Drug therapy for acute ischaemic stroke: risks versus benefits

Stroke is a very common medical emergency that, until recently, had no specific treatment. Following the results of several major trials (including 2 'mega-trials'), aspirin (acetylsalicylic acid) can be recommended for the majority of patients with acute ischaemic stroke. While the benefit of aspirin is only modest, i.e. an increase of 11 per 1000 long term independent survivors, the public health benefit in the world will be substantial as this treatment could be given to millions of patients with acute ischaemic stroke each year. Heparin is associated with a reduction in early recurrent ischaemic stroke, but there is no net benefit because of a similar sized excess of recurrent haemorrhagic stroke (even for those in atrial fibrillation). Thrombolytic therapy has not been so widely tested and the results of the small trials to date have yielded conflicting results. The only positive publication to date (comprised of 2 related trials) evaluated the recombinant tissue plasminogen activator alteplase, but such treatment is probably only indicated for highly selected patients. Further trials are almost certainly required and it would be unwise to change clinical practice based on the current evidence. No other stroke treatments have been shown to be beneficial, and much larger trials will be required to confirm or refute possible moderate benefits of treatment. A well organised stroke service and participation in clinical trials will improve the future care of patients with acute ischaemic stroke.