What is the recommended initial treatment for a patient hospitalized for a stroke?

Initial Treatment for Hospitalized Stroke Patients

Early aspirin therapy (160-325 mg) within 24-48 hours after stroke onset is the recommended initial treatment for patients hospitalized with acute ischemic stroke. 1

Immediate Management of Acute Stroke

• Patients with acute stroke should be evaluated and treated immediately as a life-threatening emergency 1
• Initial management should include:
  • Protection of airway, breathing, and circulation, especially in seriously ill patients 1
  • Cautious management of elevated blood pressure 1
  • Determination of stroke type (ischemic vs. hemorrhagic) through imaging 1

Antithrombotic Therapy for Ischemic Stroke

Aspirin Therapy

• Oral aspirin (initial dose 160-325 mg) should be administered within 24-48 hours after stroke onset 1
• Aspirin reduces the risk of early recurrent ischemic stroke and improves long-term functional outcomes 2
• For every 1000 patients treated with aspirin, approximately 13 people avoid death or dependency 2
• If the patient cannot swallow safely, aspirin can be administered rectally as a suppository 3

Anticoagulation

• Therapeutic parenteral anticoagulation is not recommended over aspirin therapy for most patients with acute ischemic stroke 1
• No convincing evidence supports anticoagulation over antiplatelet therapy for any subpopulation of ischemic stroke patients 1
• Anticoagulation may be considered in specific high-risk patients (e.g., mechanical heart valves or intracardiac thrombi) when hemorrhagic risk is low 1

Other Antiplatelet Agents

• Clopidogrel alone is not well established for acute ischemic stroke treatment 1
• Intravenous glycoprotein IIb/IIIa inhibitors (tirofiban, eptifibatide) are not recommended outside clinical trials 1
• The combination of aspirin and clopidogrel has shown benefit in minor stroke or high-risk TIA but carries increased bleeding risk 4

Thrombolytic Therapy

• Intravenous tissue plasminogen activator (tPA) is strongly recommended if treatment can be initiated within 3 hours of clearly defined symptom onset in carefully selected patients 1, 5
• Safe use of tPA requires adherence to selection criteria, close observation, and careful ancillary care 1

VTE Prophylaxis

• All stroke patients should be assessed for venous thromboembolism (VTE) risk 1
• High-risk patients should receive either:
  • Thigh-high intermittent pneumatic compression devices (IPC) within 24 hours of admission 1
  • Low-molecular-weight heparin (e.g., enoxaparin) for pharmacological prophylaxis 1
• Anti-embolism stockings alone are not recommended for VTE prophylaxis 1

Additional Care Measures

• Temperature monitoring every 4 hours for the first 48 hours 1
• For temperature >37.5°C, increase monitoring frequency, initiate temperature-reducing measures, and investigate possible infections 1
• Early mobilization with frequent, brief, out-of-bed activity beginning within 24 hours if no contraindications exist 1
• Swallowing assessment before oral intake to prevent aspiration 1
• Rehabilitation assessment as soon as possible after admission 1

Important Considerations

• Aspirin should not be used as a substitute for other acute interventions like intravenous tPA 1
• Administration of aspirin within 24 hours of intravenous fibrinolysis is not recommended 1
• Prophylactic use of anticonvulsant medications is not recommended unless seizures occur 1
• Early mobilization and adequate hydration should be encouraged to help prevent VTE 1