Objective:

To evaluate sources of treatment delay in the administration of dual antiplatelet therapy (DAPT) to patients with minor acute ischemic stroke (AIS).  

Background:

Delayed and missed administration of DAPT after minor AIS (NIHSS <6) are frequent in clinical practice despite evidence-based guidelines. We hypothesized that obtaining advanced neuroimaging was a source of DAPT delay at our center.  

Design/Methods:

We conducted a retrospective cohort study of consecutive minor AIS patients eligible for DAPT based on current guidelines from 1/1/2023-5/31/2023 at our comprehensive stroke center (CSC) and an affiliated primary stroke center (PSC) with more limited access to advanced neuroimaging. Patients’ demographics and relevant time metrics, including arrival-to-imaging and arrival-to-treatment, were calculated and compared.  

Results:

Of 136 patients with minor AIS, 52 met inclusion criteria (31 CSC, 21 PSC). Overall, 40% were female, mean age was 67.5 (SD 13.8) years, and the median NIHSS was 1 (IQR 0-3). The mean arrival-to-treatment time was 665 (SD 457) minutes; this interval did not differ by site (663 [SD 442] vs 669 [SD 489] minutes; p=0.97). Mean time-to-brain MRI was 434 (SD 370) minutes. Three patients (2 CSC, 1 PSC) did not undergo MRI and 11 (5 CSC, 6 PSC) received DAPT before MRI. Patients given DAPT prior to MRI had significantly faster treatment times than those treated after MRI (205.6 [SD 131.6] vs 788.7 [SD 433.9] minutes; p<0.001). Non-contrast head CT was obtained in all patients and CT angiogram (CTA) obtained in 19 patients (13 CSC, 6 PSC). The mean time to CTA was 171.26 (SD 241.61) minutes. No patients received DAPT prior to CT or CTA.

Conclusions:

Among eligible minor stroke patients, average time from ED arrival to DAPT initiation was nearly 11 hours. Patients who received DAPT prior to MR brain were treated significantly faster, suggesting that waiting for advanced imaging may contribute to treatment delays.