What is the appropriate treatment for a patient with a history of stroke, presenting with right-sided weakness, hypertension, and an allergy to aspirin (acetylsalicylic acid)?

Treatment for Acute Ischemic Stroke with Aspirin Allergy

For this patient with acute ischemic stroke and aspirin allergy, clopidogrel 75 mg daily is the appropriate treatment. 1, 2

Rationale for Clopidogrel

The American Heart Association/American Stroke Association explicitly recommends clopidogrel (75 mg daily) as a reasonable alternative for patients with extracranial cerebrovascular atherosclerosis in whom aspirin is contraindicated by factors including allergy (Class IIa, Level of Evidence C). 1, 2

• Clopidogrel has a comparable overall safety profile to aspirin, with lower gastrointestinal bleeding risk and fewer gastrointestinal symptoms 2
• No routine laboratory monitoring is required, unlike warfarin 2
• The drug should be initiated immediately for secondary stroke prevention 2

Why Other Options Are Incorrect

Anticoagulation (Heparin/Warfarin) - Options C & D

Full-intensity parenteral anticoagulation with unfractionated heparin is explicitly NOT recommended for patients with extracranial cerebrovascular atherosclerosis who develop acute ischemic stroke (Class III: No Benefit, Level of Evidence B). 1

• Antiplatelet agents are recommended rather than oral anticoagulation for patients with atherosclerosis of the extracranial carotid or vertebral arteries with ischemic symptoms (Class I, Level of Evidence B) 1
• Warfarin would only be considered if this patient had atrial fibrillation or a mechanical prosthetic heart valve—neither of which is mentioned in this case 1

Thrombolysis (Streptokinase) - Option E

• Streptokinase is not indicated for this patient who presents with established stroke and a hypodense lesion on CT, indicating the stroke is not hyperacute 1
• The CT finding of hypodensity suggests the stroke is beyond the acute thrombolysis window 1

Carotid Endarterectomy (CEA) - Option A

CEA is only indicated for symptomatic patients when the internal carotid artery diameter is reduced by more than 70% on noninvasive imaging or more than 50% on catheter angiography (Class I, Level of Evidence A). 1

• This patient requires vascular imaging first to determine stenosis severity before considering CEA 1
• Medical management with antiplatelet therapy must be initiated regardless of whether revascularization is eventually pursued 1

Critical Safety Consideration

Do NOT add aspirin to clopidogrel in this patient—the combination increases major hemorrhage risk without significant benefit for stroke prevention (Class III, Level of Evidence A). 1, 2

• The MATCH trial demonstrated a 1.3% absolute increase in life-threatening bleeding with combination therapy compared to clopidogrel alone, with no reduction in ischemic events 1, 2

Blood Pressure Management

• The patient's BP of 160/100 mmHg should be managed cautiously in the acute stroke setting, but this is secondary to initiating antiplatelet therapy 1