Citicoline Should Not Be Started for Acute Ischemic Stroke
Citicoline is not recommended for the treatment of acute ischemic stroke and should not be initiated, as major clinical guidelines explicitly state it cannot be recommended due to lack of consistent efficacy in improving patient outcomes. 1, 2
Guideline-Based Recommendation
The American Heart Association/American Stroke Association provides a Grade A recommendation against citicoline, stating that no agent with putative neuroprotective effects, including citicoline, can be recommended for treating patients with acute ischemic stroke. 1, 2 This represents the highest level of evidence strength based on multiple randomized controlled trials.
Key Evidence Against Use
The definitive International Citicoline Trial on Acute Stroke (ICTUS) enrolled 2,298 patients with moderate to severe ischemic stroke and found no difference in 90-day global outcomes between citicoline and placebo (OR 1.03,95% CI 0.86-1.25, p=0.364). 1, 2 This large European multicenter trial provides high-quality evidence that citicoline does not improve meaningful clinical outcomes.
Why Earlier Positive Studies Were Misleading
- A patient-level pooled analysis suggested benefit when citicoline was started within 24 hours of symptom onset, showing recovery in 25.2% of citicoline-treated patients versus 20.2% of placebo patients. 1, 3
- However, this post-hoc finding was not validated by the subsequent definitive ICTUS trial, which had adequate power and rigorous methodology. 1
- Multiple smaller trials showed positive trends but lacked the statistical power and methodological rigor to establish efficacy. 3, 4
What Should Be Done Instead
Focus on evidence-based acute stroke interventions that actually improve mortality and morbidity:
Immediate Priorities (First 24 Hours)
- Rapid brain imaging with non-contrast CT or MRI to determine stroke type and treatment eligibility. 2
- IV recombinant tissue plasminogen activator (r-tPA) within 3 hours (Grade 1A) or up to 4.5 hours (Grade 2C) of symptom onset for eligible patients. 2
- Endovascular thrombectomy for patients with large vessel occlusions within appropriate time windows. 2
- Early aspirin therapy (160-325 mg) within 24-48 hours for patients not receiving thrombolysis, after intracranial hemorrhage is excluded. 5, 1, 2
Blood Pressure Management
- For patients receiving thrombolysis or thrombectomy: lower BP to <185/110 mmHg before treatment and maintain <180/105 mmHg for 24 hours afterward. 5
- For patients not receiving reperfusion therapy: only lower BP if extremely elevated (>220/120 mmHg), with a modest 10-15% reduction over hours. 5
Specialized Care
- Admission to a stroke unit for coordinated interdisciplinary care, which improves outcomes. 1, 2
- Rapid neurological assessment using standardized scales (NIHSS). 2
Common Pitfall to Avoid
Do not delay proven therapies (thrombolysis, thrombectomy, antiplatelet agents) while considering unproven neuroprotective agents like citicoline. Time is brain—every minute counts in acute stroke management, and focus must remain on rapid assessment and administration of evidence-based treatments. 2