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Background Emergent carotid artery stenting (eCAS) is increasingly used in acute stroke due to tandem occlusion. However, the optimal timing for initiating dual antiplatelet therapy (DAPT) remains unknown. We analyze the effectiveness and safety of early versus delayed initiation of DAPT in a cohort of patients with acute stroke treated with eCAS.Methods Multicenter registry of patients treated with eCAS from 2019 to 2023. Main outcomes were stent occlusion/restenosis during follow-up, symptomatic intracranial hemorrhage (sICH) after DAPT, and good functional outcome at 3 months (modified Rankin scale (mRS) 0–2). Two timeframes for early DAPT initiation were considered: <12 hours after the procedure, and <24 hours. DAPT beyond 24 hours was considered as reference.Results 309 patients were included, 215 males (69.6%), mean (SD) age 67 (12.8) years. DAPT was initiated after eCAS in 270 patients (87.4%), <12 hours in 98 (36.3%), <24 hours in 198 (73.3%), and >24 hours in 72 (26.7%). At 3 months follow-up, stent occlusion/restenosis occurred in 25 patients (12.3%), and sICH after DAPT in 8 patients (3%); 141 (58%) achieved mRS 0–2. Early DAPT did not modify the risk of stent occlusion/restenosis: OR for DAPT <12 hours and DAPT <24 hours: 0.82 (95% CI 0.28 to 2.41) and 0.94 (95% CI 0.37 to 2.40), respectively, or sICH (OR 2.08 (95% CI 0.21 to 20.48) and 2.42 (95% CI 0.29 to 20.03)). Similarly, early DAPT did not improve the likelihood of mRS 0–2 (OR 1.76 (95% CI 0.92 to 3.69) and OR 1.30 (95% CI 0.74 to 2.28)).Conclusions In this study, early DAPT initiation following eCAS did not modify the risk of late stent occlusion/restenosis, sICH, or the chance of achieving a good outcome at 3 months.