Thursday, June 4, 2015

Management of Ischemic Stroke: Alteplase(tPA), Aspirin and Warfarin

In all patients with symptoms of stroke, a head CT without contrast should be obtained as soon as possible to rule out hemorrhage, as hemorrhagic and ischemic stroke are treated differently. Once hemorrhage is ruled out, fibrinolytic therapy should be considered. Intravenous alteplase (tPA) has been shown to improve outcomes in victims of ischemic stroke when given within 3 to 4.5 hours of symptom onset. The sooner tPA is administered, the better the outcome. Antiplatelet therapy with aspirin is indicated in all victims of ischemic stroke who are not candidates for fibrinolytic therapy. Aspirin has proven benefits for both primary and secondary stroke prevention. However, it should not be used as a substitute for fibrinolytic therapy as it does not confer the same benefits for neurologic recovery. In patients who do receive fibrinolytic therapy, aspirin should be held for 24 hours. Urgent anticoagulation with heparin is not recommended for acute ischemic stroke, even when the etiology is cardioembolic, because of the increased risk for intracerebral hemorrhage. However, anticoagulation with warfarin can be started two weeks after an acute cardioembolic stroke to prevent recurrence.
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