SPECIAL ARTICLE

Summary of evidence-based guideline: Periprocedural

management of antithrombotic medications in
patients with ischemic cerebrovascular disease
Report of the Guideline Development Subcommittee of the American
Academy of Neurology
Melissa J. Armstrong,
MD
Gary Gronseth, MD,
FAAN
David C. Anderson, MD,
FAAN, FAHA
Jos Biller, MD, FACP,
FAAN, FAHA
Brett Cucchiara, MD
Rima Dafer, MD, MPH,
FAHA
Larry B. Goldstein, MD,
FAAN, FAHA
Michael Schneck, MD,
FAHA, FAAN, FACP
Steven R. Mess, MD,
FAAN

Correspondence to
American Academy of Neurology:
[email protected]

ABSTRACT

Objective: To assess evidence regarding periprocedural management of antithrombotic drugs in

patients with ischemic cerebrovascular disease. The complete guideline on which this summary
is based is available as an online data supplement to this article.
Methods: Systematic literature review with practice recommendations.
Results and recommendations: Clinicians managing antithrombotic medications periprocedurally
must weigh bleeding risks from drug continuation against thromboembolic risks from discontinuation. Stroke patients undergoing dental procedures should routinely continue aspirin (Level A).
Stroke patients undergoing invasive ocular anesthesia, cataract surgery, dermatologic procedures,
transrectal ultrasoundguided prostate biopsy, spinal/epidural procedures, and carpal tunnel surgery should probably continue aspirin (Level B). Some stroke patients undergoing vitreoretinal surgery, EMG, transbronchial lung biopsy, colonoscopic polypectomy, upper endoscopy and biopsy/
sphincterotomy, and abdominal ultrasoundguided biopsies should possibly continue aspirin (Level
C). Stroke patients requiring warfarin should routinely continue it when undergoing dental procedures (Level A) and probably continue it for dermatologic procedures (Level B). Some patients undergoing EMG, prostate procedures, inguinal herniorrhaphy, and endothermal ablation of the great
saphenous vein should possibly continue warfarin (Level C). Whereas neurologists should counsel
that warfarin probably does not increase clinically important bleeding with ocular anesthesia (Level
B), other ophthalmologic studies lack the statistical precision to make recommendations (Level U).
Neurologists should counsel that warfarin might increase bleeding with colonoscopic polypectomy
(Level C). There is insufficient evidence to support or refute periprocedural heparin bridging therapy
to reduce thromboembolic events in chronically anticoagulated patients (Level U). Neurologists
should counsel that bridging therapy is probably associated with increased bleeding risks as compared with warfarin cessation (Level B). The risk difference as compared with continuing warfarin is
unknown (Level U). Neurology 2013;80:20652069
GLOSSARY
AC 5 anticoagulation; AP 5 antiplatelet; RR 5 relative risk; TE 5 thromboembolic.

Neurologists are frequently asked to recommend

whether practitioners should temporarily stop anticoagulation (AC) and antiplatelet (AP) agents in patients with
prior strokes or TIAs undergoing invasive procedures.
The balance of risks of recurrent vascular events with discontinuation of these agents vs increased periprocedural
bleeding with continuation is often unclear, leading to
variability in care and possibly adverse outcomes.

This article summarizes the findings, conclusions,

and recommendations of an evidence-based guideline
regarding periprocedural management of patients
with a history of ischemic cerebrovascular disease
receiving AC or AP agents. The full text of the guideline is available as a data supplement on the Neurology
Web site at www.neurology.org. Four questions are
addressed:

Supplemental data at
www.neurology.org
From the Department of Neurology (M.J.A.), University of Maryland School of Medicine, Baltimore; Department of Neurology (G.G.), University of Kansas
Medical Center, Kansas City; Department of Neurology (D.C.A.), University of Minnesota, Hennepin County Medical Center, Minneapolis; Departments
of Neurology and Neurological Surgery (J.B.), Loyola University Chicago, Stritch School of Medicine, Chicago, IL; Department of Neurology (B.C., S.R.M.),
Non-invasive Neurovascular Laboratory (B.C.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (R.D.), North Shore
University HealthSystem, Glenview, IL; Duke Stroke Center (L.B.G.), Duke University, Durham, NC; and Departments of Neurology and Neurological
Surgery (M.S.), Loyola Medicine, Maywood, IL.
Approved by the Guideline Development Subcommittee on July 14, 2012; by the Practice Committee on August 3, 2012; and by the AAN Board of
Directors on January 17, 2013.
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
2013 American Academy of Neurology

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1. What is the thromboembolic (TE) risk of temporarily discontinuing an antithrombotic medication?

2. What are the perioperative bleeding risks of continuing antithrombotic agents?
3. If oral AC is stopped, should bridging therapy be
used?
4. If an antithrombotic agent is stopped, what should
be the timing of discontinuation?
The
American Academy of Neurology Guideline Development Subcommittee (see appendices e-1 and e-2)
convened an expert panel to develop the guideline.
Literature searches of MEDLINE and EMBASE
through August 2011 were performed (see appendices
e-3 and e-4). The searches identified 5,904 citations
yielding 133 relevant articles, which were rated for
their risk of bias (see appendix e-5), and recommendations were made that were linked to the evidence
(see appendix e-6).
Articles were included if they studied patients taking oral antithrombotic agents for primary or secondary cardiovascular disease or stroke prevention
(including articles relating to atrial fibrillation), studied at least 20 subjects, included a comparison group,
assessed risks of continuing or discontinuing an agent,
and clearly described interventions and outcome
measures. Cardiovascular and cerebrovascular procedures were excluded because of confounding issues.
Bleeding was classified according to GUSTO criteria.1
Moderate or severe bleeding was considered clinically
important. All studies are presented in the evidence
table (table e-1), including Class III studies that did
not inform recommendations.
DESCRIPTION OF THE ANALYTIC PROCESS

ANALYSIS OF EVIDENCE What is the TE risk of

temporarily discontinuing AP agents? Based on one Class

I study1 and 2 Class II studies2,3 that addressed TE risks

of temporarily discontinuing AP agents, aspirin discontinuation is probably associated with increased stroke or
TIA risk. Estimated stroke risk varies with the duration of
aspirin discontinuation: relative risk (RR) was 1.97 for 2
weeks, odds ratio was 3.4 for 4 weeks, and RR was 1.40
for 5 months (one Class II study each).
What is the TE risk of temporarily discontinuing AC? Studies

of AC discontinuation enroll subjects with various AC indications, each with different TE risks. No studies meeting inclusion criteria with sufficient sample size to
support conclusions compared TE risks in subjects continuing warfarin with those discontinuing warfarin (with
or without periprocedural heparin bridging). One Class I
study4 found that the TE event risk of warfarin discontinuation is probably higher if AC is stopped for $7 days
(RR 5.5, 95% confidence interval 1.224.2) (one Class I
study).
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Neurology 80

What are the perioperative bleeding risks of continuing

antithrombotic agents? Table 1 summarizes the evidence-

based conclusions developed from the systematic review

of the literature. Only procedures for which we found
evidence appear in table 1. For specific details, including quantitative descriptions of risks, refer to the full
guideline document (www.neurology.org).
If oral AC is stopped, should bridging therapy be used?

There is insufficient evidence to support or refute a difference in TE events when heparin bridging is used
(vs discontinuation of oral AC without bridging); however, most studies suggest that heparin bridging is
probably associated with an increased risk of periprocedural bleeding in general (2 Class I studies, one Class II
study, and one Class III study showing increased risk,
with one additional Class I study showing no substantial increased risk).
There is insufficient evidence to support or refute differences in TE risk between management strategies of
continuing oral AC vs heparin bridging. One Class I
study found that the risk of bleeding is probably similar
between low-molecular-weight heparin bridging and AC
continuation in dental procedures.
If an antithrombotic agent is stopped, what should be the
timing of discontinuation? Data are insufficient to sup-

port any conclusions.

The antithrombotic effect duration of aspirin and clopidogrel is estimated to be 7 days.5
The duration of action of a single dose of warfarin is
estimated at 2 to 5 days.5 Hence, to reverse the antithrombotic effect, it is generally recommended that AP
agents be stopped 7 to 10 days, and warfarin 5 days,
preprocedure.6 Shorter discontinuation periods were
used in many of the reviewed studies.
Stopping antithrombotics increases the risk of
TE events. The exact magnitude of this risk increase
is unknown. To minimize this risk, it seems reasonable to minimize the duration of antithrombotic
discontinuation.
When considering the risks and benefits of antithrombotic discontinuation, it is important to consider both the frequency of undesirable outcomes and
their long-term consequences. TE events occur infrequently, but the associated morbidity and mortality
rates are high. In contrast, most reported bleeding outcomes are relatively mild. Decisions regarding periprocedural antithrombotic therapy depend on weighing
these competing risks in the context of individual
patient characteristics.
Patient preferences must inform these riskbenefit
judgments. In a study comparing preferences of patients
with atrial fibrillation with those of physicians, patients
were willing to experience a mean of 17.4 excess-bleeding events with warfarin and 14.7 excess-bleeding events
CLINICAL CONTEXT

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Table 1

Summary of evidence-based conclusions regarding bleeding risks associated with continuing

antithrombotics for various proceduresa

Effect on clinically important bleeding risk

and confidence in evidence

Aspirinb

Warfarinb

Highly likely not to increase bleeding risk

Dental procedures

Dental procedures

Likely not to increase bleeding risk

Invasive ocular anesthesia

Dermatologic procedures (small risk)

Cataract surgery

Invasive ocular anesthesia

Dermatologic procedures
TRUS-guided prostate biopsy
Spinal/epidural needle procedures
Carpal tunnel syndrome surgery
Possibly does not increase bleeding risk

Vitreoretinal surgery

EMG

EMG

Prostate procedures

Transbronchial biopsy

Inguinal herniorrhaphy

Colonoscopic polypectomy

Endothermal ablation of the saphenous vein

Upper-gastrointestinal endoscopic
biopsy
Sphincterotomy
Ultrasound-guided biopsies
Insufficient evidence to determine whether TURP
bleeding risk is increased or not increased

Ophthalmologic procedures (other than

anesthesia)

Possibly increases bleeding risk

Colonoscopic polypectomy

Likely to increase bleeding risk

Orthopedic hip procedures

Abbreviations: TRUS 5 transrectal ultrasound; TURP 5 transurethral resection of the prostate.

a
See complete guideline document (www.neurology.org) for specific descriptions of the procedures.
b
The experience with aspirin and warfarin cannot be confidently extrapolated to other antithrombotic medications.

with aspirin to prevent a stroke.7 Sample clinical scenarios for guideline application are presented in appendix 1.
RECOMMENDATIONS

1. It is axiomatic that clinicians managing antithrombotic medications periprocedurally weigh bleeding

risks from drug continuation against TE risks from
discontinuation at the individual patient level,
although high-quality evidence on which to base
this decision is often unavailable. In addition, even
when evidence is insufficient to exclude a difference in bleeding or shows a small increase in clinically important bleeding with antithrombotic
agents, physicians may reasonably judge that the
risks and morbidity of TE events exceed those
associated with bleeding.
2. Neurologists should counsel both patients taking
aspirin for secondary stroke prevention and their
physicians that aspirin discontinuation is probably associated with increased stroke and TIA
risk (Level B). Estimated stroke risks vary across
studies and according to duration of aspirin
discontinuation.
3. Neurologists should counsel patients taking AC
for stroke prevention that the TE risks associated

with different AC periprocedural management

strategies (continuing oral AC or stopping it with
or without bridging heparin) are unknown (Level
U) but that the risk of TE complications with
warfarin discontinuation is probably higher if AC
is stopped for $7 days (Level B).
4. Patients taking aspirin should be counseled that
aspirin continuation is highly unlikely to increase
clinically important bleeding complications with
dental procedures (Level A). Given minimal clinically important bleeding risks, it is reasonable that
stroke patients undergoing dental procedures should
routinely continue aspirin (Level A).
5. Patients taking aspirin should be counseled that
aspirin continuation probably does not increase clinically important bleeding complications with invasive ocular anesthesia, cataract surgery, dermatologic
procedures, transrectal ultrasoundguided prostate
biopsy, spinal/epidural procedures, and carpal tunnel surgery (Level B). Given minimal clinically
important bleeding risks, it is reasonable that stroke
patients undergoing these procedures should probably continue aspirin (Level B).
6. Aspirin continuation might not increase clinically important bleeding in vitreoretinal surgery,
EMG, transbronchial lung biopsy, colonoscopic
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7.

8.

9.

10.

11.

12.

13.

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polypectomy, upper endoscopy with biopsy, sphincterotomy, and abdominal ultrasoundguided biopsies. Given the weaker data supporting minimal
clinically important bleeding risks, it is reasonable that some stroke patients undergoing these
procedures should possibly continue aspirin
(Level C).
Although bleeding events were rare, studies of
transurethral resection of the prostate lack the statistical precision to exclude clinically important
bleeding risks with aspirin continuation (Level U).
Patients taking aspirin should be counseled that
aspirin probably increases bleeding risks during
orthopedic hip procedures (Level B).
Neurologists should counsel patients that there is
insufficient evidence to make recommendations
regarding appropriate periprocedural clopidogrel,
ticlopidine, or aspirin/dipyridamole management
in most situations (Level U). Aspirin recommendations cannot be extrapolated with certainty to
other AP agents.
Patients taking warfarin should be counseled that
warfarin continuation is highly unlikely to be associated with increased clinically important bleeding
complications with dental procedures (Level A).
Given minimal bleeding risks, stroke patients undergoing dental procedures should routinely continue
warfarin (Level A).
Patients taking warfarin should be counseled that
warfarin continuation is probably associated with
only a small (1.2%) increased risk difference for
bleeding during dermatologic procedures on the
basis of a meta-analysis of heterogeneous and conflicting studies (Level B). Thus, patients undergoing
dermatologic procedures should probably continue
warfarin (Level B).
Patients taking warfarin should be counseled that
warfarin continuation is probably not associated
with an increased risk of clinically important
bleeding with ocular anesthesia (Level B). However, AC practices during ophthalmologic procedures may be driven by the postanesthesia
procedure. Although bleeding events were rare,
ophthalmologic studies (other than those regarding ocular anesthesia) lack the statistical precision
to exclude clinically important bleeding risks
with warfarin continuation. Thus, there is insufficient evidence to make practice recommendations regarding warfarin discontinuation in
ophthalmologic procedures (Level U).
Warfarin might be associated with no increased clinically important bleeding with EMG, prostate procedures, inguinal herniorrhaphy, and endothermal
ablation of the great saphenous vein. Thus, patients
undergoing these procedures should possibly continue warfarin (Level C).

Neurology 80

14. Patients taking warfarin should be counseled that

warfarin continuation might increase bleeding
with colonoscopic polypectomy (Level C). Thus,
patients undergoing this procedure should possibly temporarily discontinue warfarin (Level C).
15. Neurologists should counsel patients that there is
insufficient evidence to make recommendations
regarding appropriate periprocedural management of nonwarfarin oral AC (Level U). Warfarin recommendations cannot be extrapolated
with certainty to other AC agents.
16. There is insufficient evidence to determine differences in TE in chronically anticoagulated patients
managed with heparin bridging therapy relative to
oral AC discontinuation or continuation. Patients
taking warfarin should be counseled that bridging
therapy is probably associated with increased bleeding risks in procedures in general relative to AC
cessation (Level B). Bridging probably does not
reduce clinically important bleeding relative to continued AC with warfarin in dentistry, but bleeding
risk differences between patients managed with continued warfarin vs bridging therapy in other procedures are unknown. Given that the benefits of
bridging therapy are not established and that bridging is probably associated with increased bleeding
risks, there is insufficient evidence to support or
refute bridging therapy use in general (Level U).
AUTHOR CONTRIBUTIONS
Melissa J. Armstrong: drafting/revising the manuscript, study concept or design,
analysis or interpretation of data, acquisition of data, statistical analysis. Gary
Gronseth: drafting/revising the manuscript, study concept or design, analysis
or interpretation of data. David C. Anderson: drafting/revising the manuscript,
acquisition of data. Jos Biller: drafting/revising the manuscript, study concept or
design, analysis or interpretation of data, acquisition of data, statistical analysis,
study supervision. Brett Cucchiara: drafting/revising the manuscript, analysis or
interpretation of data. Rima Dafer: drafting/revising the manuscript, analysis or
interpretation of data, acquisition of data, statistical analysis. Larry B. Goldstein:
drafting/revising the manuscript, analysis or interpretation of data. Michael
Schneck: drafting/revising the manuscript, study concept or design, analysis or
interpretation of data. Steven R. Mess: drafting/revising the manuscript, study
concept or design, analysis or interpretation of data, study supervision.

ACKNOWLEDGMENT
The authors thank Thomas S.D. Getchius and Erin Hagen for support during
guideline development and Stanley N. Cohen, MD, and Cathy Sila, MD, for
assistance with abstract review in early guideline development.

STUDY FUNDING
This guideline was developed with financial support from the American
Academy of Neurology. None of the authors received reimbursement, honoraria, or stipends for their participation in development of this guideline.

DISCLOSURE
M.J. Armstrong, G. Gronseth, D.C. Anderson, J. Biller, B. Cucchiara,
R. Dafer, and L.B. Goldstein report no disclosures. M. Schneck has participated
in the past 2 years as a local principal investigator for multicenter trials sponsored by the NIH, Lundbeck Pharmaceuticals, Brigham & Womens/Schering
Plough (Thrombolysis in Myocardial Infarction consortium), Gore Inc., and
NMT Medical. He is currently working on an investigator-initiated project

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to be supported by Baxter, Inc. He has served on speakers bureaus for Boehringer-Ingelheim and Bristol-Myers Sanofi (none in past 2 years); has received
an honorarium from the American Academy of Neurology Continuum project,
from UpToDate.com, and from various continuing medical education lectures;
and has participated in expert testimony for medical malpractice cases. He has
no significant stock or other financial conflicts of interest. S.R. Mess has
received royalties for articles on antithrombotics and stroke published on
www.UpToDate.com. He has also received research support from the NIH
for a study of the pharmacogenomics of warfarin and a study to evaluate
neurologic outcomes from surgery. Go to Neurology.org for full disclosures.

DISCLAIMER
This statement is provided as an educational service of the American Academy of Neurology. It is based on an assessment of current scientific and clinical information. It is not intended to include all possible proper methods of
care for a particular neurologic problem or all legitimate criteria for choosing
to use a specific procedure. Neither is it intended to exclude any reasonable
alternative methodologies. The AAN recognizes that specific patient care
decisions are the prerogative of the patient and the physician caring for the
patient, based on all of the circumstances involved. The clinical context section is made available in order to place the evidence-based guideline(s) into
perspective with current practice habits and challenges. Formal practice recommendations are not intended to replace clinical judgment.

CONFLICT OF INTEREST
The American Academy of Neurology is committed to producing independent, critical, and truthful clinical practice guidelines (CPGs). Significant efforts are made to minimize the potential for conflicts of interest to
influence the recommendations of this CPG. To the extent possible, the
AAN keeps separate those who have a financial stake in the success or failure of the products appraised in the CPGs and the developers of the
guidelines. Conflict of interest forms were obtained from all authors
and reviewed by an oversight committee prior to project initiation.
AAN limits the participation of authors with substantial conflicts of interest. The AAN forbids commercial participation in, or funding of, guideline projects. Drafts of the guideline have been reviewed by at least 3
AAN committees, a network of neurologists, Neurology peer reviewers,
and representatives from related fields. The AAN Guideline Author Conflict of Interest Policy can be viewed at www.aan.com.

APPENDIX 1
Sample clinical scenarios for guideline application. Clinical scenario 1: Patient A
is a 65-year-old man with a history of hypertension and hypercholesterolemia
who had a stroke 1 year ago attributed to intracranial large-artery atherosclerosis. He has mild residual left hemiparesis, and his secondary stroke prevention therapy includes risk factor control and aspirin 325 mg daily. He is due
for routine colonoscopy screening. His neurologist reviews the guideline and
assesses that the patients risk for recurrent stroke includes his known intracranial large-artery atherosclerotic event. Given that the patient may not need
polypectomy with his colonoscopy, that the risk difference for bleeding with
polypectomy associated with aspirin is approximately 2.0%, and that bleeding
with polypectomy is likely to have lower morbidity risk than recurrent stroke
risk, the neurologist recommends that aspirin be continued pericolonoscopy
and obtains the opinions of both the patient and his gastrointestinal physician.
The patient wants to have his colonoscopy, as his cousin was recently diagnosed with colon cancer, and is willing to accept an increased bleeding risk to

avoid recurrent stroke. Thus, he proceeds with colonoscopy and possible

polypectomy while continuing aspirin 325 mg daily.
Clinical scenario 2: Patient B is a 70-year-old woman who had a
small-vessel distribution ischemic stroke associated with uncontrolled
hypertension 5 years previously. She has no residual deficits and has been
diligent in controlling her vascular risk factors. She has recently been
diagnosed with breast cancer requiring mastectomy. Her neurologist reviews the guideline and notes that there is minimal literature for the risks
associated with more invasive procedures. The neurologist counsels the
patient and her oncologist that the patient likely has a relatively low risk
of recurrent stroke with brief aspirin cessation and that there is little research
on bleeding risks with aspirin during invasive procedures. Together, they
choose to stop the aspirin 7 days before the surgery and restart it the day
after the surgery. The importance of restarting the aspirin postoperatively
is stressed, and a specific start date is provided to the patient.
Clinical scenario 3: Patient C is a 60-year-old man with chronic atrial
fibrillation and prior cardioembolic stroke treated with chronic warfarin.
He is the primary caregiver for his wife with Alzheimer disease, but his cataracts have worsened to the degree that surgery is needed for him to continue to care for her and drive her to appointments. The patients
neurologist reviews the guideline and finds that the risks associated with
warfarin during ophthalmologic procedures have not been established with
sufficient precision. The patient feels strongly, however, that he would rather
tolerate the chance of increased bleeding complications than risk a recurrent
cardioembolic stroke that might impair his ability to care for his wife. Given
the riskbenefit ratio and patient preference, the ophthalmologist, neurologist, and patient decide to continue warfarin during the cataract surgery.

Received August 24, 2012. Accepted in final form January 3, 2013.

REFERENCES
1. Oscarsson A, Gupta A, Fredrikson M, et al. To continue or
discontinue aspirin in the perioperative period: a randomized,
controlled clinical trial. Br J Anaesth 2010;104:305312.
2. Maulaz AB, Bezerra DC, Michel P, Bogousslavsky J. Effect
of discontinuing aspirin therapy on the risk of brain ischemic stroke. Arch Neurol 2005;62:12171220.
3. Garcia Rodriguez LA, Cea Soriano L, Hill C, Johansson S.
Increased risk of stroke after discontinuation of acetylsalicylic acid: a UK primary care study. Neurology 2011;76:
740746.
4. Garcia DA, Regan S, Henault LE, et al. Risk of thromboembolism with short-term interruption of warfarin therapy.
Arch Intern Med 2008;168:6369.
5. Repchinsky C, ed. CPS 2009 Compendium of Pharmaceuticals and Specialties. Ottawa: Canadian Pharmacists Association;
2009.
6. Douketis JD, Berger PB, Dunn AS, et al. The perioperative
management of antithrombotic therapy: American College of
Chest Physicians evidence-based clinical practice guidelines
(8th ed). Chest 2008;133:299S339S.
7. Devereaux PJ, Anderson DR, Gardner MJ, et al. Differences
between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study.
BMJ 2001;323:12181222.

Endorsed by the American Osteopathic Association, the European Federation of Neurological Sciences, and the
European Neurological Society.

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Summary of evidence-based guideline: Periprocedural management of antithrombotic

medications in patients with ischemic cerebrovascular disease: Report of the Guideline
Development Subcommittee of the American Academy of Neurology
Melissa J. Armstrong, Gary Gronseth, David C. Anderson, et al.
Neurology 2013;80;2065-2069
DOI 10.1212/WNL.0b013e318294b32d
This information is current as of May 27, 2013

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1951, it is now a weekly with 48 issues per year. Copyright 2013 American Academy of Neurology. All
rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.

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Neurology is the official journal of the American Academy of Neurology. Published continuously since
1951, it is now a weekly with 48 issues per year. Copyright 2013 American Academy of Neurology. All
rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.