Methods

We identified references by regular reading of general medical and neurological journals, from searching the electronic literature (Medline, BIDS), and through discussion with general practitioners and neurological colleagues with specialist interests. The final selection of papers was partly subjective.

Cerebrovascular disease

The international stroke trial and the Chinese acute stroke trial, each concerning around 20 000 patients, examined antithrombotic therapy (aspirin, heparin) given within 48 hours of acute ischaemic stroke.2 3 Both found aspirin to be associated with about 10 fewer deaths or recurrent strokes in the first 4 weeks for each 1000 patients treated, but with slightly more haemorrhagic strokes. The international stroke trial reported no benefit from subcutaneous heparin (5000 or 12 500 IU twice daily) given with or without aspirin. Hence it was concluded that aspirin should be started as soon as possible after the onset of an acute ischaemic stroke.2 3 Whether aspirin use is “acute treatment” or simply early secondary prevention remains debatable.

No clinical indicators reliably differentiate ischaemic from haemorrhagic stroke. The recommendation that aspirin be started only after appropriate brain imaging in patients requiring admission to hospital will place a huge burden on acute neurological services (over 100 000 people have a first stroke in England and Wales each year). The issue is still more problematic for thrombolytic therapy (tissue type plasminogen activator, streptokinase, urokinase). An overview of previous trials indicated significant excesses of early and …