Aspirin in Acute Ischemic Stroke with Multiple Territories
Yes, immediately start aspirin 160-325 mg in this patient with acute ischemic stroke involving the left corona radiata, cerebellum, and left frontal area, but only after brain imaging has definitively excluded intracranial hemorrhage and confirmed these are ischemic (not hemorrhagic) lesions. 1, 2
Critical Pre-Administration Requirements
Before administering aspirin, you must:
- Confirm CT or MRI shows ischemic infarcts without hemorrhagic transformation - the multiple territories (corona radiata, cerebellum, frontal lobe) require careful imaging review to exclude any bleeding 1, 2, 3
- Verify the patient did NOT receive IV alteplase (tPA) in the last 24 hours - aspirin must be delayed at least 24 hours after thrombolytic therapy to avoid serious intracranial hemorrhage 1
- Perform dysphagia screening - if the patient cannot swallow safely, use nasogastric tube or rectal administration 1, 2
- Exclude active gastrointestinal bleeding or documented aspirin allergy 2
Dosing Protocol
Loading dose: 160-325 mg aspirin immediately (within 48 hours of symptom onset for maximum benefit) 1, 2, 4
- The American College of Chest Physicians specifically recommends 160-325 mg within 48 hours 1
- The American Heart Association/American Stroke Association confirms this same dosing range 1, 2
- Use non-enteric coated formulation for faster buccal absorption 2
Maintenance: 75-325 mg daily for long-term secondary prevention 1, 2
Why This Matters Despite Multiple Territories
The involvement of multiple vascular territories (left corona radiata, cerebellum, left frontal area) suggests either:
- Cardioembolic source with multiple emboli
- Large vessel occlusion with distal embolization
- Multiple small vessel disease
None of these patterns contraindicate aspirin. In fact, the multiple territory involvement increases the risk of early recurrent stroke, making aspirin even more critical. 1, 5, 6
The primary benefit of early aspirin is prevention of early recurrent ischemic stroke (not limitation of the initial stroke damage), with a number needed to treat of 79 to prevent one death or dependency. 2, 5, 6
Evidence Strength
Two landmark trials (International Stroke Trial and Chinese Acute Stroke Trial) involving over 40,000 patients demonstrated:
- Significant reduction in early recurrent ischemic stroke (1.6% vs 2.1%, p=0.01) 6, 7
- Decreased death or dependency at 6 months (OR 0.95% CI 0.91-0.99) 6
- Only minimal increase in hemorrhagic complications (1.1% vs 0.9%) 6, 7
- Prevents approximately 13 deaths or dependencies per 1000 patients treated 2, 5
Critical Timing
Do not delay beyond 48 hours - the therapeutic window for maximum benefit is within 48 hours of symptom onset, with earlier administration being superior. 1, 2, 4
Common Pitfall to Avoid
Do not use aspirin as a substitute for mechanical thrombectomy or IV thrombolysis if the patient is otherwise eligible for these acute interventions - aspirin is adjunctive therapy, not a replacement for reperfusion strategies. 1