Background: Ancillary tests are indicated to diagnose death by neurological criteria whenever clinical neurological examination is unreliable, but their use is variable and subject to debate. Methods: Survey of Canadian intensivists providing care for potential organ donors. We included closed-ended questions and different clinical scenarios regarding the use of ancillary tests. Results: Among 550 identified intensivists, 249 completed the survey. Respondents indicated they would be comfortable diagnosing death based on neurological examination without ancillary tests in the following scenarios: movement in response to stimulation (48%), spontaneous peripheral movement (31%), inability to evaluate upper/lower extremity responses (34%) or both oculocephalic and oculo-caloric reflexes (17%), presence of high cervical spinal cord injury (16%) and within 24 hours of hypoxemic-ischemic brain injury (15%). Furthermore, 93% agreed that ancillary tests should always be conducted when a complete neurological examination is impossible, 89% if there remains possibility of residual sedative effect and 59% in suspected isolated brainstem death. Conclusions: Our findings suggest that Canadian intensivists have different perceptions on what constitutes a complete and reliable clinical neurological examination for determining death by neurologic criteria. Some self-reported practices also diverge from national recommendations. Further investigation and education are required to align and standardize medical practice across physicians and systems.

Background: CT-angiography is an ancillary test used to diagnose death by neurological criteria (DNC), notably in cases of unreliable neurological examinations due to clinical confounders. We studied whether clinical confounders to the neurological examination modified CT-angiography diagnostic accuracy. Methods: Systematic review and meta-analysis of studies including deeply comatose patients undergoing DNC ancillary testing. We estimated pooled sensitivities and specificities using a Bayesian hierarchical model, including data on CT-angiography (4-point, 7-point, 10-point scales, and no intracranial flow), and performing a subgroup analysis on clinical confounders to the reference neurological examination. Results: Of 40 studies included in the meta-analysis, 7 involve CT-angiography (n=586). There was no difference between subgroups (Table). The degree of uncertainty involving sensitivity estimates was high in both subgroups. Conclusions: Statistical uncertainty in diagnostic accuracy estimates preclude any conclusion regarding the impact of clinical confounders on CT-angiography diagnostic accuracy. Further research is required to validate CT-angiography as an accurate ancillary test for DNC.

Table. Pooled sensitivities and specificities of CT-angiography for death by neurological criteria

Table.

Pooled sensitivities and specificities of CT-angiography for death by neurological criteria

Background: The ɛ4-allele of apolipoprotein E (APOE-ɛ4) increases the risk not only for Alzheimer’s disease (AD), but also for Parkinson’s disease dementia and dementia with Lewy bodies (collectively, Lewy body dementia [LBD]). Hippocampal volume is an important neuroimaging biomarker for AD and LBD, although its association with APOE-ɛ4 is inconsistently reported. We investigated the association of APOE-ε4 with hippocampal atrophy quantified using magnetic resonance imaging in AD and LBD. Methods: Electronic databases (PubMed, Embase, PsycINFO, Scopus, Web of Science) were systematically searched for studies published up until December 31st, 2020. Results: Thirty-nine studies (25 cross-sectional, 14 longitudinal) were included. We observed that: (1) APOE-ε4 was associated with greater rate of hippocampal atrophy in AD and those who progressed from mild cognitive impairment to AD, (2) APOE-ε4 carriers showed greater involvement of cornu ammonis-1 hippocampal subfield versus non-carriers in AD, (3) APOE-ɛ4 may influence hippocampal atrophy in dementia with Lewy bodies, although longitudinal investigations are required, and (4) APOE-ε4 associated with earlier rather than very late expression of mediotemporal degeneration and memory-related neurocognitive impairment. Conclusions: The role of APOE-ɛ4 in modulating hippocampal phenotypes may be further clarified through more homogenous, well-powered, pathology-proven studies. Understanding the underlying mechanisms will facilitate development of prevention strategies targeting APOE-ɛ4.

Background: We report 2 brothers sharing FHL1 identified mutation. They presented in childhood with overlapping clinical features characterized by early onset stiffness and increased muscle definition with cardiac involvement. After 30 years of neurological followup, the diagnosis is finally revealed. Methods: At early ages, both had increased definition of upper trunk musculature. The older brother had hypophonic voice with raspy character, which is to our knowledge, not reported with this mutation before. He required a pacemaker for arrhythmias, while the younger developed congestive heart failure. Results: Their initial investigations failed to unveil a diagnosis, including a negative next generation sequencing (NGS) panel for AR LGMD. An expanded NGS sent on the older brother revealed he is hemizygous for 1770 bp deletion within FHL 1 gene, this deletion includes exon 7to 8, and confirmed on the other. Conclusions: First reported in 2008, FHL1 mutations result in phenotypically distinct neuromuscular disorders: X-linked myopathy with Postural Muscle Atrophy and generalized hypertrophy, X-linked dominant scapuloperoneal Myopathy, and Reducing Body Myopathy. Subsequently other phenotypes have been reported including Emery-Dreifuss muscular dystrophy and hypertrophic cardiomyopathy. Our patients present with a phenotype that had been reported with FHL1 mutation, highlighting the possible recognition of this presentation in aiding a diagnostic approach.

Background: CIDP is an autoimmune polyneuropathy. Antibodies against the Node of Ranvier have been described, NF155,NF140/186 and contactin-1. Methods: A retrospective review of patients with CIDP who tested positive for anti-nodal/paranodal antibodies via Western blot were evaluated. We have included 20 sero-negative CIDP patients. All patients met definite or probable EFNS criteria. clinical, electrophysiological data and response to treatment were obtained. Results: Forty-five patients tested positive for the antibodies. Sixteen were positive for NF155, 11 for NF140, 5 for CNTN1,11 were double positive for NF155 and NF140, and 3 were triple positive for NF155, NF140 and CNTN1.

Age of onset was similar in both seronegative (53.9 ± 3.1 yrs.) versus seropositive (52.3 ± 2.4 yrs.).

Chronic presentation manifested in 85% of seronegative, 80% of seropositive patients.Intrestingly,all triple-positive patients presented with a more acute presentation (i.e,<8 wks.)

7/20 seronegative (35%),1/16 NF155, 6/11 NF140,1/5 contactin, 2/11 of double-positive, 3/3 of triple-positive (28%,13/46) responded to IVIg. Conclusions: No major clinical or electrophysiological differences between groups. triple-positive patients showed 100% response to IVIg.These results cast doubt on the specificity of the Western blot as a clinico-electrophysiologic discriminator. Future testing with cell-based assays will likely provide a robust measure that will guide treatment decision.

Background: Neuromuscular conditions account for 1/3 of IVIg use in BC and costs over $10 million annually. Since 2013, the BC Neuromuscular Review Panel has developed diagnostic and treatment algorithms for the use of IVIg. A framework was created to review high dose and chronic users. Methods: Utilizing Central Transfusion Registry data, all patients treated with IVIg for approved neuromuscular conditions (CIDP, MG, MMN) since April 1, 2013 were identified. Annual cohorts for patients using higher than usual dose and chronic use (>3 years) were established, and evaluated annually. Patient specific recommendations were made. Results: The initial cohort identified 38 high users of 377 patients receiving IVIg. 27 appropriate, 9 “not appropriate”. Subsequent cohorts showed a decrease in number of patients receiving inappropriate IVIg doses. In BC there has been a 36% increase in neuromuscular patients treated with IVIg (377 in 2013/14 to 512 in 2016/17). Despite this, IVIg the program has effectively reduced the annual grams/patient from 516 gm/patient in 2013/14 to 489 gm/patient in 2016/17. Conclusions: The BC Neuromuscular IVIg Review confirms that the majority of IVIg use is appropriate. Following yearly cohorts of chronic and high dose users helps optimize IVIg use, which may lead to improved patient care.

Background: Recent advances in management of peripheral nerve injuries is leading to a paradigm shift in the treatment of Canadian patients. Multi-disciplinary care models provide diagnostic, surgical and rehabilitative consultations within a single clinical encounter. Involvement of allied health care professionals has been shown to improve outcome. The purpose of this study was to ascertain the distribution and composition of multidisciplinary teams, and identify regional disparities. Methods: Representatives from clinics across Canada were invited to participate in a survey at the Annual Canadian Peripheral Nerve Symposium in London, Ontario in November 2019, with telephone follow up. Results: Delegates from 17 programs responded to the survey (12 academic centre and 5 community setting). Program provides electrodiagnostic testing, neuromuscular, rehabilitation and surgical assessment. Access to the following services was reported: occupational therapy=53% (9/17), physiotherapy 29% (5/17), research assistant=17% (3/17), social work=12% (2/17), mental health=6% (1/17). Conclusions: Complex nerve injury clinics are being established throughout Canada. Allied health care and research support are limited in many multi-disciplinary complex nerve injury programs. There is variable access, likely resulting in disparities in patient care across Canada. This data will be valuable for lobbying for resources for resources to improve the care of these complex patients.

Background: An oral, fixed-dose sodium phenylbutyrate-ursodoxicoltaurine (PB-TURSO) coformulation was evaluated in a multicenter ALS trial (CENTAUR). Methods: Adults with definite ALS, ≤18 months from symptom onset, (N=137) were randomized 2:1 to PB-TURSO or placebo for 6 months. Completing participants were eligible to receive PB-TURSO in the open-label extension (OLE) (≤30 months). The primary efficacy endpoint in both periods was rate of ALS Functional Rating Scale–Revised (ALSFRS-R) total score decline. All-cause survival was analyzed July 2020 (longest follow-up, 35 months). Safety was assessed in both periods. Results: Over 6-month randomized treatment, mean ALSFRS-R total score decline was slower with PB-TURSO vs placebo (difference, 0.42 points/month; P=0.03). Participants receiving PB-TURSO in the OLE (continued or crossover from placebo) maintained or initiated functional benefit beyond 6 months of therapy. Mean hazard of death was 44% lower (P=0.02) in the original PB-TURSO group. Overall adverse event (AE) incidence was similar, though early (week ≤3) gastrointestinal AEs were more frequent during initial exposure to PB-TURSO (randomized period or OLE). Conclusions: PB-TURSO resulted in superior retention of function in the randomized period. Long-term OLE results support functional benefits of early vs delayed therapy and of sustained treatment. Survival was longer in the original PB-TURSO group after nearly 3 years.

Background: Immune-mediated neuromuscular conditions often cause significant disability and may require ongoing immunomodulating therapies such as immunoglobulin (Ig). Ig use in several neuromuscular conditions such as Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) is supported by robust evidence, however Ig is increasingly used for other disorders. In British Columbia (BC), Ig use has increased annually; last year, expenditure exceeded 51 million dollars, 35% relating to neurological disease. Within the context of the pandemic, Ig supply is at risk of shortages. Methods: A focused literature review was conducted of CIDP, Guillain-Barré Syndrome (GBS), Multifocal Motor Neuropathy (MMN), Myasthenia Gravis (MG), and other neuromuscular conditions to compare BC Ig guidelines with international best practices. Provincial recommendations for Ig use were updated accordingly. Results: Evidence-based practices include acute and chronic Ig use in CIDP and MMN, and acute or relapse-related treatment in GBS and MG. Ig may be beneficial in other treatment-refractory inflammatory disorders such as Lambert-Eaton Myasthenic Syndrome and vasculitic neuropathy. Objective outcome measures can optimize patient care and ensure appropriate resource utilization. Conclusions: Updated BC guidelines emphasize using established diagnostic criteria, objective outcome measures and minimum effective Ig doses for neuromuscular conditions. Periodic literature reviews on Ig use allow guidelines to remain evidence-based.

Background: Resident physicians often observe stroke alerts before managing them alone. However, this practice exposes patients to potential harm from trainees’ lack of experience. To address this, we created a acute stroke simulation course. Simulation training offers a low-risk environment for skill acquisition, complimenting the Royal College’s recent transition away from a time-based to competency-based learning curriculum. The purpose of this project was to develop and implement a stroke simulation training program into resident neurology rotations at the University of Saskatchewan. Methods: Six high-fidelity acute stroke simulation cases were developed with the aid of a Simulation Operation Specialist. We identified objectives corresponding to Royal College Entrustable Professional Activities for Adult Neurology encompassing several diagnostic and therapeutic goals of acute stroke care. To increase fidelity, a standardized patient was recruited and trained on how to respond to neurologic exams given a specific stroke syndrome. A standardized debrief was given after each session in a safe, non-judgemental environment. Results: Simulation sessions have been running monthly since March 25, 2021. Conclusions: The creation and implementation of high-fidelity simulation training into a resident curriculum is feasible. Ongoing data is being collected to explore residents’ experiences and knowledge improvement in stroke, and to asses local reductions in treatment delays.

Background: On DECT, the ratio of maximum iodine concentration within parenchyma compared to the superior sagittal sinus has been shown to predict hemorrhagic transformation. We aimed to determine if this ratio also predicts the development of an infarct. Methods: 53 patients with small infarct cores (ASPECTS≥7) and good endovascular recanalization (mTICI 2b/3) were enrolled. Maximum brain parenchymal iodine concentration as per DECT relative to the superior sagittal sinus (iodine ratio) was correlated with the development of an infarct on follow up CT. Results: All patients showed contrast staining, 52 developed infarcts in the area of staining. The extent of infarction (smaller, equal or larger than area of staining) did not correlate with the iodine ratio. Conclusions: Brain parenchyma with contrast staining on post-procedure head CT almost invariably goes on to infarct, however the extent of infarct development is not predicted by the intensity of contrast staining.

n=53 patients with successful recanalization of anterior circulation LVO infarct (TICI2b,3) with post procedural parenchymal iodine staining

There was no correlation between the degree of contrast staining on initial post procedural CT as expressed in iodine ratio and F/U infarct extent.

Background: Practice-changing trials of endovascular thrombectomy (EVT) for acute stroke excluded patients with pre-morbid disability. Observational studies may inform the role of EVT in this population. We performed a meta-analysis to estimate the effect of EVT in patients with pre-morbid disability. Methods: We adhered to PRISMA guidelines and searched Medline and Embase for studies describing EVT in adults with and without pre-morbid disability with stroke. Random-effects meta-analysis was used to pool outcomes, including favorable outcomes (mRS=0-2 or return to baseline), no increase in disability at 90 days, symptomatic ICH (sICH) and 90-day mortality. Results: We included 8 studies with 5570 patients (mRS 3-5=863, mRS 0-2=4,707). Patients with pre-morbid disability were more likely to return to their baseline mRS (aOR 2.53, 95% CI=1.47-4.36), although they had higher 90-day mortality (aOR=2.21, 95% CI=1.66-2.93). aOR for favorable outcome (aOR=0.83, 95% CI=0.67-1.03) or sICH (aOR=1.07, 95% CI=0.74-1.54) was not significantly different between groups. Conclusions: Observational studies suggest that EVT is safe in patients with pre-stroke disability and may result in comparable return to pre-stroke status as in patients without such disability. These findings argue against the routine exclusion of patients with pre-morbid disability from EVT and merit validation with randomized controlled trials.

Background: Evidence informing the choice between endarterectomy and stenting for acutely symptomatic carotid stenosis (“hot carotid”) is dated, and uncertainties remain regarding the optimal imaging modality. We sought to explore the thoughts of stroke physicians regarding the perioperative management of patients with acute symptomatic carotid stenosis. Methods: We conducted semi-structured interviews regarding “hot carotid” management with purposive sampling of 20 stroke physicians from 14 centres in North America, Europe, Asia, and Australia. We identified key themes using conventional qualitative content analysis. Results: Timely imaging availability, breadth of information gained, and surgeon/interventionalist preference emerged as important themes informing the choice of imaging modality. Multidisciplinary decision making, operating room/angiography suite availability, and implications of patient age and infarct size were important themes related to the choice of revascularization. Areas of uncertainty included utility of carotid plaque imaging, timing of revascularization, and the role of intervention with borderline stenosis or intraluminal thrombus. Conclusions: Our qualitative analysis revealed themes that were important to stroke experts. Teams designing international trials will have to accommodate identified variations in practice patterns and take into consideration areas of uncertainty, such as timing of revascularization, imaging of carotid plaque and non-stenotic features of carotid disease (intraluminal thrombus, plaque morphology).

Background: Whereas the beneficial effect of antiplatelet therapy for recurrent stroke prevention is well-established, uncertainties remain regarding the optimal anti-thrombotic regimen for acutely symptomatic carotid stenosis (“hot carotid”), particularly as patients await revascularization. We sought to explore the approaches of stroke physicians to peri-procedural anti-thrombotic management of patients with “hot carotids”. Methods: We conducted semi-structured interviews regarding “hot carotid” management with purposive sampling of 20 stroke physicians from 14 centres in North America, Europe, Asia, and Australia. We identified key themes using conventional qualitative content analysis. Results: Important themes revealed from our discussion included limitations of existing clinical trial evidence, competing surgeon versus neurologist/internist preferences, and single vs dual antiplatelet therapy (DAPT) while awaiting revascularization. Areas of uncertainty included the management of stroke while on aspirin, implications of non-stenotic features of carotid disease (intraluminal thrombus, plaque morphology), the role of newer anti-platelet agents or anticoagulants, platelet aggregation testing, and how soon to start DAPT. Conclusions: Our qualitative analysis revealed themes that were important to stakeholders in stroke care. Teams designing international trials will have to accommodate identified variations in anti-thrombotic practice patterns and take into consideration areas of uncertainty, such as newer anti-thrombotic agents, and the implication of non-stenotic features of carotid disease.

Background: Neonatal Arterial Ischemic Stroke (NAIS) is a common form of paediatric stroke often affecting classical language areas. The post-stroke reorganization of functional language networks may provide insight into later-emerging language deficits and may help to identify at-risk children with NAIS. Methods: A cross-sectional study of fourteen children with left (n=8; 2M; 11.1±2.2 years) or right (n=6; 3M; 12.4±4 years) middle cerebral artery (MCA) NAIS, as well as seven neurotypical children (5M; 13.4±2.7 years), was conducted. Children listened to correct/incorrect syntactic sentences while MEG was recorded, and task-related functional connectivity in the time window and frequency band of interest was determined. Language outcomes were assessed using a battery of neuropsychological tests. Results: A network-based analysis of syntactic language processing (4-7 Hz, 1.2-1.4s) revealed a dysfunctional bilateral frontal-temporal network involving language areas in patients (p=0.01). Patients with right-MCA stroke exhibited a positive correlation between left hemispheric connectivity and measures of language skill (p<0.01), resembling the neurotypical children. In left-MCA stroke patients, greater bilateral connectivity or right laterality in the language network is correlated with good outcome (p<0.05). Conclusions: Depending on the hemispheric location of stroke, certain patterns of language network reorganization may account for impairments in a bilateral frontal-temporal language subnetwork and support language outcome.

Background: Patients with acutely symptomatic carotid stenosis (“hot carotid”) have high up-front risk of recurrent strokes. Uncertainties remain regarding optimal anti-thrombotic management, particularly while awaiting revascularization with endarterectomy or stenting (CEA/CAS). Methods: We administered a worldwide electronic survey through Neurology: Clinical Practice. Respondents chose their preferred antithrombotic regimen (1) in a general case of acutely symptomatic carotid stenosis, (2) if the patient was already on aspirin, or (3) had associated intraluminal thrombus(ILT). Responses among different groups were compared using multivariable logistic regression. Results: We received 668 responses from 71 countries. Most respondents favoured CEA(69.1%) over CAS, an aspirin-containing regimen(88.5%), and a clopidogrel-containing regimen(64.4%) if already on aspirin. Monotherapy was favoured by 54.4-70.6% across scenarios. The preferred dual therapy was low-dose aspirin(75-100mg) plus clopidogrel(22.2%), or high-dose aspirin(160-325mg) plus clopidogrel if already on aspirin(12.2%). Respondents favouring CAS more often chose ≥2 agents (adjusted odds-ratio[aOR] vs CEA: 2.00, 95%CI 1.36-2.95,p=0.001) or clopidogrel-containing regimens (aOR:1.77,1.16-2.70,p=0.008). Respondents from Europe less commonly chose multiple agents (aOR vs United States/Canada: 0.57,0.35–0.93,p=0.023) while those from Asia more often favored multi-agent regimens (aOR:1.95,1.11–3.43,p=0.020). Conclusions: Our results highlight the heterogeneous anti-thrombotic management of hot carotids. Future trials should likely include high-dose aspirin monotherapy or low-dose aspirin/clopidogrel dual-therapy as a comparator arm to stimulate enrolment.

Background: Some patients do poorly despite small infarcts after endovascular therapy(EVT) whilst others with large infarcts do well. We validated exploratory findings from the ESCAPE trial regarding factors associated with such discrepancies, in the ESCAPE-NA1 trial(NCT02930018). Methods: We identified “discrepant cases” with modified Rankin Scale(mRS)≥3 despite small follow-up infarct volume(FIV≤25th-percentile) on 24-hour CT/MRI or mRS≤2 despite large FIV(volume≥75th-percentile). We compared area-under-the-curve(AUC) of pre-specified logistic models containing (a)pre-treatment factors(age/cancer/vascular risk-factors) and (b)treatment-related/post-treatment factors(serious adverse events/SAEs) in identifying small-FIV/mRS≥3 and large-FIV/mRS≤2, with stepwise regression-derived models. Results: Among 1,091 patients, 42/287(14.6%) with FIV≤7mL(25th-percentile) had mRS≥3; 65/275(23.6%) with FIV≥92mL(75th-percentile) had mRS≤2. Pre-specified pre-treatment factors(age/cancer/vascular risk-factors) were associated with FIV≤7mL/mRS≥3; stepwise models selected similar variables(similar AUCs:0.92-0.93,p=0.42). SAEs(infarct-in-new-territory/recurrent stroke/pneumonia/heart failure) were strongly associated with FIV≤7mL/mRS≥3; stepwise models also identified onset-to-needle time and hemoglobin(24-hours) as treatment-related/post-treatment factors(similar AUCs:0.92-0.94,p=0.14). Younger age was associated with FIV≥92mL/mRS≤2; stepwise models also selected diabetes absence and baseline hemoglobin(similar AUCs:0.76-0.77,p=0.82). Absence of SAEs(stroke progression/pneumonia/intracerebral hemorrhage) was strongly associated with FIV≥92mL/mRS≤2; stepwise models also identified 24-hour hemoglobin, glucose, and BP(similar AUCs:0.79-0.80,p=0.030). Conclusions: FIV-mRS discrepancies are associated with pre-treatment factors like age/comorbidities; and post-treatment complications related to stroke evolution, secondary prevention, and post-acute care quality. Optimizing thrombolysis speed, BP, glucose, and hemoglobin are modifiable factors meriting further study.

Background: Success of Endovascular Thrombectomy (EVT) requires ultra-fast access to specialized neuro imaging, neurological assessment and an angio suite with interventional radiologists. Prior access was via transport to Vancouver and outcomes were poor, with a high rate of disability or death. This appeared primarily due to long delays. Methods: Quality control process, in parallel to the introduction of a new intervention, EVT, to Vancouver Island, to determine if this intervention could be delivered with reasonable safety and good outcomes. Patients receiving EVT from May, 2016 until Sep, 2019 are included, with 90-day outcomes. Data was collected by stroke nurses. Results: The proportion of patients having a good outcome was comparable to that of the major clinical trial involving Canadian academic centres. The proportion sustaining a poor outcome was comparable to the control group in that trial population (who still received tPA treatment where possible). This was despite a median age 4.5 years greater than in that trial. Conclusions: EVT required coordination of multiple services. Victoria General Hospital performance in terms of speed to treatment was slower than in the published trials. This is a factor in determining outcome and is therefore an important quality improvement target moving forward.

Background: Canadian Stroke Best Practice Recommendations recommend both cardiac monitoring and transthoracic echocardiography (TTE) to assess for cardioembolic sources of stroke. TTE has a diagnostic yield which is historically low at 5-10%. The goal of this project was to evaluate the practicality of a bedside, focused approach to TTE in ischemic stroke. Methods: This is a cross-sectional study evaluating patients undergoing echocardiography for evidence of possible cardioembolic stroke. It compared the standard and focused TTE imaging approaches. Of the 61 patients reported, data is currently available for 15 participants. Independent samples t-test were performed to compare measurements. Results: Mean time to finish image acquisition for the focused TTE was significantly shorter than the complete TTE (12 min or less vs 30 min or more) (p<0.0001). No cardiac sources of stroke were found by either mechanism in this cohort, representing 100% agreement between the two modalities. Conclusions: Focused echocardiography studies are quicker to execute and employ more affordable, portable, digital TTE devices. The test is done at bedside, reducing the need for patient transport. Image acquisition takes approximately half the time to obtain. This potentially allows for more rapid clinical decision making and can facilitate discharge from the hospital.

Background: Dual antiplatelet therapy (DAPT) is recommended after minor ischemic stroke/ transient ischemic attack (TIA), but Clopidogrel/ Aspirin has never been compared directly to Ticagrelor/ Aspirin. Our objective is to compare these regimens in terms of efficacy and safety. Methods: Medline, Embase, and Cochrane were searched for randomized controlled trials (RCTs) that enrolled adults with minor stroke/ TIA and administered antiplatelets within 72 hours. The primary efficacy outcome is recurrent stroke or death at 90 days. We performed a Bayesian-approach NMA. Between group comparisons were presented as odds-ratios (OR) with 95% credible intervals (95%CI). Sucraplots were based on calculated probabilities of rankings for individual outcomes. Results: 9/4014 studies were included: 5 RCTs and 4 subgroup analyses. 22,098 patients were analyzed. At 90 days, both DAPT regimens were superior to Aspirin in the prevention of recurrent stroke/ death. There was no significant difference between Clopidogrel/ ASA compared to Ticagrelor/ ASA (OR 0.90 [95%CI 0.74 – 1.09]), although Clopidogrel/ Aspirin was ranked #1 using Sucraplots. There was no significant difference between the interventions for mortality, bleeding, or adverse events. Conclusions: DAPT was superior to ASA in the prevention of recurrent strokes/ death, but there was no difference between Clopidogrel/ ASA and Ticagrelor/ ASA.