Would you recommend switching to DAPT for patients on anticoagulation who develop symptoms of a TIA secondary to ICAD?

It is important to remember that there is more to stroke secondary prevention than antithrombotics. Our use of DAPT in ICAD comes from the SAMMPRIS trial, in which patients in the control group did better than expected compared to historical controls with ICAD in the WASID trial. Recall however, that DAPT and its duration (90d) were only chosen in SAMMPRIS because it was the interventionalists' preference in patients undergoing intracranial stenting (which is what the trial was actually testing).

Besides DAPT, patients in SAMMPRIS also had aggressive management of risk factors, including tight BP control, smoking cessation, LDL <70, weight loss, and exercise with help of a lifestyle modification program - all of which likely contributed to l...

As we know the mechanism of stroke in ICAD:

1. Artery to artery embolism
2. Perforator disease
3. Hypoperfusion

For 1, 2 the best treatment is optimal medical management. While for 3, the treatment can be angioplasty/stenting.

If we looked for WASID trial which randomly assigned patients with TIA or stroke associated with angiographically verified intracranial stenosis to receive either warfarin (INR 2–3) or aspirin 1,300 mg daily in a double-blind multicenter trial. The planned mean duration of follow-up was 36 months, but the actual mean duration of follow-up was less than 2 years.

Warfarin was associated with significantly higher rates of adverse events and provided no benefit in the prevention of the primary endpoint (Ischemic stroke, brain hem...

I would consider it. If there is an indication for anticoagulation, would continue the anticoagulant and add aspirin only for 30 days if safe.