Aspirin Administration in Ischemic Stroke

Primary Recommendations

The American Heart Association recommends aspirin therapy (160-325 mg) to be started within 24-48 hours of stroke onset to reduce stroke mortality and decrease morbidity 1, 2, 3
The primary benefit of early aspirin administration is reduction of early recurrent stroke rather than limitation of neurological consequences of the initial stroke 1, 4

Aspirin should NOT be considered a substitute for intravenous recombinant tissue plasminogen activator (rtPA) in eligible patients, as per the American Heart Association guidelines 1, 2, 5
Aspirin (or other antiplatelet agents) should NOT be administered as adjunctive therapy within 24 hours of thrombolytic therapy, according to the American Heart Association and American Stroke Association guidelines 1, 2, 5
Aspirin should be avoided in patients with contraindications such as allergy or active gastrointestinal bleeding, as recommended by the American Stroke Association 6

The recommendation for aspirin administration within 24-48 hours carries a Class I, Level of Evidence A rating in American Heart Association/American Stroke Association guidelines 1, 2, 5

Clopidogrel alone or in combination with aspirin is not recommended for routine treatment of acute ischemic stroke, as per the American Heart Association guidelines 1, 4
The usefulness of clopidogrel for acute ischemic stroke is not well established (Class IIb; Level of Evidence C), according to the American Stroke Association 2, 5
Intravenous antiplatelet agents that inhibit glycoprotein IIb/IIIa receptors are not recommended outside clinical trials, as recommended by the American Heart Association and American Stroke Association guidelines 1, 2, 5

Using aspirin as a substitute for thrombolytic therapy in eligible patients is not recommended, as per the American Heart Association guidelines 1, 2, 7
Administering aspirin within 24 hours of thrombolytic therapy due to increased bleeding risk is not recommended, according to the American Heart Association and American Stroke Association guidelines 1, 5

The American Heart Association recommends aspirin monotherapy in acute ischemic stroke, initiated within 24-48 hours of symptom onset at a dose of 160-325 mg daily, after brain imaging has excluded hemorrhage 8

Aspirin 75-325 mg daily is proven effective for long-term secondary prevention, with lower doses (75-100 mg daily) having similar efficacy to higher doses with fewer gastrointestinal side effects 9
Aspirin 325 mg daily is preferred over warfarin for intracranial large artery atherosclerosis (50-99% stenosis) 8

For recent stroke/TIA (within 30 days) with severe intracranial stenosis (70-99%), adding clopidogrel 75 mg to aspirin for up to 90 days is reasonable 8
Long-term dual antiplatelet therapy (beyond 90 days) increases bleeding risk without clear benefit in most stroke patients 10