Thromboembolism and antithrombotic therapy in cerebrovascular disease

The use of antithrombotic therapy of any type assumes a thrombotic mechanism for the patient's brain ischemia. Typical, but by no means specific, clinical and radiologic features of atherothrombotic, lacunar and embolic brain ischemia are outlined. The indications for anticoagulant therapy include progressing stroke and cardiogenic brain embolus. According to previous randomized trials, transient ischemic attacks should be managed with aspirin, 1.0 to 1.5 g daily, pending the results of studies of smaller aspirin doses and other platelet-active drugs. In patients with a suspected cardiogenic brain embolus, anticoagulation should be withheld pending the results of a computed tomographic scan done 24 to 48 hours from onset. If there is no evidence of hemorrhagic transformation or a large area of infarction and the patient does not have sustained hypertension, heparin therapy should be initiated in an effort to prevent a recurrent embolus.