Antithrombotic medication is a cornerstone of acute ischemic stroke treatment and secondary prevention. The
efficacy of thrombolysis with alteplase in acute stroke has been demonstrated in several clinical trials. This safe and costeffective
therapy has transformed the practice of stroke care and has led to subsequent trials of other antithrombotic medications
for treatment of ischemic stroke in the acute phase. These antithrombotics include thrombolytic, antiplatelet and
anticoagulant agents. While, no other medication has yet demonstrated adequate efficacy, our current and evolving understanding
of infarct expansion, ischemic penumbra, collateral circulation and the blood brain barrier is allowing testing of
antithrombotic medications tailored to individual patient pathophysiology in clinical trials. This understanding accompanies
developments in neuroimaging and organization of stroke care that allow for wide-spread recruitment in these trials.
Alteplase remains the mainstay treatment of arterial acute ischemic stroke; however, anticoagulation is the standard therapy
for cerebral venous sinus thrombosis. Antithrombotic use in acute stroke, arterial and venous, has demonstrated efficacy
but leaves many questions unanswered. This patient population is a fertile ground for novel research, especially as it
relates to; combination antithrombotic therapy, combination of pharmacological and mechanical thrombolysis, and the
transition to secondary prevention. Here we review the current antithrombotics in the acute phase of ischemic stroke highlighting
the evidence-base and areas of uncertainty.
Keywords: Acute ischemic stroke, anticoagulants, antiplatelets, argatroban, cerebral venous sinus thrombosis, glycoprotein
GPIIb/IIIa inhibitors, thrombolytics, tissue plasminogen activator.
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