Last updated March 15, 2022

Antithrombotic And Thrombolytic Therapy For Ischemic Stroke

Recommendations

Acute Ischemic Stroke Treatment

In patients with acute ischemic stroke in whom treatment can be initiated within 3 h of symptom onset, we recommend IV r-tPA over no IV r-tPA. (1, A)
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In patients with acute ischemic stroke in whom treatment can be initiated within 4.5 h but not within 3 h of symptom onset, we suggest IV r-tPA over no IV r-tPA. (2, C)
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In patients with acute ischemic stroke in whom treatment cannot be initiated within 4.5 h of symptom onset, we recommend against IV r-tPA.

(1, B)
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In patients with acute ischemic stroke due to proximal cerebral artery occlusions who do not meet eligibility criteria for treatment with IV r-tPA, we suggest intraarterial (IA) r-tPA initiated within 6 h of symptom onset over no IA r-tPA. (2, C)
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In patients with acute ischemic stroke we suggest IV r-tPA over the combination IV/IA r-tPA. (2, C)
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In patients with acute ischemic stroke, we suggest against the use of mechanical thrombectomy. (2, C)
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In patients with acute ischemic stroke or TIA, we recommend early (within 48 h) aspirin therapy at a dose of 160 to 325 mg over no aspirin therapy. (1, A)
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In patients with acute ischemic stroke or TIA, we recommend early (within 48 h) aspirin therapy with an initial dose of 160 to 325 mg over therapeutic parenteral anticoagulation. (1, A)
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VTE Prevention in Ischemic and Hemorrhagic Stroke

In patients with acute ischemic stroke and restricted mobility, we suggest prophylactic- dose subcutaneous heparin (UFH or LMWH) or intermittent pneumatic compression devices over no prophylaxis. (2, B)
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In patients with acute ischemic stroke and restricted mobility, we suggest prophylactic-dose LMWH over prophylactic-dose UFH. (2, B)
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In patients with acute stroke and restricted mobility, we suggest against elastic compression stockings. (2, B)
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In patients with acute primary intracerebral hemorrhage and restricted mobility, we suggest prophylactic-dose subcutaneous heparin  (UFH or LMWH) started between days 2 and 4 or intermittent pneumatic compression devices over no prophylaxis. (2, C)
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In patients with acute primary intracerebral hemorrhage and restricted mobility, we suggest prophylactic-dose LMWH over prophylactic-dose UFH. (2, B)
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In patients with primary intracerebral hemorrhage and restricted mobility, we suggest against elastic compression stockings. (2, B)
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Secondary Stroke Prevention

In patients with a history of noncardioembolic ischemic stroke or TIA,
we recommend  long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/ extended release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet therapy, (1, A)
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  • oral anticoagulants,
(1, B)
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  • the combination of clopidogrel plus aspirin
(1, B)
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  • or triflusal.
(2, B)
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Of the recommended antiplatelet regimens,
we suggest clopidogrel or aspirin/extended-release dipyridamole over aspirin (2, B)
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  • or cilostazol.
(2, C)
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In patients with a history of ischemic stroke or TIA and AF, including paroxysmal AF,
we recommend oral anticoagulation over no antithrombotic therapy, (1, A)
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  • aspirin,
(1, B)
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  • or combination therapy with aspirin and clopidogrel.
(1, B)
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In patients with a history of ischemic stroke or TIA and AF, including paroxysmal AF, we suggest oral anticoagulation with dabigatran 150 mg bid over adjusted-dose VKA therapy (target INR range, 2.0 to 3.0). (2, B)
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In patients with a history of ischemic stroke or TIA and AF, including paroxysmal AF, who are unsuitable for or choose not to take an oral anticoagulant (for reasons other than concerns about major bleeding), we recommend combination therapy with aspirin and clopidogrel over aspirin. (1, B)
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In patients with a history of a symptomatic primary ICH, we suggest against the longterm use of antithrombotic therapy for the prevention of ischemic stroke. (2, C)
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Cerebral Venous Sinus Thrombosis

In patients with cerebral venous sinus thrombosis, we suggest anticoagulation over no anticoagulant therapy during the acute and chronic phases. (2, C)
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Recommendation Grading

Overview

Title

Antithrombotic And Thrombolytic Therapy For Ischemic Stroke

Authoring Organization

Publication Month/Year

February 1, 2012

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This article provides recommendations on the use of antithrombotic therapy in patients with stroke or transient ischemic attack (TIA).

Target Patient Population

Patients with stroke or transient ischemic attack (TIA).

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D000925 - Anticoagulants, D000991 - Antithrombins, D020521 - Stroke, D002546 - Ischemic Attack, Transient

Keywords

stroke, Stroke Prevention, Transient Ischemic Attack, Antithrombotic Agents, Acute Ischemic Stroke