What are the medications used to treat stroke?

Medications for Stroke Treatment

For acute ischemic stroke, intravenous recombinant tissue plasminogen activator (r-tPA) is the primary medication when treatment can be initiated within 3-4.5 hours of symptom onset, followed by antiplatelet therapy with aspirin within 24-48 hours. 1

Acute Ischemic Stroke Medications

Thrombolytic Therapy

• IV r-tPA (Alteplase):
  • First-line treatment for eligible patients
  • Dosing: 0.9 mg/kg (maximum 90 mg) with 10% given as bolus and 90% as infusion over 60 minutes 1
  • Time windows:
    • Strong recommendation within 3 hours of symptom onset (Grade 1A) 1
    • Suggested use between 3-4.5 hours (Grade 2C) 1
    • Not recommended beyond 4.5 hours (Grade 1B) 1
  • Contraindicated in patients with active bleeding or severe hypersensitivity reactions

Intraarterial Therapy

• Intraarterial r-tPA:
  • For patients ineligible for IV r-tPA with proximal cerebral artery occlusions
  • Must be initiated within 6 hours of symptom onset (Grade 2C) 1
  • Available only at specialized centers

Antiplatelet Therapy

• Aspirin:

  • Start within 24-48 hours of stroke onset at 160-325 mg (Grade 1A) 1
  • For patients receiving r-tPA, delay aspirin for 24 hours and after follow-up imaging confirms no hemorrhage 2
  • Continue long-term at 75-100 mg daily for secondary prevention 1

• Dual Antiplatelet Therapy for Minor Stroke/TIA:

  • For minor stroke (NIHSS ≤3) or high-risk TIA:
    • Clopidogrel loading dose (300-600 mg) plus aspirin (160-325 mg) 2
    • Start within 24 hours of symptom onset
    • Continue for 21-30 days only, then switch to monotherapy 2
    • Not recommended for moderate-to-severe strokes due to bleeding risk

Secondary Prevention Medications

Antiplatelet Agents

• Preferred options for non-cardioembolic stroke (Grade 1A) 1:

  • Clopidogrel (75 mg daily)
  • Aspirin/extended-release dipyridamole (25 mg/200 mg twice daily)
  • Aspirin (75-100 mg daily)
  • Cilostazol (100 mg twice daily)

• Preferred hierarchy (Grade 2B) 1:

  1. Clopidogrel or aspirin/extended-release dipyridamole
  2. Aspirin
  3. Cilostazol

Anticoagulation

• For stroke with atrial fibrillation (Grade 1B) 1:
  • Oral anticoagulation strongly recommended over:
    • No antithrombotic therapy
    • Aspirin alone
    • Combination of aspirin and clopidogrel
  • Direct oral anticoagulants (e.g., dabigatran) suggested over vitamin K antagonists 1
  • Typically initiated 1-2 weeks after stroke onset depending on stroke size and bleeding risk

Venous Thromboembolism Prophylaxis

• For patients with restricted mobility:
  • Prophylactic-dose LMWH preferred over UFH (Grade 2B) 1
  • Intermittent pneumatic compression devices as alternative (Grade 2B) 1
  • Elastic compression stockings not recommended (Grade 2B) 1

Important Clinical Considerations

Timing Considerations

• Door-to-needle time for r-tPA:
  • Target less than 60 minutes in 90% of patients 1
  • Median target of 30 minutes 1
  • Delays more common with early-presenting patients 3 - be vigilant about treating these patients promptly

Bleeding Risk Management

• Monitor for hemorrhagic transformation after thrombolysis
• Symptomatic intracerebral hemorrhage occurs in approximately 6.4% of r-tPA patients vs 0.6% with placebo 4
• For patients on DOACs, r-tPA is not routinely recommended due to bleeding risk 1

Common Pitfalls

1. Delaying treatment while waiting for additional tests - prioritize rapid CT and r-tPA administration when indicated
2. Inappropriate anticoagulation - routine anticoagulation with heparin is not recommended for acute ischemic stroke (Grade A) 1
3. Extending dual antiplatelet therapy beyond 30 days - increases bleeding risk without additional benefit 2
4. Overlooking atrial fibrillation - these patients require anticoagulation rather than antiplatelet therapy
5. Using combination clopidogrel plus aspirin long-term in non-cardioembolic stroke - not recommended due to bleeding risk (Grade 1B) 1

By following these evidence-based medication protocols for stroke management, clinicians can optimize patient outcomes while minimizing complications.