The investigators will conduct an open-label randomized controlled trial between October 2022 and June 2023 after approval of the ethical committee of the faculty of medicine at Kafr el-sheik University.~The investigators got written informed consent from all eligible patients or their first order of kin before randomization.~The study will be composed of 2 arms, the ticagrelor arm consisted of 150 patients who received (a 180 mg loading dose during the first 12 hours of stroke onset followed by 90 mg b.i.d from the 2nd to the 90th day), and the Clopidogrel arm consisted of 150 patients, who received (a 300 mg loading dose during the first 12 hours of stroke onset followed by 75 mg once daily from the 2nd day to the 90th day), All the patients in the two groups received open-label aspirin at a loading dose of 75 to 300 mg, followed by 75 mg daily for 21 days.~Study Procedures:~Every patient in our study will undergo:~clinical workup: History and clinical assessment & NIHSS recorded on admission, day 2 and day 7 and Modified Rankin Scale as a follow-up after one week and after 3 months.~Detection of Risk Factors & Profiles:~Echocardiography& TOE: in indicated patients~ECG Monitoring: daily ECG monitoring will be performed in indicated patients. 3- Carotid Duplex: carotid duplex in indicated patients.~4- ESR & Lipid Profile& liver functions: All will be tested routinely for all patients.~Imaging Follow UP~Non-contrast CT brain on admission~Day 2 MRI: after 2 days of admission all the patients in this study will have a brain MRI (stroke protocol; T1W, T2W, FLAIR, DWI, T2 Echo Gradient, MRA of all intra-cerebral vessels).~CT brain: Any patient with unexplained clinical deterioration at any time throughout his/her hospital stay will be urgently imaged by CT.~Primary End Point: efficacy of treatment assessed by~NIHSS: All patients will be assessed with NIHSS, on admission, second day, after 1 week and / or on discharge. Patients admitted for less than 1 week will be assessed only on discharge. The improvement will be counted only if there is a decrease in NIHSS score by 4 points or more~Infarct Size Expansion: in case of clinical deterioration of the patient, the infarction size difference between 1st MRI and follow-up MRI diffusion studies will be calculated.~Modified Rankin Scale: this will be a parameter for the patient's outcome, assessed at the end of one week and 3 months and we will categorize stroke as follows fatal stroke [stroke with the subsequent score on the modified Rankin scale of 6], severe stroke [stroke with the subsequent score on the modified Rankin scale of 4 or 5], moderate stroke [stroke with the subsequent score on the modified Rankin scale of 2 or 3], mild stroke [stroke with the subsequent score on the modified Rankin scale of 0 or 1], TIA, and no stroke or TIA)~Hospital Stay: Total hospital stay will be calculated in days for all patients. Additional analysis will involve the time of admission at ICU and ward, Neurological Critical Unit, Stroke ward unit, or ICU referral.~new ischemic stroke at 90 days~Mortality: Timing and cause will be assessed during three months~Secondary End Point:~Safety of ticagrelor versus clopidogrel is the primary interest of this study, this will be assessed in both central hemorrhagic transformation, and other probable side effects; as follows:~Hemorrhagic transformation of the Infarct: was determined by performing a follow-up C.T. brain scan after two days and after one week or discharge and at 90 days to detect the haemorrhage; additionally, the European cooperative acute stroke study (ECASS) classification14 was used to detect the type of hemorrhagic transformation.~Complication Survey & Other Adverse Manifestations:~Peripheral Bleeding: assessed by the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) criteria throughout 90 days~Drug Allergy: All suspected allergic reactions will be reported.~GIT upset & Diarrhea: Both will be specifically assessed in all patients.
Along with the current clinical trial, the efficacy and safety of 180 mg loading dose of ticagrelor administered within 12 hours of first-ever ischemic stroke compared to 300 mg clopidogrel were assessed through NIHSS, mRS, duration of hospital stay, and possible adverse effects.