Very mild stroke from large artery disease may do better on dual antiplatelets than alteplase, in an exploratory analysis

Design

Post hoc subgroup analysis of a randomised trial (ARAMIS)

Population

478 patients with minor non-disabling stroke and vessel imaging

Primary outcome

Excellent functional outcome (mRS 0 to 1) at 90 days

Effect

NIHSS 0 to 3 with LAA: 97.3% vs 85.1%, adjusted OR 6.45 (0.68 to 60.81)

ARAMIS found dual antiplatelet therapy non-inferior to alteplase in minor non-disabling stroke (NIHSS 0 to 5). This post hoc analysis took 478 patients with vessel imaging and split them by severity (NIHSS 0 to 3 or 4 to 5) and by whether large artery atherosclerosis was the cause.

In NIHSS 0 to 3 with large artery disease, excellent 90-day outcome was 97.3% with dual antiplatelets and 85.1% with alteplase (adjusted OR 6.45, 0.68 to 60.81), reaching significance only in a weighted sensitivity analysis (OR 6.49, 1.54 to 27.39). Without large artery disease the gap was small. The interaction test was not significant, and bleeding was similar.

The authors call it hypothesis-generating, and it is. It does not change the main ARAMIS message, but it adds a reason to image the vessels early in minor stroke.

• Image the intracranial and extracranial vessels early in minor stroke
• Do not change thrombolysis decisions on this subgroup analysis
• In non-disabling minor stroke, dual antiplatelet therapy is a reasonable alternative to alteplase, as in the main ARAMIS result
• Large artery atherosclerosis may be the group where antiplatelets perform best, pending confirmation

Why it matters

It raises the idea that stroke mechanism, not just severity, could guide acute minor stroke treatment.

Don't overread it

This is a post hoc subgroup with no adjustment for multiple comparisons.

The statistics, in plain English

The confidence interval of 0.68 to 60.81 is extremely wide, showing how few events there were. A non-significant interaction test means the trial cannot show that the treatment effect truly differs between subgroups.

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