Is aspirin 300mg indicated for ischemic stroke?

Aspirin 300mg in Acute Ischemic Stroke Management

Aspirin 300mg is indicated for acute ischemic stroke within 24-48 hours of symptom onset, provided there are no contraindications and the patient is not receiving thrombolytic therapy. 1

Evidence-Based Recommendations

Timing and Dosing

• Aspirin should be administered within 24-48 hours after stroke onset 1
• Dosage range of 160-300mg is supported by high-quality evidence 1
• The 300mg dose specifically was evaluated in the International Stroke Trial and showed benefit 1

Clinical Benefits

• Reduces risk of early recurrent ischemic stroke 1, 2
• Decreases mortality and dependency at follow-up 2
• For every 1000 patients treated with aspirin:
  • 13 more patients will be alive and independent at follow-up 2
  • 10 more patients will make a complete recovery 3
  • 7 fewer recurrent ischemic strokes will occur 3

Important Precautions

• Aspirin should NOT be used as a substitute for thrombolytic therapy in eligible patients 1
• Administration should be delayed until 24 hours after IV alteplase (thrombolysis) 1
• Brain imaging must be performed before administration to exclude intracranial hemorrhage 1

Administration Considerations

Route of Administration

• Oral administration is preferred if the patient can swallow safely
• For patients with dysphagia:
  • Rectal administration (suppository) is appropriate 1, 4
  • Nasogastric tube administration is an option 2

Bleeding Risk

• Small but significant increase in risk of:
  • Symptomatic intracranial hemorrhage (approximately 2 per 1000 patients treated) 3
  • Systemic hemorrhage 1
• This risk is outweighed by the benefits in reduction of recurrent stroke and improved outcomes 2, 3

Algorithm for Decision-Making

1. Confirm ischemic stroke diagnosis with brain imaging
2. Determine if patient is eligible for thrombolysis:
   • If YES: Administer thrombolysis first, then start aspirin after 24 hours
   • If NO: Proceed to step 3
3. Check for contraindications to aspirin:
   • Active bleeding
   • Known aspirin allergy
   • Recent gastrointestinal bleeding
4. If no contraindications, administer aspirin 300mg:
   • Within 24-48 hours of symptom onset
   • Choose appropriate route based on swallowing ability

Special Considerations

• The benefit of aspirin appears primarily related to prevention of early recurrent events rather than limiting neurological consequences of the initial stroke 1
• While some guidelines have moved away from specifying the exact dose, the evidence specifically supports doses between 160-300mg 1
• The 2018 AHA/ASA guidelines removed the specific 325mg dosing recommendation that was in previous guidelines, acknowledging that clinical trials supporting aspirin use included doses of 160-300mg 1

Aspirin 300mg represents a well-established, evidence-based intervention that provides a modest but significant benefit in reducing mortality and disability following acute ischemic stroke.