This chapter about treatment and prevention of
stroke is part of the 7th ACCP Conference on Antithrombotic and
Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al). Among the key recommendations in this chapter are the following: For patients with
acute ischemic stroke (AIS), we recommend administration of i.v.
tissue plasminogen activator (tPA), if treatment is initiated within 3 h of clearly defined symptom onset (Grade 1A). For patients with extensive and clearly identifiable hypodensity on CT, we recommend against
thrombolytic therapy (Grade 1B). For unselected patients with AIS of > 3 h but < 6 h, we suggest clinicians not use i.v. tPA (Grade 2A). For patients with AIS, we recommend against
streptokinase (Grade 1A) and suggest clinicians not use full-dose anticoagulation with i.v. or subcutaneous heparins or
heparinoids (Grade 2B). For patients with AIS who are not receiving thrombolysis, we recommend early
aspirin therapy, 160 to 325 mg qd (Grade 1A). For AIS patients with restricted mobility, we recommend prophylactic low-dose subcutaneous
heparin or low molecular weight heparins or
heparinoids (Grade 1A); and for patients who have
contraindications to
anticoagulants, we recommend use of
intermittent pneumatic compression devices or
elastic stockings (Grade 1C). In patients with acute intracerebral
hematoma, we recommend the initial use of intermittent pneumatic compression (Grade 1C+). In patients with noncardioembolic
stroke or
transient ischemic attack (TIA) [ie, atherothrombotic, lacunar or cryptogenic], we recommend treatment with an
antiplatelet agent (Grade 1A) including
aspirin, 50 to 325 mg qd; the combination of
aspirin and extended-release
dipyridamole, 25 mg/200 mg bid; or
clopidogrel, 75 mg qd. In these patients, we suggest use of the combination of
aspirin and extended-release
dipyridamole, 25/200 mg bid, over
aspirin (Grade 2A) and
clopidogrel over
aspirin (Grade 2B). For patients who are allergic to
aspirin, we recommend
clopidogrel (Grade 1C+). In patients with
atrial fibrillation and a recent
stroke or TIA, we recommend long-term oral anticoagulation (target international normalized ratio, 2.5; range, 2.0 to 3.0) [Grade 1A]. In patients with venous
sinus thrombosis, we recommend
unfractionated heparin (Grade 1B) or
low molecular weight heparin (Grade 1B) over no
anticoagulant therapy during the acute phase.