Early Anticoagulation, Dual Antiplatelet Therapy, and Endovascular Thrombectomy in Late Presentation

This session addresses the limited role of early anticoagulation in ischemic stroke, the evidence for dual antiplatelet therapy (DAPT) from the CHANCE trial, the timing of DAPT benefit, and the criteria and outcomes for endovascular thrombectomy in individuals presenting 6-24 hours after stroke onset, including clinical-imaging mismatch definitions and medium vessel occlusions.

Practitioner-Guided Note

DAPT benefit is concentrated in the first three weeks after symptom onset per CHANCE trial analyses. For thrombectomy in the 6-24-hour window, confirm occlusion in the intracranial ICA or M1 segment and verify clinical-imaging mismatch (e.g., NIHSS 10+ with infarct volume under 21 mL in those under 80). Involvement of more than one-third of the MCA territory on CT/MRI generally excludes thrombectomy candidacy.

Key Takeaways

Early anticoagulation has no established role in most acute ischemic strokes; exceptions include mechanical heart valves and arterial dissection.Ticagrelor plus aspirin is an emerging DAPT option for large vessel disease.CHANCE trial: short-course DAPT reduces early recurrent stroke risk without increasing major bleeding.DAPT benefit is concentrated in the first three weeks after symptom onset.Thrombectomy in the 6-24-hour window is effective when clinical-imaging mismatch is confirmed (intracranial ICA or M1 occlusion).Mismatch criteria: NIHSS 10+ with infarct under 21 mL, or NIHSS 20+ with infarct under 51 mL (for those under 80).Infarct volume is assessed by DWI-MRI or CT perfusion; involvement of more than one-third of MCA territory excludes thrombectomy.Medium vessel occlusions (M2, M3, A2, A3) may also benefit from thrombectomy per emerging evidence.