Do you start aspirin (acetylsalicylic acid) for a patient presenting with stroke-like symptoms?

Aspirin for Stroke-Like Symptoms

Yes, administer aspirin 160-325 mg immediately for patients presenting with stroke-like symptoms, but only after brain imaging excludes intracranial hemorrhage and the patient has not received IV thrombolysis within the past 24 hours. 1, 2, 3

Critical Pre-Administration Requirements

Before giving aspirin, you must:

• Obtain brain imaging (CT or MRI) to exclude hemorrhagic stroke - aspirin cannot be given until hemorrhage is ruled out 2, 3
• Confirm the patient did NOT receive IV thrombolysis (tPA) within 24 hours - administering aspirin within 24 hours of thrombolytic therapy significantly increases risk of serious intracranial bleeding 2
• Perform dysphagia screening - ensure safe swallowing before oral administration 3
• Check for aspirin contraindications - active gastrointestinal bleeding or documented aspirin allergy 1

Acute Dosing Protocol

Loading dose: 160-325 mg aspirin immediately after imaging confirms ischemic stroke 1, 3, 4

• The American Heart Association/American Stroke Association specifically recommends 160-325 mg within 24-48 hours of symptom onset 1, 3
• Non-enteric coated formulation is preferred for faster buccal absorption 1
• This reduces stroke mortality and morbidity with a number needed to treat of 79 to prevent one death or dependency 1, 5

Alternative Routes for Dysphagia

If the patient cannot swallow safely:

• Enteral tube: 80-81 mg daily 3
• Rectal suppository: 325 mg daily 3, 4

Evidence for Immediate Aspirin

The recommendation is based on two landmark trials (CAST and IST) involving 40,000 patients, which demonstrated:

• 7 per 1,000 reduction in recurrent ischemic stroke 6
• 4 per 1,000 reduction in death without further stroke 6
• Only 2 per 1,000 increase in hemorrhagic stroke - a favorable risk-benefit ratio 6
• Net benefit of 9 per 1,000 fewer deaths or strokes 6

This benefit applies across all patient subgroups including elderly, those with atrial fibrillation, different blood pressures, and various stroke subtypes 6.

Long-Term Maintenance

After the acute phase, continue aspirin 81-325 mg daily indefinitely for secondary stroke prevention 3

Critical Pitfalls to Avoid

• Never give aspirin within 24 hours of thrombolytic therapy - this dramatically increases intracranial hemorrhage risk 2
• Never give aspirin before brain imaging - you could worsen a hemorrhagic stroke 2, 3
• Do not delay aspirin beyond 48 hours in confirmed ischemic stroke - early administration (within 48 hours) provides maximum benefit 1, 4, 6
• Do not use enteric-coated formulations acutely - they delay absorption when rapid platelet inhibition is needed 1

Special Consideration: Minor Stroke or High-Risk TIA

For minor stroke or high-risk TIA, consider dual antiplatelet therapy:

• Aspirin 160-325 mg plus clopidogrel 300-600 mg loading doses 3
• Followed by aspirin 75-100 mg plus clopidogrel 75 mg daily for 21-30 days only 3