Citicoline in Suspected Stroke: Not Recommended
Citicoline is not recommended for patients with suspected stroke as multiple clinical trials have failed to demonstrate consistent efficacy in improving outcomes. 1
Evidence Against Citicoline Use in Acute Stroke
The American Heart Association/American Stroke Association guidelines explicitly state that no agent with putative neuroprotective effects, including citicoline, can be recommended for the treatment of patients with acute ischemic stroke (Grade A recommendation) 1
The International Citicoline Trial on Acute Stroke (ICTUS), a large European multicenter randomized trial enrolling 2,298 patients with moderate to severe ischemic stroke, found no difference in the 90-day global outcome endpoint between citicoline and placebo 1
Earlier trials showed mixed results, with some post-hoc analyses suggesting potential benefit in specific subgroups, but these findings were not confirmed in subsequent definitive trials 2, 3
Recommended Acute Stroke Management
All patients with suspected acute stroke should undergo immediate brain imaging with non-contrast CT or MRI to determine stroke type and eligibility for evidence-based treatments 4
For patients with confirmed ischemic stroke within appropriate time windows, IV recombinant tissue plasminogen activator (r-tPA) is recommended if treatment can be initiated within 3 hours (Grade 1A) or 4.5 hours (Grade 2C) of symptom onset 4
Early aspirin therapy (160-325 mg) within 48 hours is recommended for patients with acute ischemic stroke who are not receiving thrombolysis 4
For patients with large vessel occlusions, endovascular thrombectomy should be considered within appropriate time windows 4
Critical Initial Assessment Steps
Rapid neurological assessment using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) 4
Initial blood work including electrolytes, random glucose, complete blood count, coagulation status (INR, aPTT), and creatinine should be conducted but should not delay imaging or treatment decisions 4
Assessment of vital signs including heart rate and rhythm, blood pressure, temperature, oxygen saturation, and hydration status 4
Why Not Citicoline?
Despite theoretical neuroprotective mechanisms such as stabilizing cell membranes and reducing free radical generation, clinical trials have not demonstrated consistent benefits 2, 3
Some smaller studies suggested potential benefits in specific subgroups or with early administration, but these findings were not replicated in larger, more definitive trials 5, 6, 7
Current stroke management guidelines focus on proven interventions such as rapid reperfusion therapy, early antiplatelet therapy, and specialized stroke unit care 4
Important Considerations
Time is critical in acute stroke management - focus should be on rapid assessment, imaging, and administration of proven therapies rather than unproven neuroprotective agents 4
The management of physiological parameters, including blood pressure control, is crucial in acute ischemic stroke care 4
Patients with suspected stroke should be treated in specialized stroke units with coordinated care by interdisciplinary teams with expertise in stroke management 4