Acute Ischemic Stroke Management

Initial Treatment (First 24-72 hours)

For acute ischemic stroke, administer an initial dose of aspirin 160-325 mg immediately after excluding intracranial hemorrhage by neuroimaging, followed by clopidogrel 300-600 mg if the stroke is minor (NIHSS ≤3) or high-risk transient ischemic attack (ABCD2 ≥4), as recommended by the American College of Chest Physicians 1, 2
The American Heart Association recommends administering aspirin within 24-48 hours of symptom onset 1, 3
If the patient received thrombolysis with rtPA, wait 24 hours after treatment before starting aspirin, as suggested by the American Heart Association 3, 2
For patients with dysphagia, use rectal aspirin 325 mg/day or enteral aspirin 81 mg/day, as recommended by the Praxis Medical Insights 2, 4

After completing 21-30 days of dual therapy, transition to monotherapy with aspirin 75-100 mg/day or clopidogrel 75 mg/day indefinitely, as recommended by the American College of Chest Physicians 1, 2, 5
The European Heart Journal suggests that aspirin 75-100 mg/day is the preferred maintenance dose 6, 1, 2, 5
Clopidogrel 75 mg/day is an equally effective alternative, especially in patients with peripheral arterial disease or aspirin intolerance, as recommended by the European Heart Journal 6, 1, 2, 5

For intracranial stenosis (50-99%), use aspirin 325 mg/day, as recommended by the Praxis Medical Insights 4
For cardioembolic stroke (atrial fibrillation), oral anticoagulation is preferred over antiplatelet therapy, as recommended by the American College of Chest Physicians 1, 5
If anticoagulation is contraindicated, use single antiplatelet therapy, as suggested by the American College of Chest Physicians 1
For aspirin intolerance, clopidogrel 75 mg/day is the recommended alternative, as suggested by the European Heart Journal 6, 1, 5