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Antithrombotic and Thrombolytic Therapy for Ischemic Stroke

Gregory W. Albers, MD, Chair; Pierre Amarenco, MD; J. Donald Easton, MD; Ralph L. Sacco, MD; Philip Teal, MD
Author and Funding Information

Correspondence to: Gregory W. Albers, MD, Stanford Stroke Center, Building B, Suite 325, 701 Welch Rd, Palo Alto, CA 94304-1705; e-mail: albers@leland.stanford.edu



Chest. 2001;119(1_suppl):300S-320S. doi:10.1378/chest.119.1_suppl.300S
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Ischemic stroke is a syndrome of multiple etiologies and protean clinical manifestations. The optimal use of antithrombotic therapies for stroke treatment or prevention is guided by the specific pathogenesis (Fig 1 , 2 ) and clinical features. Patients who are at increased risk for ischemic stroke can be identified (Fig 3 ). Atherosclerosis of the arteries, large and small, that supply the brain is the most common cause of ischemic stroke. Atherosclerosis of the proximal aorta is also a source of atherogenic brain emboli. Large artery atherosclerotic infarction occurs when there is an impediment to normal perfusion, usually caused by a severe arterial stenosis or occlusion due to atherosclerosis and coexisting thrombosis or artery-to-artery embolism. Microatheroma, lipohyalinosis, and other occlusive diseases of the small penetrating brain arteries are the most frequent causes of small, subcortical “lacunar” infarcts. About 20% of ischemic strokes are due to cardiogenic embolism, most commonly from atrial fibrillation. A variety of other arterial occlusive disorders may be the primary cause or variably contribute to stroke pathogenesis. Overall, about 30% of ischemic strokes remain cryptogenic despite a reasonably thorough evaluation. Cerebral angiography done within a few hours of cryptogenic stroke often reveals occlusions of intracranial arteries. Most of these occlusions resolve within a few days, suggesting transient embolic or thrombotic obstruction. Thus, the specific pathogenesis of stroke in individual patients is sometimes difficult to elucidate, and determining the optimal choice of antithrombotic therapy for prevention of stroke worsening or recurrence is challenging.

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