Aspirin versus recombinant tissue plasminogen activator for acute minor stroke: a systematic review and meta-analysis

Minor ischemic stroke is common and may lead to significant disability, even when symptoms appear mild or are poorly tolerated. Treatment choice remains uncertain: Recombinant Tissue Plasminogen Activator (r-tPA) may aid recovery but carries bleeding risk, while aspirin is safer but possibly less effective. This meta-analysis compares aspirin and intravenous r-tPA in this population.

We systematically searched PubMed, Embase, and Cochrane Library through July 2024 for randomized controlled trials (RCTs) and prospective cohorts comparing aspirin and r-tPA in adults with acute minor ischemic stroke. Outcomes included modified Rankin Scale (mRS) scores at 3 months (0-1 and 0-2), mortality, recurrent stroke, and symptomatic hemorrhage. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Heterogeneity was assessed via I² statistic.

Four studies met inclusion criteria. Aspirin and r-tPA showed no significant difference in achieving mRS 0-1 (OR = 0.79; 95% CI, 0.50-1.24; I² = 52.1%) or mRS 0-2 (OR = 0.76; 95% CI, 0.40-1.42; I² = 57.5%). No difference was found in recurrent stroke (OR = 0.99; 95% CI, 0.58-1.68) or mortality (OR = 2.44; 95% CI, 0.66-9.05). Aspirin was associated with a non-significantly lower risk of symptomatic hemorrhage (OR = 0.43; 95% CI, 0.17-1.14; p = 0.09). Subgroup analyses restricted to RCTs and leave-one-out sensitivity analyses yielded consistent results across all outcomes.

Both aspirin and r-tPA were associated with clinical benefit and yielded similar outcomes in minor strokes.