Acute Stroke Patients on Daily Anticoagulant or Antiplatelet Therapy Receiving Thrombolysis or Thrombectomy

Objective The use of anticoagulant and antiplatelet medication has traditionally been cited as a contraindication for acute ischemic stroke treatments. However, the 2026 American Heart Association (AHA)/American Stroke Association (ASA) Guidelines have updated these standards, designating tenecteplase (TNK) as a preferred thrombolytic agent and identifying the benefit-to-risk ratio for thrombolysis in patients with recent anticoagulant exposure as uncertain. Conversely, mechanical thrombectomy is increasingly utilized regardless of antithrombotic status. This study examines the difference in post-intervention intracranial hemorrhage (ICH) and modified Rankin score (mRS) between patients receiving comprehensive stroke treatment who were taking these medications versus patients who were not on antithrombotic pharmacotherapy. Methods This study was a retrospective chart review. Inclusion criteria consisted of adult patients who were evaluated in the emergency department for stroke and received either thrombolysis (tissue plasminogen activator (tPA) or TNK) or procedural neurointervention between March 2018 and May 2020. Data collected included patient demographics, pre-stroke antiplatelet use, anticoagulant use, post-intervention mRS, and incidence of ICH. ICH and mRS outcomes were compared between patients based on their antithrombotic use for each of the neurointervention groups. Results A total of 251 patients met the inclusion criteria. Patients taking antiplatelets who received both thrombolysis and thrombectomy had significantly higher mRS scores compared to patients not taking these agents. Patients taking antiplatelets who received thrombolysis alone tended to have higher mRS but failed to reach significance. Patients taking only anticoagulants showed no difference in mRS for any intervention. Patients taking both anticoagulants and antiplatelets had a higher mRS than those not taking either medication. Crucially, there were no significant differences in the rate of ICH after any intervention regardless of medication usage. There was also no difference in any outcomes between patients on single versus dual antiplatelets. Conclusion Our results suggest that patients on antiplatelet and anticoagulant medication may be able to safely receive procedural neurointervention and thrombolysis for acute ischemic stroke without an increased risk of ICH. While functional outcomes (mRS) were higher in medicated groups, these results likely reflect underlying comorbidities rather than procedural complications. These hypothesis-generating findings align with the evolving 2026 clinical landscape and underscore the need for prospective studies to resolve current clinical uncertainties regarding antithrombotic status and reperfusion therapy.