LAUSR

Kamarova et al1 reviewed antiplatelet agents used in primary and secondary stroke prevention. In their analysis on dual antiplatelet therapy (DAPT) following an acute ischemic stroke, the authors concluded that DAPT for up to 21 days reduced recurrent ischemic strokes in patients with minor stroke or high-risk transient ischemic attack (TIA) according to the CHANCE and POINT clinical trials.2,3 In the POINT trial, the risk of hemorrhagic complications outweighed the benefits of stroke prevention with DAPT beyond 30 days.3 An additional prevention measure recommended by the authors was aggressive lifestyle management based on the results of the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial.4 However, another major finding from the SAMMPRIS trial that needs to be highlighted was that 90 days of DAPT may be warranted in select patients with severe intracranial atherosclerotic disease (ICAD). ICAD is attributed to approximately 10% of acute ischemic strokes in the United States with a high stroke recurrence.5,6 SAMMPRIS was a randomized clinical trial comparing patients with symptomatic ICAD (70%-99% intracranial stenosis) managed within 30 days of an ischemic stroke or TIA with either intracranial stenting plus aggressive medical therapy or medical therapy alone. Medical therapy included DAPT for 90 days with aspirin and clopidogrel as well as high-intensity statin therapy. After 30 days, rate of stroke or death was higher in the stenting group compared with medical management alone (14.7% vs 5.8%, P = 0.002). In addition, symptomatic intracranial hemorrhage was also higher (4.5% vs 0.4%).4 The final results of the trial after a median follow-up of 32.4 months demonstrated similar trends in stroke or death (23% vs 15%).7 While the results support 90-day DAPT in severe ICAD, the use of a single antiplatelet is not well studied in this population. Nonetheless, comparing results from other trials on symptomatic ICAD such as Warfarin-Aspirin Symptomatic Intracranial Disease (WASID),8 the guidelines recommend DAPT for 90 days to reduce recurrent strokes in patients with recent stroke or TIA (within 30 days) and severe ICAD (Class 2a, Level B-Nonrandomized).9