What antiplatelet regimen is recommended for a patient with multiple brain infarcts?

Antiplatelet Therapy for Multiple Brain Infarcts

For patients with multiple brain infarcts, initiate dual antiplatelet therapy (DAPT) with aspirin 160-325 mg plus clopidogrel 300-600 mg loading doses within 12-24 hours after excluding intracranial hemorrhage, followed by aspirin 75-100 mg daily plus clopidogrel 75 mg daily for exactly 21 days, then transition to single antiplatelet therapy (aspirin 75-100 mg daily or clopidogrel 75 mg daily) indefinitely. 1

Initial Assessment and Treatment Window

• Confirm the diagnosis by ruling out intracranial hemorrhage on neuroimaging before initiating any antiplatelet therapy 1
• Assess stroke severity using NIHSS score—patients with minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 score ≥4) qualify for DAPT 1
• Time is critical: DAPT should be initiated within 12-24 hours of symptom onset for maximum benefit 1

Loading Dose Protocol

• Administer aspirin 160-325 mg as the loading dose 1
• Administer clopidogrel 300-600 mg as the loading dose 1
• If the patient received IV alteplase, delay antiplatelet therapy until 24 hours post-thrombolysis to minimize hemorrhagic risk 1
• For patients unable to swallow, use rectal aspirin 325 mg as an alternative 1

Maintenance Phase: Days 1-21

• Continue aspirin 75-100 mg daily plus clopidogrel 75 mg daily for exactly 21 days 1, 2
• The American Heart Association supports extending DAPT up to a maximum of 30 days based on individual risk assessment, though 21 days is the optimal duration that maximizes efficacy while minimizing bleeding risk 1, 2
• Monitor hemoglobin weekly during DAPT, especially in patients with baseline anemia or bleeding risk factors 2
• Consider adding a proton pump inhibitor for GI protection if additional bleeding risk factors are present 2

Long-Term Maintenance: After 21-30 Days

• Transition to single antiplatelet therapy after completing the DAPT course 1, 2
• First-line option: Aspirin 75-100 mg daily 1
• Equally effective alternative: Clopidogrel 75 mg daily 1
• Another reasonable option: Aspirin 25 mg plus extended-release dipyridamole 200 mg twice daily 1
• Continue single antiplatelet therapy indefinitely for secondary stroke prevention 1

Special Considerations for Intracranial Stenosis

• If multiple brain infarcts are due to symptomatic intracranial stenosis (50-99%), aggressive medical management is superior to intracranial stenting 3
• For intracranial stenosis without a stent, use the same DAPT protocol (21-90 days based on CHANCE trial), then transition to single antiplatelet therapy 3
• Essential adjunctive management includes: target systolic BP <140 mmHg, high-dose statin therapy, smoking cessation, diabetes control, and at least moderate physical activity 3

Critical Pitfalls to Avoid

• Never extend DAPT beyond 30 days in patients with non-cardioembolic stroke, as this significantly increases bleeding risk (HR 2.22-2.32 for major hemorrhage) without additional benefit 1, 2
• Do not discontinue DAPT prematurely before completing 21 days unless active bleeding or severe anemia develops, as early recurrent stroke risk is highest in the first weeks 2
• Do not use aspirin plus clopidogrel combination long-term beyond 30 days for routine secondary prevention, as this increases hemorrhage risk without improving outcomes 1, 2
• Avoid enteric-coated aspirin for the loading dose as it has a slower onset of action 1
• Do not use glycoprotein IIb/IIIa inhibitors in acute ischemic stroke, as these are potentially harmful 1

Evidence Quality and Strength

• The DAPT recommendation is supported by the CHANCE and POINT trials, which demonstrated that DAPT reduces recurrent stroke risk in the first 21-90 days 1, 2
• Major hemorrhage occurred in 0.9% of DAPT patients versus 0.4% with aspirin alone (HR 2.32,95% CI 1.10-4.87) in the POINT trial 2
• The recommendation for antiplatelet therapy after ischemic stroke is supported by Grade 1A evidence from large randomized controlled trials involving over 40,000 patients 1

Monitoring During DAPT

• Assess for bleeding signs including melena, hematuria, excessive bruising, or neurological deterioration 2
• Monitor hemoglobin weekly, especially in patients with mild anemia at baseline 2
• Educate patients on reporting signs of bleeding immediately 2
• If mild anemia develops during DAPT and the patient is within the 21-30 day window with no active bleeding, continue DAPT with close monitoring 2