An elderly man with a remote history of hemorrhagic stroke has a new deficit consistent with cerebrovascular accident. His chart says anticoagulation is contraindicated. CT is negative for hemorrhage. Can some anticoagulation, in particular, clopidogrel (Plavix), be used?
—Edib Korkut, MD, Alexandria, La.

This case raises several important issues. The history of the prior hemorrhagic stroke is critical. Was the patient on warfarin? Was there trauma? Was there true hemorrhage or only CT or MRI evidence of minor changes? Did the patient have any evidence of prior small, “silent” hemorrhages that could suggest amyloid angiopathy, which has a significant possibility of hemorrhage? Does the patient have any evidence of coagulopathy? Is he on any anti-platelet-aggregating medications?

Concerning the current management, one would want to have done a recent 2-D echocardiogram, carotid Doppler, and, possibly, an MRI of the brain without gadolinium. If the patient is not currently on aspirin, then that would be the first choice, assuming no contraindications. If the patient was taking aspirin at the time of the most recent event, then the choice would be dipyridamole-aspirin in a long-acting preparation (Aggrenox). One would start with one tablet in the morning and aspirin 81 mg, enteric-coated, in the evening for one to two weeks, and then increase the dipyramidole-aspirin combination to twice a day and discontinue the aspirin 81 mg. It is also important to address any other issues that may increase the risk of secondary stroke, such as hypertension, diabetes, hyperlipidemia, obesity, lifestyle, tobacco or alcohol use, and sleep apnea. A neurologist could be very helpful in this complicated case.
—Jay E. Selman, MD

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