Optimal pharmacological therapy for minor acute ischemic stroke: a network meta-analysis

Minor acute ischemic stroke (mAIS), typically defined as a National Institutes of Health Stroke Scale (NIHSS) score ≤ 5, accounts for over 50% of all ischemic strokes. However, the optimal pharmacological therapy for patients with mAIS remains controversial. Hence, this systematic review and network meta-analysis (NMA) was conducted to compare the effectiveness and safety of available pharmacological therapies for mAIS patients.

PubMed, Embase, the Cochrane Library, and Web of Science databases were systematically searched for publications up to June 1, 2025. Randomized controlled trials (RCTs) and cohort studies investigating various antithrombotic drugs for mAIS were retrieved. The included outcome measures were functional outcomes (modified Rankin Scale [mRS] 0-1, mRS 0-2), early neurological improvement within 24 h, intracranial hemorrhage, newly diagnosed ischemic stroke within 90 days, and all-cause mortality (ACM). Bayesian NMA was performed using R 4.5.1 and STATA 15.1.

Eleven eligible studies, involving 26,176 patients, were included, which evaluated 9 different antithrombotic interventions. According to the NMA, single antiplatelet therapy (SAPT) (surface under the cumulative ranking curve [SUCRA] = 67.3%) and aspirin (SUCRA = 71.9%) were the most likely best interventions for achieving an mRS score of 0-1 and 0-2, respectively. Alteplase (SUCRA = 81.9%) had the highest probability of being the most effective in improving early neurological function within 24 h. Aspirin (SUCRA = 87.6%) was associated with the lowest incidence of symptomatic intracranial hemorrhage. Dual antiplatelet therapy (DAPT) represented the most likely best intervention in reducing newly diagnosed ischemic stroke within 90 days and ACM, with a SUCRA of 87.7 and 68.3%, respectively.

Both DAPT and aspirin may represent safe and effective interventions for treating mAIS. However, individual patient circumstances should be considered in clinical decision-making. This analysis provides insights that may support the selection of individualized treatment strategies. The findings of this NMA, based on limited studies, remain to be further validated in future well-designed large-scale RCTs.

https://www.crd.york.ac.uk/PROSPERO/search, identifier CRD420251238111.