eMedicine Specialties > Neurology > Neuro-vascular Diseases

Stroke Anticoagulation and Prophylaxis

Author: Uwe Walter, MD, PhD, Associate Professor, Department of Neurology, University Hospital of Rostock, Germany; Director Neurological Intensive Care Unit and Stroke Unit, Head of Neurosonological Lab
Coauthor(s): Friedhelm Sandbrink, MD, Director EMG laboratory, Chief Chronic Pain Clinic, Assistant Professor, Department of Neurology, Veterans Affairs Medical Center Washington DC; Reiner Benecke, MD, Chair, Professor, Department of Neurology, University Hospital of Rostock, Germany
Contributor Information and Disclosures

Updated: May 9, 2007

Introduction

Background

Anticoagulation is the controlled therapeutic inhibition of blood coagulation by means of appropriate drugs (ie, anticoagulants). The role of anticoagulants in the treatment of cerebral ischemia still is evolving. No single treatment has proved effective against all forms of brain ischemia, including heparin, heparin analogues, and warfarin. In the past decade, randomized, controlled studies have helped to define patients who would potentially benefit from anticoagulation therapy, despite the possible hemorrhagic complications.

Several new oral anticoagulant medications are in the final stages of clinical trials for use in the prophylaxis of ischemic thromboembolic stroke. Once approved for use, the potential of such drugs in the arena of stroke treatment is significant.

More on Stroke Anticoagulation and Prophylaxis

Overview: Stroke Anticoagulation and Prophylaxis
Differential Diagnoses & Workup: Stroke Anticoagulation and Prophylaxis
Treatment & Medication: Stroke Anticoagulation and Prophylaxis
Follow-up: Stroke Anticoagulation and Prophylaxis
References
[ CLOSE WINDOW ]

References

  1. Albers GW, Diener HC, Frison L, et al. Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillation: a randomized trial. JAMA. Feb 9 2005;293(6):690-8. [Medline].

  2. The ESPRIT Study Group; Algra A. Medium intensity oral anticoagulants versus aspirin after cerebral ischaemia of arterial origin (ESPRIT): a randomised controlled trial. Lancet Neurol. Feb 2007;6(2):115-24. [Medline].

  3. Chimowitz MI, Lynn MJ, Howlett-Smith H, et al. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med. Mar 31 2005;352(13):1305-16. [Medline].

  4. Levine SR, Brey RL, Tilley BC, Thompson JL, Sacco RL, Sciacca RR. Antiphospholipid antibodies and subsequent thrombo-occlusive events in patients with ischemic stroke. JAMA. Feb 4 2004;291(5):576-84. [Medline].

  5. Crowther MA, Ginsberg JS, Julian J, Denburg J, Hirsh J, Douketis J. A comparison of two intensities of warfarin for the prevention of recurrent thrombosis in patients with the antiphospholipid antibody syndrome. N Engl J Med. Sep 18 2003;349(12):1133-8. [Medline].

  6. Finazzi G, Marchioli R, Brancaccio V, Schinco P, Wisloff F, Musial J. A randomized clinical trial of high-intensity warfarin vs. conventional antithrombotic therapy for the prevention of recurrent thrombosis in patients with the antiphospholipid syndrome (WAPS). J Thromb Haemost. May 2005;3(5):848-53. [Medline].

  7. Lim W, Crowther MA, Eikelboom JW. Management of antiphospholipid antibody syndrome: a systematic review. JAMA. Mar 1 2006;295(9):1050-7. [Medline].

  8. ACTIVE Writing Group on behalf of the ACTIVE Investigators, Connolly S, Pogue J, Hart R, Pfeffer M, Hohnloser S. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. Jun 10 2006;367(9526):1903-12. [Medline].

  9. Adams HP, Bendixen BH, Leira E, et al. Antithrombotic treatment of ischemic stroke among patients with occlusion or severe stenosis of the internal carotid artery: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. Jul 13 1999;53(1):122-5. [Medline]. [Full Text].

  10. Akins PT, Feldman HA, Zoble RG, Newman D, Spitzer SG, Diener HC. Secondary stroke prevention with ximelagatran versus warfarin in patients with atrial fibrillation: pooled analysis of SPORTIF III and V clinical trials. Stroke. Mar 2007;38(3):874-80. [Medline].

  11. Anand SS, Yusuf S. Oral anticoagulant therapy in patients with coronary artery disease: a meta-analysis. JAMA. Dec 1 1999;282(21):2058-67. [Medline].

  12. Atrial Fibrillation Investigators. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med. Jul 11 1994;154(13):1449-57. [Medline].

  13. Baker WF, Bick RL. Treatment of hereditary and acquired thrombophilic disorders. Semin Thromb Hemost. 1999;25(4):387-406. [Medline].

  14. Bath PM, Iddenden R, Bath FJ. Low-molecular-weight heparins and heparinoids in acute ischemic stroke : a meta-analysis of randomized controlled trials. Stroke. Jul 2000;31(7):1770-8. [Medline].

  15. Baumgartner RW, Studer A, Arnold M, Georgiadis D. Recanalisation of cerebral venous thrombosis. J Neurol Neurosurg Psychiatry. Apr 2003;74(4):459-61. [Medline].

  16. Benesch CG, Chimowitz MI. Best treatment for intracranial arterial stenosis? 50 years of uncertainty. The WASID Investigators. Neurology. Aug 22 2000;55(4):465-6. [Medline].

  17. Berge E, Abdelnoor M, Nakstad PH, Sandset PM. Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. HAEST Study Group. Heparin in Acute Embolic Stroke Trial. Lancet. Apr 8 2000;355(9211):1205-10. [Medline].

  18. Bertram M, Bonsanto M, Hacke W, Schwab S. Managing the therapeutic dilemma: patients with spontaneous intracerebral hemorrhage and urgent need for anticoagulation. J Neurol. Mar 2000;247(3):209-14. [Medline].

  19. Bogousslavsky J, Kaste M, Skyhoj Olsen T, et al. Risk factors and stroke prevention. European Stroke Initiative (EUSI). Cerebrovasc Dis. 2000;10 Suppl 3:12-21. [Medline].

  20. Bonow RO, Carabello B, de Leon AC Jr, et al. Guidelines for the management of patients with valvular heart disease: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart. Circulation. Nov 3 1998;98(18):1949-84. [Medline].

  21. Brandt T, Caplan L. Spontaneous Arterial Dissection. Curr Treat Options Neurol. Sep 2001;3(5):463-469. [Medline].

  22. Cairns JA, Théroux P, Lewis HD Jr, et al. Antithrombotic agents in coronary artery disease. Chest. Jan 2001;119(1 Suppl):228S-252S. [Medline].

  23. Cauli C, Barcellona D, Marongiu F. Oral anticoagulant therapy in the primary and secondary prophylaxis of stroke. Ital Heart J. Nov 2003;4(11):755-67. [Medline].

  24. Chaves CJ, Caplan LR. Heparin and oral anticoagulants in the treatment of brain ischemia. J Neurol Sci. Feb 1 2000;173(1):3-9. [Medline].

  25. De Schryver EL. Design of ESPRIT: an international randomized trial for secondary prevention after non-disabling cerebral ischaemia of arterial origin. European/Australian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT) group. Cerebrovasc Dis. Mar-Apr 2000;10(2):147-50. [Medline].

  26. Ezekowitz JA, Straus SE, Majumdar SR, McAlister FA. Stroke: strategies for primary prevention. Am Fam Physician. Dec 15 2003;68(12):2379-86. [Medline].

  27. Gorelick PB, Sacco RL, Smith DB, et al. Prevention of a first stroke: a review of guidelines and a multidisciplinary consensus statement from the National Stroke Association. JAMA. Mar 24-31 1999;281(12):1112-20. [Medline].

  28. Gustafsson D, Elg M. The pharmacodynamics and pharmacokinetics of the oral direct thrombin inhibitor ximelagatran and its active metabolite melagatran: a mini-review. Thromb Res. Jul 15 2003;109 Suppl 1:S9-15. [Medline].

  29. Hacke W, Kaste M, Skyhoj Olsen T, et al. Acute treatment of ischemic stroke. European Stroke Initiative (EUSI). Cerebrovasc Dis. 2000;10 Suppl 3:22-33. [Medline].

  30. Hagens VE, Ranchor AV, Van Sonderen E, et al. Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. Results from the Rate Control Versus Electrical Cardioversion (RACE) Study. J Am Coll Cardiol. Jan 21 2004;43(2):241-7. [Medline].

  31. Halperin JL. Ximelagatran compared with warfarin for prevention of thromboembolism in patients with nonvalvular atrial fibrillation: Rationale, objectives, and design of a pair of clinical studies and baseline patient characteristics (SPORTIF III and V). Am Heart J. Sep 2003;146(3):431-8. [Medline].

  32. Hart RG, Palacio S, Pearce LA. Atrial fibrillation, stroke, and acute antithrombotic therapy: analysis of randomized clinical trials. Stroke. Nov 2002;33(11):2722-7. [Medline].

  33. Kalafut MA, Gandhi R, Kidwell CS, Saver JL. Safety and cost of low-molecular-weight heparin as bridging anticoagulant therapy in subacute cerebral ischemia. Stroke. Nov 2000;31(11):2563-8. [Medline]. [Full Text].

  34. Koga M, Saku Y, Toyoda K, et al. Reappraisal of early CT signs to predict the arterial occlusion site in acute embolic stroke. J Neurol Neurosurg Psychiatry. May 2003;74(5):649-53. [Medline].

  35. Laupacis A, Albers G, Dalen J, et al. Antithrombotic therapy in atrial fibrillation. Chest. Nov 1998;114(5 Suppl):579S-589S. [Medline].

  36. Mas JL, Arquizan C, Lamy C, et al. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med. Dec 13 2001;345(24):1740-6. [Medline].

  37. Olshansky B, Rosenfeld LE, Warner AL, et al. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study: approaches to control rate in atrial fibrillation. J Am Coll Cardiol. Apr 7 2004;43(7):1201-8. [Medline].

  38. Olsson SB, Executive Steering Committee on behalf of the SPORTIF III Investigators. Stroke prevention with the oral direct thrombin inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial fibrillation (SPORTIF III): randomised controlled trial. Lancet. Nov 22 2003;362(9397):1691-8. [Medline].

  39. Pessin MS, Adams HP, Adams RJ, et al. American Heart Association Prevention Conference. IV. Prevention and Rehabilitation of Stroke. Acute interventions. Stroke. Jul 1997;28(7):1518-21. [Medline].

  40. Pessin MS, Estol CJ, Lafranchise F, Caplan LR. Safety of anticoagulation after hemorrhagic infarction. Neurology. Jul 1993;43(7):1298-303. [Medline].

  41. Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: Stroke prevention in patients with nonvalvular atrial fibrillation. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. Sep 1998;51(3):671-3. [Medline].

  42. Reiffel JA. Will direct thrombin inhibitors replace warfarin for preventing embolic events in atrial fibrillation?. Curr Opin Cardiol. Jan 2004;19(1):58-63. [Medline].

  43. Ringelstein EB, Nabavi D. Long-term prevention of ischaemic stroke and stroke recurrence. Thromb Res. May 1 2000;98(3):83-96. [Medline].

  44. Ryan TJ, Antman EM, Brooks NH, et al. 1999 update: ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction: Executive Summary and Recommendations: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. Aug 31 1999;100(9):1016-30. [Medline].

  45. Sherman DG. Antithrombotic and hypofibrinogenetic therapy in acute ischemic stroke: what is the next step?. Cerebrovasc Dis. 2004;17 Suppl 1:138-43. [Medline].

  46. Zweifler RM. Management of acute stroke. South Med J. Apr 2003;96(4):380-5. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

cerebral ischemia, ischemic thromboembolic stroke, anticoagulants, anticoagulation therapy, anticoagulant, anticoagulant therapy, blood coagulation, heparin, heparin analogues, warfarin

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Uwe Walter, MD, PhD, Associate Professor, Department of Neurology, University Hospital of Rostock, Germany; Director Neurological Intensive Care Unit and Stroke Unit, Head of Neurosonological Lab
Uwe Walter, MD, PhD is a member of the following medical societies: European Society of Neurosonology and Cerebral Hemodynamics, German Society of Clinical Neurophysiology, German Society of Neurology, German Society of Ultrasound in Medicine, and Movement Disorders Society
Disclosure: Nothing to disclose.

Coauthor(s)

Friedhelm Sandbrink, MD, Director EMG laboratory, Chief Chronic Pain Clinic, Assistant Professor, Department of Neurology, Veterans Affairs Medical Center Washington DC
Friedhelm Sandbrink, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and German Society of Clinical Neurophysiology
Disclosure: Nothing to disclose.

Reiner Benecke, MD, Chair, Professor, Department of Neurology, University Hospital of Rostock, Germany
Reiner Benecke, MD is a member of the following medical societies: German Society of Clinical Neurophysiology, German Society of Neurology, and Movement Disorders Society
Disclosure: Nothing to disclose.

Medical Editor

Draga Jichici, HBSc, MD, FRCP(C), FAHA, Assistant Professor, Department of Medicine, Division of Critical Care Medicine, McMaster University Medical School, Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Howard Kirshner, MD, Vice-Chair, Professor, Department of Neurology, Vanderbilt University School of Medicine
Howard Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor of Neurology, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida College of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Associate Professor, Department of Neurology, Oregon Health and Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Nothing to disclose.

RELATED EMEDICINE ARTICLES
Patient Education
 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.