Two large studies that included more than 40,000 patients investigated the benefits of aspirin administered within 48 hours of acute stroke onset. In the Chinese Aspirin Stroke Trial, the dose of aspirin was 160 mg/day; in the International Stroke Trial, it was 300 mg/day (100,101). Collectively, these trials showed that, for every 1000 patients treated with aspirin after stroke onset, death or disability could be prevented in about 10 and that there were fewer recurrent strokes. The benefit of aspirin in these trials might have been related to its antiplatelet effects and its ability to prevent recurrent stroke, but it is also possible that acute administration of aspirin produces other beneficial effects.
To date, no study has shown a benefit for acute anticoagulation in patients with stroke; in fact, most studies show an excess of hemorrhagic complications (101-107). The lack of benefit for anticoagulation in acute stroke is true even for patients with atrial fibrillation ( 108 ). Thus, anticoagulation is not indicated for treatment of the average stroke patient. Low-dose anticoagulation, however, can prevent deep venous thrombosis and pulmonary embolism in patients with stroke (107). Moreover, despite a lack of rigorous data to support its use, anticoagulation might be the best therapy for patients with cerebral vein thrombosis (109,110 ).
Observational studies show that magnesium levels drop in injured brain (111). Experimental data suggest that magnesium is neuroprotective (112,113). The potential benefits of magnesium could be related to its effects on ionotropic N-methyl-D-aspartate receptors or to the fact that magnesium might function as a vasodilator (114,115). Unfortunately, an initial prospective, randomized, controlled trial of magnesium administration within 12 hours of ischemic stroke failed to show any benefit (116). Another trial in which magnesium is administered by paramedics within one to two hours of symptom onset is underway (117).
The results of a Phase III European study of the neuroprotective agent NXY-059 were recently announced (118). This drug, which is thought to act as a free radical scavenger, improved neurologic outcome at three months in patients who received it within six hours of stroke onset. Approximately 30% of treated patients also received rtPA. A similar trial is ongoing in North America. Pending the results of this trial, approval to market the drug will be sought.
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