Antithrombotic treatment of acute ischemic stroke and transient ischemic attack
- Jamary Oliveira Filho, MD, MS, PhD
Jamary Oliveira Filho, MD, MS, PhD
- Associate Professor of Neuroanatomy
- Federal University of Bahia
- Director, Neurocritical Care Unit
- Hospital Santa Izabel, Brazil
- Michael T Mullen, MD
Michael T Mullen, MD
- Assistant Professor of Neurology
- University of Pennsylvania School of Medicine
The management of patients with acute ischemic stroke involves several phases (see "Initial assessment and management of acute stroke"). The goals in the initial phase include:
●Insuring medical stability
●Determining eligibility for thrombolytic therapy (table 1)
●Moving toward uncovering the pathophysiologic basis of the stroke
Timely restoration of blood flow using thrombolytic therapy, including intravenous tissue plasminogen activator (tPA) and mechanical thrombectomy, is the most effective maneuver for salvaging ischemic brain tissue that is not already infarcted. There is a narrow window during which this can be accomplished, up to 4.5 hours after symptom onset for tPA and up to 6 hours for mechanical thrombectomy. Recommendations for patients able to receive thrombolytic therapy are found elsewhere. (See "Intravenous fibrinolytic (thrombolytic) therapy in acute ischemic stroke: Therapeutic use" and "Reperfusion therapy for acute ischemic stroke".)
- The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet 1997; 349:1569.
- CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. CAST (Chinese Acute Stroke Trial) Collaborative Group. Lancet 1997; 349:1641.
- Chen ZM, Sandercock P, Pan HC, et al. Indications for early aspirin use in acute ischemic stroke : A combined analysis of 40 000 randomized patients from the chinese acute stroke trial and the international stroke trial. On behalf of the CAST and IST collaborative groups. Stroke 2000; 31:1240.
- Sandercock PA, Counsell C, Tseng MC, Cecconi E. Oral antiplatelet therapy for acute ischaemic stroke. Cochrane Database Syst Rev 2014; :CD000029.
- Rothwell PM, Algra A, Chen Z, et al. Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials. Lancet 2016; 388:365.
- Johnston SC, Amarenco P, Albers GW, et al. Ticagrelor versus Aspirin in Acute Stroke or Transient Ischemic Attack. N Engl J Med 2016; 375:35.
- Amarenco P, Albers GW, Denison H, et al. Efficacy and safety of ticagrelor versus aspirin in acute stroke or transient ischaemic attack of atherosclerotic origin: a subgroup analysis of SOCRATES, a randomised, double-blind, controlled trial. Lancet Neurol 2017; 16:301.
- Wang Y, Wang Y, Zhao X, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med 2013; 369:11.
- Wang Y, Zhao X, Lin J, et al. Association Between CYP2C19 Loss-of-Function Allele Status and Efficacy of Clopidogrel for Risk Reduction Among Patients With Minor Stroke or Transient Ischemic Attack. JAMA 2016; 316:70.
- Dengler R, Diener HC, Schwartz A, et al. Early treatment with aspirin plus extended-release dipyridamole for transient ischaemic attack or ischaemic stroke within 24 h of symptom onset (EARLY trial): a randomised, open-label, blinded-endpoint trial. Lancet Neurol 2010; 9:159.
- Kennedy J, Hill MD, Ryckborst KJ, et al. Fast assessment of stroke and transient ischaemic attack to prevent early recurrence (FASTER): a randomised controlled pilot trial. Lancet Neurol 2007; 6:961.
- Wong KS, Wang Y, Leng X, et al. Early dual versus mono antiplatelet therapy for acute non-cardioembolic ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis. Circulation 2013; 128:1656.
- Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med 2011; 365:993.
- Derdeyn CP, Chimowitz MI, Lynn MJ, et al. Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial. Lancet 2014; 383:333.
- Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trial http://clinicaltrials.gov/ct2/show/NCT00991029 (Accessed on July 02, 2013).
- Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) http://clinicaltrials.gov/show/NCT01661322 (Accessed on July 02, 2013).
- Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 2004; 364:331.
- Lansberg MG, O'Donnell MJ, Khatri P, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e601S.
- Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870.
- National Institute for Health and Clinical Excellence. Stroke: The diagnosis and acute management of stroke and transient ischaemic attacks. Royal College of Physicians, London 2008. http://www.nice.org.uk/CG068 (Accessed on February 01, 2011).
- Berge E, Sandercock P. Anticoagulants versus antiplatelet agents for acute ischaemic stroke. Cochrane Database Syst Rev 2002; :CD003242.
- Camerlingo M, Salvi P, Belloni G, et al. Intravenous heparin started within the first 3 hours after onset of symptoms as a treatment for acute nonlacunar hemispheric cerebral infarctions. Stroke 2005; 36:2415.
- Sandercock PA, Counsell C, Kane EJ. Anticoagulants for acute ischaemic stroke. Cochrane Database Syst Rev 2015; :CD000024.
- Whiteley WN, Adams HP Jr, Bath PM, et al. Targeted use of heparin, heparinoids, or low-molecular-weight heparin to improve outcome after acute ischaemic stroke: an individual patient data meta-analysis of randomised controlled trials. Lancet Neurol 2013; 12:539.
- Low molecular weight heparinoid, ORG 10172 (danaparoid), and outcome after acute ischemic stroke: a randomized controlled trial. The Publications Committee for the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. JAMA 1998; 279:1265.
- Adams HP Jr, Bendixen BH, Leira E, et al. Antithrombotic treatment of ischemic stroke among patients with occlusion or severe stenosis of the internal carotid artery: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 1999; 53:122.
- Wong KS, Chen C, Ng PW, et al. Low-molecular-weight heparin compared with aspirin for the treatment of acute ischaemic stroke in Asian patients with large artery occlusive disease: a randomised study. Lancet Neurol 2007; 6:407.
- Kay R, Wong KS, Yu YL, et al. Low-molecular-weight heparin for the treatment of acute ischemic stroke. N Engl J Med 1995; 333:1588.
- Diener HC, Ringelstein EB, von Kummer R, et al. Treatment of acute ischemic stroke with the low-molecular-weight heparin certoparin: results of the TOPAS trial. Therapy of Patients With Acute Stroke (TOPAS) Investigators. Stroke 2001; 32:22.
- Bath PM, Lindenstrom E, Boysen G, et al. Tinzaparin in acute ischaemic stroke (TAIST): a randomised aspirin-controlled trial. Lancet 2001; 358:702.
- Paciaroni M, Agnelli G, Micheli S, Caso V. Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials. Stroke 2007; 38:423.
- Rödén-Jüllig A, Britton M. Effectiveness of heparin treatment for progressing ischaemic stroke: before and after study. J Intern Med 2000; 248:287.
- Toth C, Voll C. Validation of a weight-based nomogram for the use of intravenous heparin in transient ischemic attack or stroke. Stroke 2002; 33:670.
- Thijs VN, Lansberg MG, Beaulieu C, et al. Is early ischemic lesion volume on diffusion-weighted imaging an independent predictor of stroke outcome? A multivariable analysis. Stroke 2000; 31:2597.
- Fink JN, Selim MH, Kumar S, et al. Is the association of National Institutes of Health Stroke Scale scores and acute magnetic resonance imaging stroke volume equal for patients with right- and left-hemisphere ischemic stroke? Stroke 2002; 33:954.
- ANTIPLATELET AGENTS
- Combination antiplatelets
- Choosing early antiplatelet therapy
- PARENTERAL ANTICOAGULATION
- Stroke subtypes
- - Atrial fibrillation and cardioembolic stroke
- Progressing stroke
- Role of early anticoagulation
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS