Navigating the waters of acute minor stroke therapies: a systematic review and network meta-analysis

Although acute minor stroke often presents with mild symptoms, such as unilateral limb weakness, mild aphasia, dizziness, or mild cognitive impairment, untreated outcomes could be poor, and optimal treatment methods are still debated.

We aimed to identify the optimum treatment for minor strokes with a network meta-analysis.

Studies from Embase, Ovid, and Cochrane Library were considered. Randomized controlled trials and prospective cohort studies on ischemic stroke with a National Institutes of Health Stroke Scale score no more than 5, explicit intravenous thrombolysis, or antiplatelet therapy were included. Efficacy outcome was measured by 3-month modified Rankin scale (mRS), with primary outcome defined as mRS score of 0 to 1 and secondary outcome defined as mRS score of 0 to 2. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and mortality at 3 months.

Nine studies encompassing 10 665 patients were meta-analyzed. Aspirin plus clopidogrel (n = 4283) was more strongly associated with primary outcome than aspirin (n = 2128; odds ratio [OR], 1.26; 95% CI, 1.04∼1.54) and recombinant tissue plasminogen activator (rt-PA; n = 1840; OR, 1.23; 95% CI, 1.00∼1.50). Aspirin plus clopidogrel (n = 3933) also had a lower sICH risk than rt-PA (n = 2538; OR, 0.11; 95% CI, 0.04∼0.30) and tenecteplase (n = 194; OR, 0.15; 95% CI, 0.03∼0.68), as well as a lower mortality than aspirin alone (n = 830; OR, 0.27; 95% CI, 0.10∼0.71). Patients treated with aspirin (n = 815) also had a lower sICH risk than rt-PA (n = 2538; OR, 0.20; 95% CI, 0.04∼0.95).

Dual antiplatelet therapy based on aspirin and clopidogrel offers balanced efficacy and safety, positioning it as a potentially optimal treatment for minor stroke. rt-PA showed comparable efficacy, while its associated risks were more pronounced.