Cerebral infarction (ischaemic stroke) – Related resources

Cochrane reviews

Pharmacotherapy

• Fibrinogen depleting agents reduce stroke recurrence in acute ischaemic stroke, but they can also cause serious intracranial bleeding . Anticoagulants have similar efficacy as aspirin for acute ischemic stroke with more adverse effects .
• Aspirin (160 to 300 mg/day) started within 48 hours of onset of presumed ischaemic stroke reduces the risk of early recurrent stroke and improves long-term outcome .
• Calcium antagonists are not beneficial for patients with acute ischaemic stroke .
• Immediate anticoagulant therapy in patients with acute ischaemic stroke is not associated with net short- or long-term benefit . Anticoagulants reduce the risk of recurrent stroke by two-thirds in patients with non-rheumatic atrial fibrillation. They are more effective than aspirin or indobufen .
• Ginkgo biloba extract may be of some benefit in the treatment of acute ischaemic stroke but evidence from good quality studies is lacking .
• Corticosteroids are probably not effective in the treatment of acute presumed ischaemic stroke .
• Intravenous glycerol may not be beneficial in the treatment of acute stroke as regards mortality or functional outcome .
• Naftidrofuryl is not effective in the treatment of acute ischaemic or haemorrhagic stroke . There is insufficient evidence to support the routine use of mannitol in acute stroke patients .
• Piracetam is not beneficial in the treatment of acute stroke . Lowering of blood pressure in acute stroke appears not to have effect on survival or functional outcome. Ticlopidine and clopidogrel are slightly but significantly more effective than aspirin in preventing serious vascular events in high-risk individuals (and specifically in TIA/stroke patients). Clopidogrel and aspirin plus dipyridamole are as effective in reducing the risk of recurrent stroke. The risk of major haemorrhagic events, including intracranial haemorrhage, is lower with clopidogrel .
• Beta receptor antagonists, calcium channel blockers, nitric oxide, and prostacyclin lower BP in acute stroke. However, these data do not allow the effect of changing BP on outcome to be assessed .
• In ischaemic stroke intra-arterial thrombolysis appears to result in higher rates of recanalisation than non-thrombolytic standard care, translating into improved functional outcome at 3-month follow-up, despite increased rate of symptomatic intracranial haemorrhages .
• Preventive antibiotic therapy may reduce the risk of infection in patients with acute ischaemic stroke, but may not reduce the number of dependent or deceased patients .
• GABA receptor agonists (chlormethiazole or diazepam) appear not to be effective for the treatment of acute ischemic or hemorrhagic stroke .
• Atenolol may not reduce the risk of stroke, heart attack, or death from vascular disease after ischaemic stroke or transient ischaemic attack (TIA) .
• Continuous monitoring of physiological variables within 3 days of stroke might possibly improve outcomes and prevent complications, but the evidence is insufficient .
• In acute stroke, higher doses of thrombolytic agents might possibly lead to higher rates of bleeding and intra-arterial treatment might possibly not be more beneficial than intravenous, although the evidence is insufficient .
• There is no randomised evidence to determine whether, for patients with carotid artery dissection, either antiplatelet or anticoagulant therapy is superior to control, or whether anticoagulant is superior to antiplatelet therapy .
• Colony stimulating factors appear not to be effective in the treatment of recent stroke. There appears to be significant safety concerns regarding EPO therapy.

Other treatments

• Acupuncture appears to a have no clear effect in the treatment of stroke in the acute nor in the chronic stage .
• Adjunctive hyperbaric oxygen therapy (HBOT) is probably not effective in the treatment of acute ischaemic stroke .
• Use of graduated compression stockings (GCS) may not reduce the risk of deep vein thrombosis compared to routine medical care in patients with recent stroke. Thigh-length GCS appear to be better than below-knee stockings. There is insufficient evidence on the use of intermittent pneumatic compression in such patients .
• Active provision of information to stroke survivors and their carers appears to improve patient and carer knowledge of stroke and aspects of patient satisfaction, and may also reduce patient depression scores .
• Psychotherapy appears to have a small but significant effect on improving mood and preventing depression in stroke survivors, whereas antidepressants appear not to prevent depression or improve physical recovery in these patients .
• In stroke there appears to be no difference in the efficacy of very early (within 24 hours of stroke) and conventional mobilisation .There is no evidence to support routine use of physical or pharmacological strategies to reduce temperature in patients with acute stroke .
• In acute stroke, sonothrombolysis appears to reduce death or dependency at 3 months and increase recanalisation without clear hazard .

Other evidence summaries

• Aspirin increases the risk of haemorrhagic stroke (12 events per 10000 persons), but this is outweighed by its beneficial effect on total mortality and ischaemic stroke . Early anticoagulation within 48 hours is not effective in acute cardioembolic stroke .
• Treatment with i.v. recombinant tissue plasminogen activator (rtPA) may have less favourable outcomes in stroke patients 80 years or older than in younger patients .

Literature

• Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet 2008 May 10;371(9624):1612-23.
• Hankey GJ. Clinical update: management of stroke. Lancet 2007 Apr 21;369(9570):1330-2.
• van der Worp HB, van Gijn J. Clinical practice. Acute ischemic stroke. N Engl J Med 2007 Aug 9;357(6):572-9.