Prescrire Int. 2005 Aug;14(78):146-52.
(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.
(1) 在缺血性卒中急性期，抗血小板或抗凝治疗可降低复发风险和肺栓塞风险，但有出血性转化风险。(2) 阿司匹林已在多项安慰剂对照试验中得到验证，其风险效益比为正，每1000例缺血性卒中患者中可预防约5例死亡。一旦计算机断层扫描排除脑内出血，应立即给予阿司匹林，除非计划进行溶栓治疗。(3) 肝素的潜在益处和风险一样多：低剂量时往往有益，高剂量时则有害。低剂量肝素治疗似乎是合理的，特别是对于有栓塞性心脏病、严重颈动脉狭窄或有肺栓塞风险的患者。高剂量肝素仅适用于极少数血栓形成风险高的患者。(4) 一些溶栓药物可降低并发症的发生率和严重程度，但其使用会带来因出血性转化而导致病情加重或死亡的高即时风险。阿替普酶在某些高度特定的情况下风险效益比略有正值：例如，在一些持续性缺血性卒中患者中，发病3小时内接受治疗，且无严重卒中体征或出血风险因素（高血压、使用阿司匹林）。(5) 临床试验表明，常规使用“神经保护”治疗（钙通道阻滞剂、血液稀释、胃肠外给予镁、氧疗）并不能降低死亡或残疾风险。(6) 动脉高血压常在卒中后立即出现，随后一般会消退。很少有临床试验评估在这种情况下使用抗高血压药物，几乎没有证据表明有益。一项试验表明，血压突然下降会导致神经功能恶化。抗高血压药物仅应用于有严重高血压或心脏并发症的卒中患者。(7) 脑水肿是卒中后死亡的重要原因：对治疗（尤其是甘露醇、机械通气和神经外科手术）的评估不足。(8) 其他仅推荐用于有持续性并发症患者的治疗包括氧疗、抗生素、对乙酰氨基酚、胰岛素和抗惊厥药。(9) 一项有争议的荟萃分析表明，与在非专科病房管理相比，由专业多学科团队管理可降低中期死亡和残疾风险。
