Citicoline Should Not Be Given for Acute Ischemic Stroke
No, you should not give citicoline for acute ischemic stroke—the American Heart Association/American Stroke Association explicitly states that citicoline cannot be recommended for treatment of acute ischemic stroke based on Grade A evidence from multiple randomized controlled trials that failed to demonstrate consistent efficacy. 1, 2
Guideline-Based Recommendation
The evidence against citicoline is definitive and comes from the highest quality sources:
The AHA/ASA guidelines state no agent with putative neuroprotective effects, including citicoline, can be recommended for acute ischemic stroke treatment (Grade A recommendation). 1, 2
The International Citicoline Trial on Acute Stroke (ICTUS), the largest and most definitive trial with 2,298 patients with moderate to severe ischemic stroke, 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
Why Earlier Positive Findings Were Misleading
While a pooled analysis of four US trials suggested benefit (25.2% recovery with citicoline vs 20.2% with placebo), 3 this finding was not confirmed by the subsequent large, well-designed ICTUS trial. 1 Individual trials also failed their primary endpoints despite post-hoc analyses suggesting possible subgroup benefits. 4, 5
The pattern of failed primary analyses with positive post-hoc findings is a classic red flag for publication bias and data dredging—this is why guidelines rely on pre-specified primary outcomes. 1
What You Should Do Instead
Focus on proven, time-sensitive interventions:
IV thrombolysis (rtPA) within 3-4.5 hours of symptom onset for eligible patients. 2
Endovascular thrombectomy for large vessel occlusions within appropriate time windows. 2
Early aspirin therapy (160-325 mg) within 24-48 hours for patients not receiving thrombolysis, after excluding hemorrhage. 2
Admission to a specialized stroke unit with coordinated interdisciplinary care. 1, 2
Blood pressure management: Lower to <185/110 mmHg before reperfusion therapy and maintain <180/105 mmHg for 24 hours afterward. 2
Critical Caveat
Time is brain—every minute spent considering unproven therapies like citicoline delays proven interventions. 2 The median time to treatment in citicoline trials was 12-13 hours, 4, 5 but for rtPA, every 15-minute delay reduces the odds of good outcome. Your focus should be on rapid assessment, imaging, and administration of evidence-based therapies, not neuroprotective agents that have consistently failed to show benefit. 1, 2