Management of acute ischaemic stroke The principles of management of patients with ischaemic stroke include slowing the progression of stroke, decreasing the recurrence of stroke, decreasing death and disability, preventing deep vein thrombosis and pulmonary embolism, and suppressing fever, managing hypertension and controlling glucose levels. Pathophysiological classification of stroke Thrombosis Atherosclerosis Vasculitis Thrombophilic disorders Drug abuse such as cocaine, amphetamines Embolism From the heart From the major cerebrovascular vessels Unknown source Lipohyalinolysis Small penetrating arteries Vasospasm Migraine Subarachnoid haemorrhage Dissection Spontaneous Traumatic Antiplatelet treatment Aspirin is the only antiplatelet drug evaluated for the treatment of acute ischaemic stroke and is recommended early in the management at a dose of 160-325 mg daily. Two major randomised trials (the international stroke trial (IST) and the Chinese acute stroke trial (CAST)) have shown that starting daily aspirin promptly (< 48 hours after the start rather than the end of the hospital stay) in patients with suspected acute ischaemic stroke reduces the immediate risk of further stroke or death in hospital, and the overall risk of death and dependency at six months later. About 10 deaths or recurrent strokes are avoided in every 1000 patients treated with aspirin in the first few weeks after an ischaemic stroke. The benefit of aspirin is seen in a wide range of patients irrespective of age, sex, atrial fibrillation, blood pressure, stroke subtype, and computed tomographic findings. In IST 300 mg of aspirin was used and in CAST 160 mg. Thus, the two studies show that giving aspirin early in acute stroke is safe, although side effects should always be considered. Other trials have shown that continuing treatment with low dose aspirin gives protection in the longer term. Until further evidence is available, however, aspirin should be withheld from patients receiving other forms of anticoagulant (except low dose heparin (5000 IU twice daily)) or thrombolytic treatment (and for 24 hours after finishing treatment). Computed tomogram of the brain showing lacunar infarcts in the anterior limb of the left internal capsule The results of the IST and CAST studies apply chiefly to patients who had a computed tomography scan to exclude intracranial haemorrhage. A meta-analysis of subgroups from the trials showed that aspirin was safe and beneficial. Even among patients who did not have a computed tomogram and patients with haemorrhagic stroke, aspirin treatment did not result in net hazard. Thus, aspirin can be started in patients with suspected ischaemic stroke even when computed tomography is not available immediately. Anticoagulation treatment Heparin is not routinely recommended for patients with acute ischaemic stroke. There are no randomised trials supporting the use of standard doses of heparin (for example > 10 000 IU daily) even in patients with acute stroke and risk factors for recurrent events. The risk:benefit ratio of heparin administration is narrow, ill defined, and probably depends on the pathophysiological subtype of stroke and the factors that predispose to haemorrhage. For patients with atrial fibrillation and acute ischaemic stroke, there seems to be no net benefit from standard dose heparin (aspirin should be given immediately, then warfarin started for secondary prevention as soon as the patient is medically stable). However, a subgroup analysis from IST showed that in acute ischaemic stroke low dose heparin (5000 IU twice daily) reduced death and recurrence, especially if combined with aspirin, and it is indicated if appreciable leg weakness is present for prevention of venous thromboembolism. View larger version: In this window In a new window Thromboembolic and major haemorrhagic events in the International Stroke Trial. ICH=intracranial haemorrhage No particular benefit was observed in ischaemic stroke in the vertebrobasilar region with anticoagulation at six months. Trials with low molecular weight heparins or heparinoids have yielded contradictory (but generally negative) results, and they are not recommended for use at the moment. Thrombolytic treatment Thrombolytic treatment for acute ischaemic stroke has been in vogue since its immense benefit was seen with myocardial infarction. The National Institute of Neurological Disorders and Stroke (NINDS) rtPA Study Group trial showed that recombinant tissue plasminogen activator administered within three hours of onset of acute cerebral infarct at a dose of 0.9 mg/kg (maximum 90 mg) given over an hour under strict treatment protocols increased the likelihood of minimal or no disability at three months by at least 30%. This benefit was seen in all stroke patients. Recombinant tissue plasminogen activator is licensed for treating acute cerebral infarct in several countries. However, the risk:benefit ratio is narrow because of substantial risk of intracerebral haemorrhage, and the need to start treatment (after computed tomographic assessment) within three hours of stroke onset severely restricts the number of patients who can be treated. Cardiac disorders predisposing to stroke Major risk Atrial fibrillation Prosthetic mechanical heart valve Mitral stenosis Severe left ventricular dysfunction with mobile left ventricular thrombus Recent myocardial infarction Infective endocarditis Minor risk* Mitral annular calcification Mitral valve prolapse Patent foramen ovale Calcific aortic stenosis Atrial septal aneurysm *Occasionally can cause cardioembolic stroke, but the risk of initial stroke is low and often unrelated when identified during the evaluation of patients with cerebral ischaemia Streptokinase is not approved for use in acute cerebral infarct because of the results of three large trials, which were terminated early due to excessive bleeding. These trials used streptokinase at a dose of 1.5 million units given more than...