%), and recurrent stroke (62%). Notably, aspirin was ranked highest for sICH (74%).

In ischemic stroke with an NIHSS ≤5, DAPT (aspirin and clopidogrel)  and aspirin alone have comparable efficacy and safety to IV alteplase. Well-designed randomized clinical trials in this population are warranted.