[Therapy and prevention of cerebral ischemia]

Two large randomized studies - NINDS and ECASS - have shown that fibrinolytics, when given early enough, reduce morbidity and mortality in acute stroke. The treatment has to be initiated within three hours after onset of symptoms. In middle cerebral artery stroke, fibrinolysis can be performed within six hours from onset, guided by computed tomography criteria. Thereafter, s.c. low-molecular-weight heparin can still improve the fate of the patient. Currently, the potential benefit or harm of unfractionated heparin and aspirin is not yet known. However, large-scale studies using standard heparin, aspirin of low-molecular-weight heparin are in progress with results expected soon. After the acute stage of stroke, risk factors have to be eliminated or modified, and anticoagulants, platelet inhibitors and, in selected cases, carotid endarterectomy are useful in preventing recurrent stroke or other vascular events.