Seizing the opportune moment: early use of antiplatelet therapy for thrombolysis

Intravenous thrombolysis remains a cornerstone intervention for restoring cerebral perfusion in patients with acute ischemic stroke (AIS), with recombinant tissue plasminogen activator (rt-PA) being the most widely employed agent globally. Post-thrombolytic complications, including hemorrhagic transformation, vascular reocclusion, cerebral edema, seizures, and allergic reactions, pose significant clinical challenges. Among these, hemorrhagic transformation is a primary concern during early revascularization, particularly in patients treated within the therapeutic time window. Despite its clinical importance, the optimal timing for initiating antiplatelet therapy after ischemic stroke remains unresolved, and considerable controversy persists in practice. This narrative review critically examines current clinical evidence and underlying pathophysiological mechanisms related to early antiplatelet therapy following intravenous thrombolysis. We focus on a key clinical challenge: the safety and efficacy of initiating antiplatelet treatment in the early post-thrombolysis period, particularly among patients experiencing early neurological deterioration or at elevated risk for specific hemorrhagic transformation subtypes, such as hemorrhagic infarction (HI). By comparing early antiplatelet strategies with the conventional 24-hour delayed initiation protocol, this review integrates findings from pivotal clinical trials and mechanistic studies to elucidate the balance between the risk of symptomatic intracranial hemorrhage (sICH) and the potential for achieving functional independence at three months.