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Antithrombotic strategy in stroke
1Service de Neurologie, Hĵpital Lariboisière, Paris, France. marie-germaine.bousser@lrb.ap-hop-paris.fr
Insights
Evidence-based antithrombotic strategies are crucial for stroke prevention and treatment. Aspirin is recommended for atherothrombotic stroke and acute treatment, while anticoagulants are used for cardioembolic stroke.
Area of Science:
- Neurology
- Cardiology
- Pharmacology
Background:
- Antithrombotic therapy is vital for managing ischemic stroke, but carries a risk of intracranial hemorrhage.
- Stroke management strategies vary based on etiology and acute treatment options.
Purpose of the Study:
- To outline evidence-based antithrombotic strategies for stroke prevention and acute treatment.
- To provide recommendations based on numerous randomized controlled trials.
Main Methods:
- Review of randomized controlled trials (RCTs) on antithrombotic therapy in stroke.
- Analysis of treatment strategies based on stroke etiology (atherothrombotic vs. cardioembolic).
- Evaluation of acute treatment protocols, including intravenous thrombolysis (IV rt-PA) and antiplatelet/anticoagulant use.
Main Results:
- Aspirin is the first-choice antiplatelet for atherothrombotic stroke prevention.
- Oral anticoagulants are recommended for cardioembolic stroke prevention.
- Intravenous rt-PA is recommended within 3 hours for acute ischemic stroke if criteria are met; otherwise, aspirin is the choice.
- Low-dose low-molecular-weight heparin (LMWH) may be used with aspirin for immobile patients.
- High-dose heparin or LMWH lacks efficacy in stroke, except for cerebral venous thrombosis.
Conclusions:
- Antithrombotic strategies are tailored to stroke type and acute presentation.
- Careful patient selection and adherence to guidelines are essential for effective and safe stroke treatment.
- Further research may refine optimal antithrombotic approaches in specific stroke subtypes.
Abstract:
Numerous randomised controlled trials have been devoted to antithrombotic strategy in stroke, thus making evidence-based recommendations possible. The use of antithrombotic drugs is crucial in the treatment of ischemic stroke though often limited by the inherent risk of intra-cerebral bleeding. In the prevention of stroke, the strategy depends on the underlying etiology: (i) antiplatelet drugs (with aspirin as first choice) in atherothrombotic stroke, and (ii) oral anticoagulants in cardioembolic stroke. In the acute treatment, the strategy depends on whether IV rt-PA can be performed; if rt-PA is available and approved, its use is recommended within 3 h of the onset of symptoms provided there is strict adherence to the inclusion and exclusion criteria. In all other cases, aspirin is the treatment of choice, associated with low dose LMWH in the event of restricted mobility. There is no evidence for efficacy of high dose heparin (or LMWH) in stroke, except in cerebral venous thrombosis.