Antithrombotic Therapy for Cerebrovascular Disorders: Progressing Thrombotic Strokes
Progressing Thrombotic Strokes
1. Definition and occurrence: A progressing thrombotic stroke is a focal neurologic impairment attributed to thrombosis in an artery serving the brain, and exhibiting a stepwise worsening of the neurologic deficit over minutes, hours, or days following presentation. Up to 40% of patients with thrombotic stroke may exhibit such progression.
2. Prevention and therapy: Three level II randomized trials have been published. Two demonstrated favorable trends in preventing deterioration and death following oral anticoagulants, but both were small trials, and their 95% confidence limits included potential risk increased up to 80% as well as potential benefits. The third level II trial compared oral anticoagulants alone with oral anticoagulants plus streptokinase. The risk of deterioration or death was 70% higher in the group receiving streptokinase; however, the 95% confidence limits on this effect included a benefit of 23%. Reading here
3. Recommendations: Individual clinical judgment should determine whether to use anticoagulant therapy in progressing stroke. This grade B recommendation is based on 2 level II studies, each of which produced trends favoring anticoagulants.
Completed Thrombotic Strokes
1. Definition and occurrence: A completed thrombotic stroke is a stable (for at least 24 h), focal neurologic impairment attributed to thrombosis in an artery serving the brain.
2. Prevention and therapy: Eight level II trials have been completed, and their trends suggested that anticoagulants are either of no value or are harmful to patients with completed strokes. On the other hand, level I trials of aspirin in TIA suggested, on subgroup analysis, that patients who entered with residua following their qualifying TIAs benefited from aspirin therapy.
3. Recommendations: It is recommended that anticoagulant therapy not be administered to patients with completed thrombotic stroke. It is recommended that aspirin (1 g/day) should be administered to patients with completed stroke, unless they are known to have or develop GI intolerance, in which case aspirin (325 mg/day) is recommended. This grade B recommendation is based on subgroup analyses of TIA patients with residua in the level I trials of aspirin in TIA.
Category: Antithrombotic Therapy
Tags: antithrombotic therapy, cardioembolic source, cerebrovascular disorders