Ischaemic stroke: acute-phase drug therapy. Mostly aspirin and heparin.

(1) In the acute phase of ischaemic stroke, antiplatelet or anticoagulant treatments reduce the risk of recurrence and pulmonary embolism, but carry a risk of haemorrhagic transformation. (2) Aspirin has been tested in several placebo-controlled trials and has a positive risk-benefit balance, preventing about 5 deaths per 1000 patients with ischaemic stroke. Aspirin must be given as soon as computed tomography has ruled out intracerebral haemorrhage, unless thrombolytic treatment is planned. (3) Heparin has as many potential benefits as risks: it tends to be beneficial at low doses but harmful at high doses. Low-dose heparin therapy appears to be justified, especially for patients with emboligenic heart disease, tight carotid stenosis, or at risk of pulmonary embolism. Higher-dose heparin is only warranted for the rare patient with a high thrombotic risk. (4) Some thrombolytic drugs can reduce the frequency and severity of complications, but their use carries a high immediate risk of aggravation or death by haemorrhagic transformation. Alteplase has a somewhat positive risk-benefit balance in certain highly specific situations: for example, in some patients with persistent ischaemic stroke who are treated within three hours of onset, and without signs of severe stroke or risk factors for bleeding (high blood pressure, aspirin use). (5) Clinical trials have shown that routine use of "neuroprotective" treatments (calcium channel blockers, haemodilution, parenteral magnesium, oxygen therapy) does not reduce the risk of death or disability. (6) Arterial hypertension frequently occurs in the immediate aftermath of stroke, and then generally subsides. Few clinical trials have evaluated the use of antihypertensive drugs in this setting and there is little evidence of benefit. One trial showed that a sudden drop in blood pressure led to neurological aggravation. Antihypertensive drugs should only be used in stroke patients with severe hypertension or cardiac complications. (7) Cerebral oedema is an important cause of death after stroke: treatments (especially mannitol, mechanical ventilation and neurosurgery) have been poorly evaluated. (8) Other treatments recommended only for patients with persistent complications include oxygen therapy, antibiotics, paracetamol, insulin, and anticonvulsants. (9) A controversial meta-analysis suggested that management by a specialised multidisciplinary team reduced the mid-term risk of death and disability in comparison with management in a non specialised unit.