Dear Editor, We read the findings of Zhao et al. [1] with great interest. Recently, 2 independent, multicenter, randomized, double-blind, placebo-controlled trials (CHANCE and POINT) have established the efficacy of short-term dual antiplatelet therapy (DAPT) to prevent recurrent ischemic stroke in patients with minor stroke or high-risk TIA[2, 3]. Thus, starting DAPT (aspirin and clopidogrel) within 24 h after symptom onset is recommended by the most recent AHA guidelines [4] in patients presenting with minor noncardioembolic ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤3) who did not receive intravenous alteplase. (Patients who are candidates for thrombolysis were not represented in these trials, so results cannot be generalized to this group.) Zhao et al. [1] treated 102 patients with aspirin and clopidogrel after intravenous thrombolysis for acute minor ischemic stroke and compared them with 105 patients treated with aspirin. Functional outcome was better in the dual antiplatelet group, without significant difference in terms of symptomatic intracerebral hemorrhage or mortality. However, in this study, minor stroke was defined as a score of ≤5 points on the National Institutes of Health Stroke Scale (NIHSS). About one-third of these patients harbor a large vessel occlusion [5] and potentially develop a medium to large infarction with increased risk of hemorrhagic conversion. Thus, it would be useful to know how many patients in the study had an ischemic lesion on follow-up imaging and the size of the lesions. Further, the half-life of alteplase is nearly 4 min, but its effect on the coagulation system persists much longer. The fibrinolytic activity of alteplase is associated with consumptive coagulopathy with hypofibrinogenemia that may last ≥24 h after completion of the alteplase infusion. Early hypofibrinogenemia (fibrinogen level <200 mg/dL at 2 h after alteplase infusion) occurs in about 20% of the patients after alteplase infusion and is associated with a substantially increased risk of symptomatic intracerebral hemorrhage [6]. In patients with minor stroke treated with intravenous thrombolysis, before starting early DAPT, it would be appropriate to consider the infarct size and exclude alteplase-related coagulopathy.

中文翻译：

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静脉溶栓治疗急性轻微脑卒中患者的早期双重抗血小板治疗

尊敬的编辑，我们阅读了赵等人的研究结果。[1] 兴致勃勃。最近，2 项独立、多中心、随机、双盲、安慰剂对照试验（CHANCE 和 POINT）确立了短期双重抗血小板治疗（DAPT）预防轻度卒中或高危患者缺血性卒中复发的疗效。 TIA[2, 3]。因此，最新的 AHA 指南 [4] 建议在症状出现后 24 小时内开始 DAPT（阿司匹林和氯吡格雷）治疗的轻度非心源性缺血性卒中（美国国立卫生研究院卒中量表 [NIHSS] 评分≤3）的患者未接受静脉阿替普酶。（这些试验中没有溶栓候选患者，因此结果不能推广到该组。）赵等人。[1] 对 102 名急性轻微缺血性卒中静脉溶栓后使用阿司匹林和氯吡格雷的患者进行治疗，并与 105 名接受阿司匹林治疗的患者进行比较。双联抗血小板组的功能结果更好，在症状性脑出血或死亡率方面没有显着差异。然而，在这项研究中，轻微卒中被定义为美国国立卫生研究院卒中量表 (NIHSS) ≤ 5 分。这些患者中约有三分之一存在大血管闭塞 [5] 并可能发生中至大梗塞，增加出血性转化的风险。因此，了解研究中有多少患者在后续成像中具有缺血性病变以及病变的大小将是有用的。此外，阿替普酶的半衰期接近 4 分钟，但它对凝血系统的影响会持续更长时间。阿替普酶的纤溶活性与伴有低纤维蛋白原血症的消耗性凝血病有关，在阿替普酶输注完成后可能持续≥24小时。大约 20% 的患者在阿替普酶输注后发生早期低纤维蛋白原血症（阿替普酶输注后 2 小时时纤维蛋白原水平 <200 mg/dL），并且与症状性脑出血的风险显着增加有关 [6]。对于接受静脉溶栓治疗的轻微卒中患者，在开始早期 DAPT 之前，应考虑梗死面积并排除阿替普酶相关的凝血病。阿替普酶的纤溶活性与伴有低纤维蛋白原血症的消耗性凝血病有关，在阿替普酶输注完成后可能持续≥24小时。大约 20% 的患者在阿替普酶输注后发生早期低纤维蛋白原血症（阿替普酶输注后 2 小时时纤维蛋白原水平 <200 mg/dL），并且与症状性脑出血的风险显着增加有关 [6]。对于接受静脉溶栓治疗的轻微卒中患者，在开始早期 DAPT 之前，应考虑梗死面积并排除阿替普酶相关的凝血病。阿替普酶的纤溶活性与伴有低纤维蛋白原血症的消耗性凝血病有关，在阿替普酶输注完成后可能持续≥24小时。大约 20% 的患者在阿替普酶输注后发生早期低纤维蛋白原血症（阿替普酶输注后 2 小时时纤维蛋白原水平 <200 mg/dL），并且与症状性脑出血的风险显着增加有关 [6]。对于接受静脉溶栓治疗的轻微卒中患者，在开始早期 DAPT 之前，应考虑梗死面积并排除阿替普酶相关的凝血病。阿替普酶输注后 2 小时 200 mg/dL）发生在约 20% 的阿替普酶输注后患者中，并且与症状性脑出血的风险显着增加有关 [6]。对于接受静脉溶栓治疗的轻微卒中患者，在开始早期 DAPT 之前，应考虑梗死面积并排除阿替普酶相关的凝血病。阿替普酶输注后 2 小时 200 mg/dL）发生在约 20% 的阿替普酶输注后患者中，并且与症状性脑出血的风险显着增加有关 [6]。对于接受静脉溶栓治疗的轻微卒中患者，在开始早期 DAPT 之前，应考虑梗死面积并排除阿替普酶相关的凝血病。