Indication, risk and benefit of anti‒thrombotic therapy for patients with ischemic cerebrovascular diseases：basic knowledge for neurosurgeons

Abstract

Anti‒thrombotic therapies including aspirin, or dual anti‒platelet therapy (DAPT) comprising aspirin and clopidogrel, or intravenous infusion of ozagrel sodium or argatroban are currently available for patients with acute non‒cardioembolic stroke. Based on the clinical condition of the patient with acute ischemic stroke, DAPT is highly recommended, but should be switched to single‒agent anti‒platelet therapy within a week, or chronically, up to one year from onset. In patients with acute cardioembolic stroke with non‒valvular atrial fibrillation (NVAF), anti‒coagulant therapy using warfarin or direct oral anticoagulants (DOACs) should be initiated within two weeks；there is no evidence for clinical benefits from heparin infusion. From the perspective of reducing hemorrhagic complications in patients with NVAF, DOAC is preferentially recommended over warfarin. The latter is used in patients with mechanical valves, only because DOAC is not indicated for such patients. Anti‒coagulant therapy is recommended for patients with embolic stroke of undetermined source (ESUS), particularly in those with medium risk of heart disease, paradoxical cerebral embolism and venous thrombosis in the lower extremities. Anti‒platelet therapy is recommended for patients with other ESUS, according to their individual clinical needs. Anti‒thrombotic therapy requires patient blood pressure to preferably be under 130/80 mmHg. This is of significance in patients with cerebral microbleeds, previous cerebral hemorrhage, and lacunar infarction, where strict control of blood pressure prevents recurrent stroke and symptomatic cerebral hemorrhage. Peri‒operative management of anti‒thrombotic therapy is facilitated by team conferences with neurosurgeons, cardiologists, gastroenterologists, anesthesiologists and other medical staff. It is recommended for neurosurgeons to suspend and restart anti‒thrombotic agents during the peri‒operative period, after obtaining patient informed consent regarding the risks and benefits of anti‒thrombotic therapy described in guidelines and according to consensus of the management team.