Antiplatelet Therapy for Intracranial Stenting in Low NIHSS Stroke
For patients with an intracranial stent, dual antiplatelet therapy with aspirin 75-325 mg daily plus clopidogrel 75 mg daily is mandatory, starting with loading doses (aspirin 160-325 mg plus clopidogrel 300-600 mg) prior to or immediately after stent placement, continued for a minimum of 4 weeks for bare-metal stents or 6-12 months for drug-eluting stents, followed by aspirin monotherapy indefinitely. 1
Critical Context: Intracranial Stenting Is NOT First-Line Therapy
Before discussing antiplatelet regimens for intracranial stents, it's essential to understand that intracranial stenting is not recommended for recently symptomatic intracranial stenosis (50-99%) based on the SAMMPRIS trial, which demonstrated that aggressive medical management is superior to stenting. 2 The medical management arm in SAMMPRIS included dual antiplatelet therapy with aspirin 325 mg plus clopidogrel 75 mg for up to 90 days, along with aggressive risk factor control. 2
When an Intracranial Stent Is Already Placed
Standard DAPT Protocol
Loading doses: Aspirin 160-325 mg plus clopidogrel 300-600 mg should be administered prior to or immediately after stent placement. 1
Maintenance therapy: Aspirin 75-325 mg daily plus clopidogrel 75 mg daily. 1
Duration for bare-metal stents: Minimum 4 weeks of DAPT, then transition to aspirin monotherapy indefinitely. 1
Duration for drug-eluting stents: 6-12 months of DAPT, then transition to aspirin monotherapy indefinitely. 1
Why Ticagrelor Is NOT Recommended
Do not use ticagrelor for intracranial stenting. 1 While ticagrelor plus aspirin is recommended for acute coronary syndrome and coronary stents, it lacks guideline support and robust safety data for intracranial stent applications and carries increased intracranial hemorrhage risk without proven benefit. 1
However, emerging research suggests ticagrelor 60 mg twice daily (a lower dose than the standard 90 mg) may be safe and effective for intracranial stenting, with no ischemic events, comparable hemorrhage rates (1.7%), and lower in-stent stenosis rates (5% vs 21%) compared to clopidogrel in a retrospective study of 119 patients. 3 Despite these promising findings, this remains investigational and should not replace the guideline-recommended aspirin plus clopidogrel regimen until validated in larger prospective trials. 3
For Intracranial Stenosis WITHOUT a Stent (Low NIHSS)
Acute Phase (First 21-90 Days)
For patients with minor ischemic stroke (NIHSS ≤3) or high-risk TIA caused by intracranial stenosis:
Initiate DAPT with aspirin 81 mg daily plus clopidogrel 75 mg daily within 12-24 hours after excluding intracranial hemorrhage. 2
Loading doses: Aspirin 160-325 mg plus clopidogrel 300-600 mg at initiation. 2
Duration: Continue DAPT for 21-90 days based on the CHANCE trial protocol. 2
Important Nuance on DAPT for Intracranial Stenosis
The evidence for DAPT specifically in intracranial stenosis is mixed. While the World Stroke Organization guidelines state there are no strong recommendations supporting DAPT over single antiplatelet therapy (SAPT) for moderate-to-high-grade intracranial stenosis (50-99%), 2 the SAMMPRIS trial showed DAPT was better than stenting (though it didn't prove DAPT was better than SAPT). 2 A post-hoc analysis of CHANCE showed no difference in the beneficial effect of DAPT versus SAPT specifically in patients with intracranial atherosclerotic disease. 2
Long-Term Management (After 90 Days)
Transition to aspirin 325 mg daily monotherapy is recommended over oral anticoagulation for moderate-to-high-grade intracranial stenosis (50-99%). 2
Exploratory data from SAMMPRIS suggests prolonged DAPT beyond 90 days may lower stroke risk (6.0% vs 10.8% in the medical arm) but may increase major hemorrhage risk (4.0% vs 2.5%), though these differences were not statistically significant. 4
Essential Adjunctive Medical Management
Regardless of antiplatelet regimen, all patients with intracranial stenosis require:
Blood pressure control: Target systolic BP <140 mmHg. 2
High-dose statin therapy to reduce recurrent stroke risk. 2
At least moderate physical activity. 2
Aggressive management of diabetes, smoking cessation, and lifestyle modification. 2
Critical Pitfalls to Avoid
Never discontinue DAPT prematurely before 4 weeks for bare-metal intracranial stents or 6 months for drug-eluting stents, as this significantly increases thrombotic risk. 1
Do not use anticoagulation for intracranial stenosis unless there is another indication (e.g., atrial fibrillation). 2
Avoid intracranial stenting as first-line therapy for recently symptomatic intracranial stenosis; aggressive medical management is superior. 2
If oral anticoagulation is required (e.g., for atrial fibrillation in a patient with an intracranial stent), use clopidogrel as the sole antiplatelet agent rather than DAPT to minimize bleeding risk. 1