Article Text

Antithrombotic dilemmas in stroke medicine: new data, unsolved challenges
  1. Jonathan G Best1,
  2. Beatrix Cardus2,
  3. Catharina J M Klijn3,
  4. Gregory Lip4,5,
  5. David J Seiffge6,
  6. Eric E Smith7,
  7. David J Werring1
  1. 1Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
  2. 2Royal Surrey County Hospital, Royal Surrey NHS Foundation Trust, Guildford, UK
  3. 3Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
  4. 4Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
  5. 5Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
  6. 6Department of Neurology, Inselspital University Hospital, Bern, Switzerland
  7. 7Calgary Stroke Program, Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Dr David J Werring, Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK; d.werring{at}


Antithrombotic therapy is a key element of secondary prevention in patients who have had an ischaemic stroke or transient ischaemic attack. However, its use in clinical practice is not always straightforward. This review provides an update on certain difficult scenarios in antithrombotic management, with a focus on recent clinical trials and large observational studies. We discuss the approach to patients with an indication for antithrombotic treatment who also have clinical or radiological evidence of previous intracranial bleeding, patients with indications for both anticoagulant and antiplatelet treatment, and patients in whom antithrombotic treatment fails to prevent stroke. We also review the timing of anticoagulation initiation after cardioembolic stroke, and the use of antithrombotics in patients with asymptomatic cerebrovascular disease. Despite a wealth of new evidence, numerous uncertainties remain and we highlight ongoing trials addressing these.

  • cerebrovascular disease
  • stroke
  • clinical neurology

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  • Contributors DJW had the idea for the article, and developed the outline with JB. All authors drafted sections of the manuscript, critically reviewed and revised the manuscript for intellectual content and approved the final submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests DJW reports personal fees from Bayer, Alnylam and Portola outside the submitted work. EES reports personal fees from Alnylam Pharmaceuticals, Bayer and Portola, outside the submitted work. GL reports consultancy and speaker fees from Bayer, Bayer/Janssen, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche and Daiichi-Sankyo outside the submitted work. DJS reports funding from Bayer and Pfizer, outside the submitted work.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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