Title : Dual antiplatelet therapy versus Intravenous Thrombolysis (IVT) in acute minor ischemic stroke: An umbrella review of meta-analyses
Abstract:
Introduction: The optimal treatment for acute minor ischemic stroke remains debated, particularly regarding Dual Antiplatelet Therapy (DAPT) versus Intravenous Thrombolysis (IVT). This umbrella review synthesizes recent meta-analyses comparing efficacy and safety outcomes.
Methods: Following PRIOR guidelines, PubMed, Google Scholar, Web of Science, and Scopus were searched from inception to September 2025. Eligible systematic reviews and meta-analyses (2010-2025) compared DAPT (aspirin + clopidogrel) with IVT in adults with minor ischemic stroke (NIHSS≤5). Outcomes included functional status (mRS), mortality, and symptomatic Intracranial Hemorrhage (sICH). Odds ratios and mean differences were extracted, and overlap among reviews was assessed using Corrected Covered Area (CCA). Methodological quality was evaluated with AMSTAR-2.
Results: Functional outcomes demonstrated largely comparable efficacy between DAPT and IVT. For excellent outcomes (mRS 0-1), Abbas et al. (2024, n=5) reported no significant difference (OR 1.11, 95% CI 0.79-1.55), consistent with Viana et al. (2024, n=5; OR 1.26, 95% CI 0.85-1.89) and Zhang et al. (2024, n=20; OR 1.10, 95% CI 0.89-1.37). Yao et al. (2025, n=9) was the only meta-analysis showing a significant advantage for DAPT (OR 1.23, 95% CI 1.00-1.50). For good outcomes (mRS 0-2), Abbas (OR 0.90, 95% CI 0.61-1.31), Zhang (OR 1.16, 95% CI 0.95-1.43), and Qin (2024, n=5) all found no significant differences. Safety outcomes diverged substantially. All five analyses demonstrated lower sICH risk with DAPT compared to IVT. Abbas (2024) reported a 90% risk reduction (OR 0.10, 95% CI 0.04-0.26), corroborated by Yao (2025; OR 0.11, 95% CI 0.04-0.30). Qin (2024) highlighted IVT's increased risk (OR 9.31, 95% CI 3.39- 25.57). Viana (2024) confirmed DAPT's safety (OR 0.11, 95% CI 0.003-0.36), while Zhang (2024) reported over a seven-fold higher sICH risk with IVT (OR 7.48, 95% CI 3.55-15.76). Additional findings included IVT's association with higher early neurological deterioration (Qin, OR 2.75, 95% CI 1.76-4.30), whereas mortality did not differ significantly (Viana, 2024).
Conclusions: Across five meta-analyses, DAPT and IVT produced comparable functional outcomes in minor stroke. However, DAPT was consistently associated with markedly lower risk of sICH, underscoring its role as a safe and effective alternative to IVT in this population. While effect sizes varied due to methodological heterogeneity, the overall evidence strongly favors DAPT's superior safety profile with preserved efficacy.
