What duration of dual antiplatelet therapy do you use for secondary prevention of ischemic stroke due to intracranial atherosclerotic disease?
It is a fair question that we don't have a solid evidence-based answer for. I agree that the SAMMPRIS trial was driven by events within the first 30 days, although this was primarily driven by procedure-related events in the stented group.
We do know that intracranial athero (ICAS) risk of stroke re...
This is an area of uncertainty and the NIH-funded CAPTIVA study will test different durations (including beyond 90 days) and different regimens (NCT05047172).
In the meantime, 90 days of DAPT are reasonable but one can't be dogmatic about it.
The duration of DAPT in 3 weeks, in general, comes from POI...
My clear-cut answer would be to adopt the SAMMPRIS protocol of 90 days.
Caveat: 90 days is acceptable if there is less risk of complication (i.e., hemorrhage). Otherwise, there needs to be a risk/benefit discussion in patients who are deemed high risk (known CAA, uncontrolled hypertension, etc.). Oth...
Many questions must be addressed in future trials. I strongly advocate for 21-30 days of DAPT in symptomatic ICAD while optimizing the management of other risk factors like dyslipidemia and HTN. We cannot underestimate the risk of hemorrhagic complications.
In cases of recurrent strokes ...
I prefer tailoring the treatment for each patient, based on their stroke risk factors, vasculopathy, compliance with healthcare, frequency of doctor visits, and potential bleeding risks or complications. While 30 to 90 days is acceptable for most patients, some may require extended treatment duratio...
The latest guidelines from ASA: 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack; Kleindorfer et al., PMID 34024117 (figure 6, page e428).
Dual antiplatelets for high-risk patients for 90 days.
Longer is better than shorter, although the hemorrhagic complication rate might be higher in the former.