Which antiplatelet agents are used for the treatment of middle cerebral artery (MCA) stroke?

Updated: Aug 09, 2021
  • Author: Daniel I Slater, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Medication selection is based on the etiology of the MCA stroke, comorbidities, and past medical history. Commonly used antiplatelet agents include aspirin, dipyridamole/aspirin, and clopidogrel. An increased bleeding risk is common to all of the medications within this class. Of note, prasugrel is contraindicated in patients with a history of stroke [72] and ticagrelor is only approved for use in patients with acute coronary syndrome. [73] While warfarin remains a common oral anticoagulant, newer agents include apixaban, dabigatran, and rivaroxaban.

Table 1. Hematologic Agents Mechanisms of Action and Considerations (Open Table in a new window)


Mechanism of Action




Inhibits cyclo-oxygenase

May also be used to treat mild to moderate pain and headaches


Inhibits platelet adenosine uptake and cyclo-oxygenase [74]

Twice daily dosing

Headaches are a common adverse effect, which may limit tolerability of therapy [75]


Blocks platelet adenosine diphosphate (ADP) P2Y12 receptor [76]

Avoidance of omeprazole and esomeprazole with clopidogrel was recommended in the 2009 FDA release warning about reduced efficacy [77]



Direct factor Xa inhibitor [78]

Not recommended for use in patients with CrCl < 15 mL/min or severe liver impairment


Direct thrombin inhibitor [79]

Dosage adjustment needed for CrCl 50 mL/min or less


Direct factor Xa inhibitor [80]

Dosage adjustment needed for CrCl 50 mL/min or less

Underweight patients have a slightly increased level/response [80]


Inhibits formation of vitamin-K dependent clotting factors [81]

Dosing based on international normalized ratio

Multiple food and drug interactions [81]

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