Abstract DP310: Dual Antiplatelet versus Anticoagulant-Plus-Antiplatelet Therapy in Symptomatic Intracranial Atherosclerosis: A Multicenter Comparative Study

Introduction: Intracranial atherosclerosis (ICAS) is a leading cause of ischemic stroke (IS) worldwide and carries a high risk of recurrence. Current guidelines favor 90 days of dual antiplatelet therapy (DAPT) for severe symptomatic ICAS, but recurrence remain high. Limited data suggest possible benefit of single antiplatelet plus anticoagulation (SAPT+AC). We compared the effectiveness and safety of DAPT versus SAPT+AC. We hypothesized that DAPT would lower 90-day recurrent IS risk without significantly increasing bleeding. Methods: This substudy of the Biomarkers and Recurrence Risk in Symptomatic Intracranial Arterial Stenosis (BIORISK-ICAS) included patients from 35 centers (Jan 2019–Jun 2024) with symptomatic 50–99% ICAS in the intracranial internal carotid, vertebral, basilar, or M1 segment of the MCA, presenting ≤72 hours from last known well. The primary efficacy outcome was recurrent IS in the same vascular territory at 90 days; the primary safety outcome was severe bleeding (symptomatic intracranial hemorrhage or major extracranial bleeding). Categorical variables were compared using χ 2 and continuous variables with the Student's t test; multivariable Cox regression adjusted for key covariates. Results: Of 2050 BIORISK-ICAS patients, 1658 met criteria (DAPT n=1499; SAPT+AC n=159). Mean age was 67 vs. 73 years, and 44% were women. At 90 days, recurrent IS occurred in 121 DAPT patients (8.07%) vs. 13 SAPT+AC patients (8.17%); unadjusted HR 0.83 (95% CI, 0.50–1.36; p=0.46). After adjustment for age, diabetes, coronary heart disease, atrial fibrillation, active smoking, and borderzone infarct, the adjusted HR was 0.99 (95% CI, 0.52–1.86; p=0.97). Severe bleeding occurred in 34 DAPT patients (2.26%) and 5 SAPT+AC patients (3.14%); unadjusted HR 0.79 (95% CI, 0.28–1.85; p=0.50), adjusted HR 0.66 (95% CI, 0.21–2.09; p=0.47). Conclusions: In patients with symptomatic ICAS, DAPT and SAPT+AC were associated with similar risks of 90-day recurrent ischemic stroke and severe bleeding. Well-powered randomized trials are needed to determine the optimal antithrombotic regimen in this high-risk population.

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Journal
Stroke
Published
2026-01-29
DOI
https://doi.org/10.1161/str.57.suppl_1.dp310
Primary Topic
Cerebrovascular and Carotid Artery Diseases
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article

Abstract DP310: Dual Antiplatelet versus Anticoagulant-Plus-Antiplatelet Therapy in Symptomatic Intracranial Atherosclerosis: A Multicenter Comparative Study

William Almiri, James P. Klaas, Maarij Malik, Praveen Hariharan et al.
Stroke
Cerebrovascular and Carotid Artery Diseases
article

Abstract DP310: Dual Antiplatelet versus Anticoagulant-Plus-Antiplatelet Therapy in Symptomatic Intracranial Atherosclerosis: A Multicenter Comparative Study

William Almiri, James P. Klaas, Maarij Malik, Praveen Hariharan, Cameron D. Owens, M. Aemaz Ur Rehman, Liqi Shu, Mohammad W Khasawneh, James Ernest Siegler, Faddi Saleh Velez, Sofia Vasilopoulou, Dawson C Cooper, Mahmoud I. Dibas, Sarwat Sultana, Alexis N. Simpkins, Shaista Alam, Fahad Khan, Mirjam R. Heldner, Abhiram Parameswaran Pillai, Anicléia Rodrigues de Lima, Mohammad AlMajali, Johanna Helenius, D Liebeskind, Ahmad Abu Qdais, Muhib Khan, Stefano Vozzi, Diana Aguiar de Sousa, Pooja Khatri, Mafalda Delgado Soares, Michele Romoli, Malik Ghannam, Cheran Elangovan, Ekaterina Bakradze, Joao Pedro Marto, Shadi Yaghi, Marrone Nicola, Christopher Leon Guerrero, Aaron Rothstein, Camila Pinto, Sami Al Kasab, Thanh N. Nguyen, Nils Henninger, Piers Klein, Argyro Tountopoulou, Kateryna Antonenko, Adam de Havenon, Ayush Agarwal, Sridhara Yaddanapudi
article en

Abstract

Introduction: Intracranial atherosclerosis (ICAS) is a leading cause of ischemic stroke (IS) worldwide and carries a high risk of recurrence. Current guidelines favor 90 days of dual antiplatelet therapy (DAPT) for severe symptomatic ICAS, but recurrence remain high. Limited data suggest possible benefit of single antiplatelet plus anticoagulation (SAPT+AC). We compared the effectiveness and safety of DAPT versus SAPT+AC. We hypothesized that DAPT would lower 90-day recurrent IS risk without significantly increasing bleeding. Methods: This substudy of the Biomarkers and Recurrence Risk in Symptomatic Intracranial Arterial Stenosis (BIORISK-ICAS) included patients from 35 centers (Jan 2019–Jun 2024) with symptomatic 50–99% ICAS in the intracranial internal carotid, vertebral, basilar, or M1 segment of the MCA, presenting ≤72 hours from last known well. The primary efficacy outcome was recurrent IS in the same vascular territory at 90 days; the primary safety outcome was severe bleeding (symptomatic intracranial hemorrhage or major extracranial bleeding). Categorical variables were compared using χ 2 and continuous variables with the Student's t test; multivariable Cox regression adjusted for key covariates. Results: Of 2050 BIORISK-ICAS patients, 1658 met criteria (DAPT n=1499; SAPT+AC n=159). Mean age was 67 vs. 73 years, and 44% were women. At 90 days, recurrent IS occurred in 121 DAPT patients (8.07%) vs. 13 SAPT+AC patients (8.17%); unadjusted HR 0.83 (95% CI, 0.50–1.36; p=0.46). After adjustment for age, diabetes, coronary heart disease, atrial fibrillation, active smoking, and borderzone infarct, the adjusted HR was 0.99 (95% CI, 0.52–1.86; p=0.97). Severe bleeding occurred in 34 DAPT patients (2.26%) and 5 SAPT+AC patients (3.14%); unadjusted HR 0.79 (95% CI, 0.28–1.85; p=0.50), adjusted HR 0.66 (95% CI, 0.21–2.09; p=0.47). Conclusions: In patients with symptomatic ICAS, DAPT and SAPT+AC were associated with similar risks of 90-day recurrent ischemic stroke and severe bleeding. Well-powered randomized trials are needed to determine the optimal antithrombotic regimen in this high-risk population.

StrokeVol. 57(Suppl_1)
Boston University (US), University of Iowa (US), University of Maryland, Baltimore (US), Cedars-Sinai Medical Center (US), All India Institute of Medical Sciences Raipur (IN), Mercy St. Vincent Medical Center (US), University of Minnesota (US), Mayo Clinic (US), University of Lisbon (PT), Medical University of South Carolina (US), University of Tennessee Health Science Center (US), National and Kapodistrian University of Athens (GR), Washington University in St. Louis (US), Brown University (US), Thomas Jefferson University Hospital (US), UCLA Health (US), University of Minnesota System (US), University Hospital of Bern (CH), University of Alabama at Birmingham (US), Yale University (US), University of Chicago (US), Unidade Local de Saúde de São José (PT), Atrium Medical Cente (US), Hospital de Egas Moniz (PT), All India Institute of Medical Sciences Bhopal (IN), Ospedale “M. Bufalini” di Cesena (IT), Frontier Science Foundation-Hellas (GR), Jefferson Hospital (US), UMass Memorial Medical Center (US), Mercy Health (US), All India Institute of Medical Sciences (IN), University of Pennsylvania (US), University of Oklahoma (US)
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Cerebrovascular and Carotid Artery Diseases
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