What is the treatment for a subacute cerebral infarct (stroke)?

Treatment for Subacute Cerebral Infarct (Stroke)

Aspirin (160-325 mg daily) is the cornerstone of treatment for subacute cerebral infarction, provided there are no contraindications such as allergy, gastrointestinal bleeding, or recent treatment with recombinant tissue-type plasminogen activator (rtPA). 1

Initial Management

Antiplatelet Therapy

• First-line treatment: Aspirin 160-325 mg daily
  • Start within 24-48 hours of stroke onset 1
  • Continue for at least the first 2-4 weeks 2
  • For long-term secondary prevention, doses of 75-100 mg daily are appropriate 2
  • Avoid aspirin if patient has received or will receive thrombolytic therapy until 24 hours post-thrombolysis 2

Monitoring and General Care

• Close neurological and cardiovascular monitoring in an intermediate or intensive care stroke unit 1
• Ensure sufficient cerebral oxygenation 1
• Treat hyperthermia 1
• Correct hypovolemia with isotonic fluids 1
• Avoid oral intake initially if swallowing is impaired 1
• Elevate head of bed 0-30° if increased intracranial pressure is suspected 1
• Treat hyperglycemia if blood glucose >8 mmol/l 1

Blood Pressure Management

• For non-thrombolysed patients: Upper limits of systolic BP 220 mmHg, diastolic BP 120 mmHg 1
• For thrombolysed patients: Upper limits of systolic BP 185 mmHg, diastolic BP 110 mmHg 1
• In exceptional cases with systemic hypotension causing neurological sequelae, vasopressors may be prescribed under close monitoring 1

Venous Thromboembolism Prophylaxis

• Subcutaneous low-dose heparin, low molecular weight heparin, or heparinoids for DVT prophylaxis in at-risk patients 1, 2
• Consider intermittent pneumatic compression and elastic stockings for the lower limbs 1
• Early mobilization when appropriate 2

What NOT to Do

1. Do not use full-dose anticoagulation with unfractionated heparin, LMW heparin, or heparinoids as evidence indicates it is not efficacious and may increase bleeding complications 1
2. Do not administer corticosteroids 1
3. Do not use hemodilution by volume expansion 1
4. Do not administer vasodilatory agents such as pentoxifylline 1
5. Do not use neuroprotective agents as clinical trials have produced disappointing results 1

Special Considerations

For Large Space-Occupying Infarctions

• Consider decompressive craniectomy in appropriate candidates 1
• Avoid antiplatelet agents if craniectomy is likely to be performed 1

For Specific Stroke Subtypes

• Despite theoretical benefits, IV unfractionated heparin or high-dose LMW heparin/heparinoids are not recommended for any specific stroke subtype (cardioembolic, large vessel atherosclerotic, vertebrobasilar) 1
• Even for patients with atrial fibrillation, immediate anticoagulation may have risks that outweigh benefits in the acute phase 1

Common Pitfalls to Avoid

1. Delaying aspirin administration - Should be given within 24-48 hours unless contraindicated
2. Using anticoagulation instead of antiplatelet therapy - Evidence shows no benefit and potential harm with acute anticoagulation 1
3. Inadequate DVT prophylaxis - Essential in immobile stroke patients
4. Overlooking blood pressure management - Both hypertension and hypotension can worsen outcomes
5. Neglecting swallowing assessment - Critical to prevent aspiration pneumonia

The evidence strongly supports aspirin as the mainstay of treatment for subacute cerebral infarction, with careful attention to supportive care and complication prevention. Despite theoretical benefits, anticoagulation has not been shown to improve outcomes and may increase bleeding risk.