Thrombolysis for acute stroke under antiplatelet therapy: safe enough to be beneficial?

Controversy exists over whether chronic antiplatelet therapy in patients with acute ischemic stroke is a contraindication to treatment with tissue plasminogen activator (tPA). Antiplatelets impair thrombocyte function and might, therefore, increase the risk of symptomatic intracerebral hemorrhage (SICH) after intravenous thrombolysis. This Practice Point commentary discusses a recent study by Uyttenboogaart et al. that aimed to further explore the interactions between antiplatelet and tPA therapies. The single-center study, which included 301 consecutive patients with ischemic stroke, found that the incidence of SICH was indeed increased among patients who were pretreated with antiplatelets, but that these patients nevertheless had a greater net benefit of thrombolysis than did those who had not received previous antiplatelet therapy. The commentary authors consider the study's shortcomings, but conclude that the widespread practice of using tPA in the presence of antiplatelet therapy is justified.