Download PDF
Hamostaseologie 1997; 17(02): 100-107
DOI: 10.1055/s-0038-1660024
Übersichtsarbeiten/Review Articles
Schattauer GmbH

Heparinbehandlung des akuten ischämischen zerebralen Insultes

J. Glahn
1   Neurologische Klinik, Klinikum Minden (Chefarzt: Prof. Dr. O. Busse)
,
O. Busse
1   Neurologische Klinik, Klinikum Minden (Chefarzt: Prof. Dr. O. Busse)
› Author Affiliations
Further Information

Publication History

Publication Date:
27 June 2018 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Die Antikoagulation mit Heparin in der Akutphase des ischämischen Hirninfarkts ist keine kurative Maßnahme, sondern dient der Prophylaxe von Rezidivinsulten oder anderen thrombembolischen Komplikationen. Die subkutane Heparinbehandlung zur Prävention venöser thrombembolischer Komplikationen gilt im allgemeinen als gesichertes Therapieprinzip. Im Gegensatz hierzu ist die Wirksamkeit der intravenösen Heparinbehandlung mit PTT-wirksamen Dosen zur Rezidivprophylaxe nicht gesichert, wenn auch bei kardiogenen Embolien und Hochrisikopatienten mit atherothrombotischen Insulten sehr wahrscheinlich. Unverzichtbar vor der intravenösen Behandlung mit Heparin ist ein Computertomogramm zum Ausschluß einer Hirnblutung. Unter Berücksichtigung und Kenntnis potentieller Risikopatienten und Nebenwirkungen ist die Antikoagulation mit Heparin eine risikoarme Behandlung.

Schlüsselwörter

Ischämischer zerebraler Insult - intravenöses Heparin - subkutanes Heparin - Sekundärprophylaxe
 

  • LITERATUR

  • 1 Adams HPA, Bendixen BH, Kappelle LJ. et al. and the TOAST Investigators. Classification of subtype of acute ischemic stroke. Stroke 1993; 24: 35-41.
    CrossrefPubMedGoogle Scholar
  • 2 Babikian VL, Kase CS, Pessin MS. et al. Intracerebral hemorrhage in stroke patients anticoagulated with heparin. Stroke 1989; 20: 1500-3.
    CrossrefPubMedGoogle Scholar
  • 3 Bauer T, Hornig CR, Trittmacher S. et al. Hemorraghic transformation in cardio-embolie stroke – ACT and MRI study. Cerebrovasc Dis 1992; 2: 201.
    PubMedGoogle Scholar
  • 4 Becker RC, Ansell J. Anithrombotic therapy. An abbreviated reference for clinicans. Arch Intern Med 1995; 155: 149-61.
    CrossrefPubMedGoogle Scholar
  • 5 Biller J, Bruno A, Adams HP. et al. A randomized trial of aspirin or heparin in hospitalized patients with recent transient ischemic attacks – A pilot study. Stroke 1989; 20: 441-7.
    CrossrefPubMedGoogle Scholar
  • 6 Biller J, Massey EW, Marler JR. et al. A dose escalation study of ORG 1072 (low molecular weight heparinoid) in stroke. Neurology 1989; 39: 262-5.
    CrossrefPubMedGoogle Scholar
  • 7 Boeer A, Voth F, Henze Th, Prange HW. Early heparin therapy in patients with spontaneous intracerebral haemorrhage. J Neurol Neurosurg Psychiatry 1991; 54: 466-7.
    CrossrefPubMedGoogle Scholar
  • 8 Bogousslavsky J, Van Melle G, Regli F. The Lausanne Stroke Registry: Analysis of 1,000 consecutive patients with first stroke. Stroke 1988; 19: 1083-92.
    CrossrefPubMedGoogle Scholar
  • 9 Bogousslavsky J, Regli F, Uské A, Maeder PH. Early spontaneous hematoma in cerebral infarct: Is primary cerebral hemorrhage overdiagnosed?. Neurology 1991; 41: 837-40.
    CrossrefPubMedGoogle Scholar
  • 10 Boysen G, Petersen P, Godtfredsen J. Prevention of cardioembolic stroke. In: Stroke Prevention. Dorndorf W, Marx P. (eds) Basel: Karger; 1994: 188-96.
    Google Scholar
  • 11 Brainin M. Zur ätiologischen Klassifikation des zerebralen Insults. Erfahrungen aus einem prospektiven Datenregister. Nervenarzt 1990; 61: 719-24.
    PubMedGoogle Scholar
  • 12 Bruhn HD. »Low-dose heparin« nach neu-rochirugischem Eingriff und Schlaganfall. In: Niedrig dosiertes Heparin. Wirkungsweise und Indikationen. Bruhn HD. (Hrsg) Stuttgart, New York: Schattauer; 1996: 69-74.
    Google Scholar
  • 13 Busse O. Spontane Dissektion extrakra-nieller hirnversorgender Arterien. Dtsch Med Wochenschr 1988; 113: 1191-3.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Busse O, Laun A. Therapie des raumfordernden Kleinhirninfarkts. Akt Neurol 1988; 15: 6-8.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Busse O. Antithrombotische Therapie nach akuten intrakraniellen Thrombembolien. Hämostaseologie 1990; 10: 21-7.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Busse O. Anticoagulants in ischemic stroke. Curr Opin Therap Patents 1991; 1: 375-87.
    PubMedGoogle Scholar
  • 17 Busse O, Hornig CR, Hacke W, Ringelstein EB. Antikoagulation und Thrombolyse beim akuten Hirninfarkt. Münch Med Wochenschr 1994; 136: 442-6.
    PubMedGoogle Scholar
  • 18 Calandre L, Ortega JF, Bermejo F. Anticoagulation and hemorrhagic infarction in cerebral embolism secondary to rheumatic heart disease. Arch Neurol 1984; 41: 1152-4.
    CrossrefPubMedGoogle Scholar
  • 19 Caplan LR. Brain embolism, revisited. Neurology 1993; 43: 1281-7.
    CrossrefPubMedGoogle Scholar
  • 20 Cerebral Embolism Study Group.. Immediate anticoagulation of embolic stroke. Stroke 1983; 14: 668-76.
    CrossrefPubMedGoogle Scholar
  • 21 Cerebral Embolism Study Group.. Immediate anticoagulation of embolic stroke: Brain hemorrhage and management options. Stroke 1984; 15: 779-89.
    CrossrefPubMedGoogle Scholar
  • 22 Cerebral Embolism Study Group.. Cardioembolic stroke, early anticoagulation and brain hemorrhage. Arch Int Med 1987; 147: 636-40.
    CrossrefPubMedGoogle Scholar
  • 23 Cerebral Embolism Task Force.. Cardiogenic brain embolism. Arch Neurol 1989; 46: 727-43.
    CrossrefPubMedGoogle Scholar
  • 24 Chamorro A, Vila N, Saiz A. et al. Early anticoagulation after large cerebral embolic infarction: A safety study. Neurology 1995; 45: 861-5.
    CrossrefPubMedGoogle Scholar
  • 25 Chesterman CN, Chong BH. Uses of heparin. Standard heparin still the anticoagulant of choise in most clinical settings. Br Med J 1993; 306: 871-2.
    CrossrefPubMedGoogle Scholar
  • 26 Czechanowski B, Heinrich F. Prophylaxe venöser Thrombosen bei frischem ischämischem zerebrovaskulärem Insult. Doppelblindstudie mit Heparin-Dihydergot. Dtsch Med Wochenschr 1981; 106: 1254-60.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Dahl T, Sandset PM, Abildgaard U. Heparin treatment in 52 patients with progressive ischemic stroke. Cerebrovasc Dis 1994; 4: 101-5.
    CrossrefPubMedGoogle Scholar
  • 28 Dickmann U, Voth E, Schicha H. et al. Heparin therapy, deep vein thrombosis and pulmonary embolism after intracerebral haemorrhage. Klin Wochenschr 1988; 66: 1182-3.
    CrossrefPubMedGoogle Scholar
  • 29 Dorman P, Counsell C, Sandercock P. Antithrombotic therapy in acute ischemic stroke. Arch Int Med 1995; 155: 2481.
    CrossrefPubMedGoogle Scholar
  • 30 Duke RJ, Turpie AG, Bloch RF, Trebilock RG. Clinical trial of low-dose subcutaneous heparin for the prevention of stroke progression: natural history of acute partial stroke and stroke in evolution. In: Reivich M, Hurtig HI. (eds) Cerebrovascular Disease. New York: Raven Press; 1983: 399-405.
    Google Scholar
  • 31 Duke RJ, Bloch RF, Turpie AGG. et al. Intravenous heparin for the prevention of stroke progression in acute partial stable stroke: A randomized controlled trial. Ann Int Med 1986; 105: 825-8.
    CrossrefPubMedGoogle Scholar
  • 32 Elias A, Milandre L, Lagrange G. et al. Prevention of deep-vein thrombosis of the lower limbs with a very low molecular weight heparin fraction (CY 222) in patients with hemiplegia due to cerebral infarction: A randomized pilot study in 30 patients. Rev Med Interne 1990; 11: 95-8.
    CrossrefPubMedGoogle Scholar
  • 33 Estol CJ, Pessin MS. Anticoagulation: Is there still a role in atherothrombotic stroke?. Stroke 1990; 21: 820-4.
    CrossrefPubMedGoogle Scholar
  • 34 Foulkes MA, Wolf PA, Price TR. et al. The Stroke Data Bank: Design, methods, and baseline characteristics. Stroke 1988; 19: 547-554.
    CrossrefPubMedGoogle Scholar
  • 35 Furlan AJ, Cavalier SJ, Hobbs RE. et al. Hemorrhage and anticoagulation after non-septic embolic brain infarction. Neurology 1982; 32: 280-2.
    CrossrefPubMedGoogle Scholar
  • 36 Glahn J, Straeten V, Busse O. Heparin im akuten Stadium des ischämischen zerebralen Insults zur Rezidivprophylaxe. In: Verhandlungen der Deutschen Gesellschaft für Neurologie. Schimrigk K, Haaß A, Hamann G. (Hrsg) Zweibrücken: Verlag Conrad und Bothner; 1992: 760-3.
    Google Scholar
  • 37 Glahn J, Straeten V. Pathogenese und klinischer Verlauf akuter ischämischer zerebrovaskulärer Insulte an einem kommunalen Schwerpunktkrankenhaus. Nervenarzt 1994; 65: 101-8.
    PubMedGoogle Scholar
  • 38 Glahn J, Busse O. Risk of bleeding complications in large ischemic MCA-infarction treated with heparin. Cerebrovasc Dis 1994; 4: 224.
    CrossrefPubMedGoogle Scholar
  • 39 Glahn J, Busse O. The course of aPTT in heparin treatment started with a bolus injection in patients with an acute ischemic stroke. Emergency Management And Care Of Stroke. Satellite Conference to the Joint third World Stroke Congress and the fifth European Sroke Conference. Heidelberg 05.-07. 09.1996
    PubMedGoogle Scholar
  • 40 Greinacher A, Mueller-Eckhardt C. Diagnostik der Heparin-assoziierten Thrombozytopenie. Dtsch Med Wochenschr 1991; 116: 120-3.
    PubMedGoogle Scholar
  • 41 Greinacher A, Mueller-Eckhardt C. Therapie der Heparin-assoziierten Thrombozytopenie. Dtsch Med Wochenschr 1991; 116: 1483-4.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 42 Grotta JC. The current status of neuronal protective therapy: Why have all drugs worked in animals but none so far in stroke patients. Cerebrovasc Dis 1994; 4: 115-20.
    CrossrefPubMedGoogle Scholar
  • 43 Géraud G, Bès A. Is anticoagulant therapy too frequently used in ischemic stroke?. Cerebrovasc Dis 1991; 1: 120-3.
    CrossrefPubMedGoogle Scholar
  • 44 Hacke W, Kaste M, Fieschi C. et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke: The European Cooperative Stroke Study (ECASS). J Am Med Assoc 1995; 274: 1017-25.
    CrossrefPubMedGoogle Scholar
  • 45 Haley EC, Kassell NF, Torner JC. Failure of heparin to prevent progression in progressing ischemic infarction. Stroke 1988; 19: 10-4.
    CrossrefPubMedGoogle Scholar
  • 46 Hart RG, Coull BM, Hart D. Anticoagulation and embolic infarction. Neurology 1983; 33: 253.
    PubMedGoogle Scholar
  • 47 Hart RG, Easton JD. Dissections. Stroke 1985; 16: 925-7.
    CrossrefPubMedGoogle Scholar
  • 48 Hart RG, Easton JD. Hemorrhagic infarcts. Stroke 1986; 17: 586-9.
    CrossrefPubMedGoogle Scholar
  • 49 Hart RG, Foster JW, Luther MF, Kanter M. Stroke in infective endocarditis. Stroke 1990; 21: 695-700.
    CrossrefPubMedGoogle Scholar
  • 50 Hornig CR, Dorndorf W, Agnoli AL. Hemorrhagic cerebral infarction – A prospective study. Stroke 1986; 17: 179-85.
    CrossrefPubMedGoogle Scholar
  • 51 Hornig CR, Kramer W, Dorndorf W. Hirnembolien nach Herzinfarkten. Akt Neurol 1990; 17: 1-11.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 52 Jonas S. Anticoagulant therapy in cerebrovascular disease: Review and metaanalysis. Stroke 1988; 19: 1043-8.
    CrossrefPubMedGoogle Scholar
  • 53 Kay R, Sing Wong K, Ling Yu Y. et al. Low-molecular-weight heparin for the treatment of acute ischemic stroke. N Engl J Med 1995; 333: 1588-93.
    CrossrefPubMedGoogle Scholar
  • 54 Koller RL. Recurrent cerebral infarction and anticoagulation. Neurology 1982; 32: 283-5.
    CrossrefPubMedGoogle Scholar
  • 55 Korczyn AD. Heparin in the treatment of acute stroke. Neurologic Clinics 1992; 10: 209-17.
    CrossrefPubMedGoogle Scholar
  • 56 Kunze I, Glahn J, Busse O. Heparintherapie bei embolischen, zerebralen Insulten. Nervenarzt 1991; 62: 477-82.
    PubMedGoogle Scholar
  • 57 Lee RJ, Bartzokis T, Yeoh TK. et al. Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography. Stroke 1991; 22: 734-9.
    CrossrefPubMedGoogle Scholar
  • 58 Leonhardt G, Weiller C, Müllges W. et al. Antikoagulation beim akuten Schlaganfall. Nervenarzt 1991; 62: 470-6.
    PubMedGoogle Scholar
  • 59 Levine MN, Hirsh J. Hemorrhagic complications of anticoagulant therapie. Sem Thromb Hemost 1986; 12: 39-57.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 60 Lindley RI, Sandercock PAG. Uses of heparin. Withhold in acute ischemic stroke. Br Med J 1993; 306.
    PubMedGoogle Scholar
  • 61 Lindley RI, Amayo EO, Marshall J. et al. Acute stroke treatment in UK hospitals: the stroke association survey of consultant opinion. J Royal Coll Phys 1995; 29: 479-84.
    PubMedGoogle Scholar
  • 62 Lodder J, Van der Lugt PJM. Evaluation of the risk of immediate anticoagulant therapie in patients with embolic stroke of cardiac origin. Stroke 1983; 14: 42-6.
    CrossrefPubMedGoogle Scholar
  • 63 Marsh III EE., Adams HP, Biller J. et al. Use of antithrombotic drugs in the treatment of acute ischemic stroke: A survey of neurologists in practice in the United States. Neurology 1989; 39: 1631-4.
    CrossrefPubMedGoogle Scholar
  • 64 Marshall J. Anticoagulants in the treatment of stroke. In: Poeck K, Ringelstein EB, Hacke W. (eds) New Trends in Diagnosis and Management of Stroke. Berlin: Springer; 1987: 97-101.
    CrossrefGoogle Scholar
  • 65 Massey EW, Biller J, Davis JN. et al. Large-dose infusions of heparinoid ORG 10172 in ischemic stroke. Stroke 1990; 21: 1289-92.
    CrossrefPubMedGoogle Scholar
  • 66 McCarthy ST, Robertson D, Turner JJ, Hawkey CJ. Low-dose heparin as a prophylaxis against deep vein thrombosis after acute stroke. Lancet 1977; ii: 800-1.
    PubMedGoogle Scholar
  • 67 McCarthy ST, Turner J. Low-dose subcutaneous heparin in the prevention of deep vein thrombosis and pulmonary emboli following acute stroke. Age Aging 1986; 15: 84-8.
    CrossrefPubMedGoogle Scholar
  • 68 Miller VT, Hart RG. Heparin anticoagulation in acute brain ischemia. Stroke 1988; 19: 403-6.
    CrossrefPubMedGoogle Scholar
  • 69 Mokri BO, Houser OW, Sandok BA, Piep-gras DG. Spontaneous dissection of the vertebral arteries. Neurology 1988; 38: 880-5.
    CrossrefPubMedGoogle Scholar
  • 70 Miick AO, Heinrich F. Thromboembolie-prophylaxe mit niedrigdosierten Heparin-regimen bei frischem Schlaganfall. Med Klin 1992; 87: 422-7.
    PubMedGoogle Scholar
  • 71 Müllges W, Ringelstein EB, Weiller C. et al. Dissections of the internal carotid artery – New diagnostic and pathogenetic aspects. Fortschr Neurol Psychiat 1991; 59: 12-24.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 72 Okada Y, Yamaguchi T, Minematsu K. et al. Hemorrhagic transformation in cerebral embolism. Stroke 1989; 20: 598-603.
    CrossrefPubMedGoogle Scholar
  • 73 Pessin MS, Estol CJ, Lafranchise F, Caplan LR. Safety of anticoagulation after hemorrhagic infarction. Neurology 1993; 43: 1298-1303.
    CrossrefPubMedGoogle Scholar
  • 74 Petersen P, Kastrup J, Helweg-Larsen S. et al. Arch Intern Med 1990; 150: 819-21.
    CrossrefPubMed
  • 75 Phillips SJ. An alternative view of heparin anticoagulation in acute focal brain ischemia. Stroke 1989; 20: 295-8.
    CrossrefPubMedGoogle Scholar
  • 76 Prins MH, Gelsema R, Sing AK. et al. Prophylaxis of deep vein thrombosis with a low-molecular-weight heparin (Kabi 2165/Fragmin) in stroke patients. Haemostasis 1989; 19: 245-50.
    PubMedGoogle Scholar
  • 77 Putman SF, Adams HP. Usefulness of heparin in initial managment of patients with recent transient ischemic attacks. Arch Neurol 1985; 42: 960-2.
    CrossrefPubMedGoogle Scholar
  • 78 Ramirez-Lassepas M, Quinones MR, Nino HH. Treatment of acute ischemic stroke. Open trial with continuous intravenous heparinisation. Arch Neurol 1986; 43: 386-90.
    CrossrefPubMedGoogle Scholar
  • 79 Rothrock JF, Dittrich HC, McAllen St. et al. Acute anticoagulation following cardioem-bolic stroke. Stroke 1989; 20: 730-4.
    CrossrefPubMedGoogle Scholar
  • 80 Sacco RL, Foulkes MA, Mohr JP. et al. Determinants of early recurrence of cerebral infarction. Stroke 1989; 20: 983-9.
    CrossrefPubMedGoogle Scholar
  • 81 Sage JI. Stroke. The use and overuse of heparin in therapeutic trials. Arch Neurol 1985; 42: 315-6.
    CrossrefPubMedGoogle Scholar
  • 82 Sandercock PAG, van den Belt AGM, Lindley RI, Slattery J. Antithrombotic therapy in acute ischemic stroke: an overview of the completed randomised trials. J Neurol Neurosurg Psychiatry 1993; 56: 17-25.
    CrossrefPubMedGoogle Scholar
  • 83 Sandercock PAG. for the International Stroke Trial Collaborative Group. The International Stroke Trial. Preliminary results: effects of aspirin and heparin separately and in combination. Joint third World Stroke Congress and fifth European Stroke Conference. München, 01-04. 09.1996.
    PubMedGoogle Scholar
  • 84 Sandset PM, Dahl T, Stiris M. et al. A double-blind and randomized placebo-controlled trial of low molecular weight heparin once daily to prevent deep vein thrombosis in acute ischemic stroke. Sem Thromb Hemosts 1990; Suppl 16: 25-33.
    PubMedGoogle Scholar
  • 85 Scheinberg P. Heparin anticoagulation. Stroke 1989; 20: 173-4.
    CrossrefPubMedGoogle Scholar
  • 86 Schwab S, Rieke K, Krieger D. et al. Kra-niektomie bei raumfordernden Mediainfarkten. Nervenarzt 1995; 66: 430-7.
    PubMedGoogle Scholar
  • 87 Sherman DG, Dyken ML, Gent M. et al. Antithrombotic therapy for cerebrovascular disorders. An update. Chest 1995; 108 Suppl S444-S456.
    CrossrefPubMedGoogle Scholar
  • 88 Shields RW, Laureilo R, Lachman T, Victor M. Anticoagulant-related hemorrhage in acute cerebral embolism. Stroke 1984; 15: 426-37.
    CrossrefPubMedGoogle Scholar
  • 89 Slivka A, Levy D. Natural history of progressive ischemic stroke in a population treated with heparin. Stroke 1990; 21: 1657-62.
    CrossrefPubMedGoogle Scholar
  • 90 Spitzer K, Becker V, Thie A, Kunze K. The Hamburg Stroke Data Bank: Goals, design and preliminary results. J Neurol 1989; 236: 139-44.
    CrossrefPubMedGoogle Scholar
  • 91 Stein B, Fuster V, Halperin JL, Chesebro JH. Antithrombotic therapy in cardiac disease. An emerging approach based on pathogenesis and risk. Circulation 1989; 80: 1501-13.
    CrossrefPubMedGoogle Scholar
  • 92 Ten Cate H, Henny CP, Büller HR. et al. Use of a heparinoid in patients with hemorrhagic stroke and thromboembolic disease. Ann Neurol 1984; 15: 268-70.
    CrossrefPubMedGoogle Scholar
  • 93 The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group.. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: 1581-7.
    CrossrefPubMedGoogle Scholar
  • 94 Turpie AGG, Levine MN, Hirsh J. et al. Double-blind randomised trial of ORG 10172 low-molecular-weight heparinoid in prevention of deep-vein thrombosis in thrombotic stroke. Lancet 1987; i: 523-6.
    PubMedGoogle Scholar
  • 95 Turpie AGG, Gent M, Côte R. et al. A low-molecular-weight heparinoid compared with unfractionated heparin in the prevention of deep vein thrombosis in patients with acute ischemic stroke. Ann Intern Med 1992; 117: 353-7.
    CrossrefPubMedGoogle Scholar
  • 96 Vermylen J, Verstraete M, Fuster V. Role of platelet activation and fibrin formation in thrombogenesis. J Am Coll Cardiol 1986; 8: 2B-9B.
    CrossrefPubMedGoogle Scholar
  • 97 Walker AM, Jick H. Predictors of bleeding during heparin therapy. J Am Med Assoc 1980; 244: 724-9.
    PubMedGoogle Scholar
  • 98 Weksler BB, Lewin M. Anticoagulation in cerebral ischemia. Stroke 1983; 14: 658-63.
    CrossrefPubMedGoogle Scholar
  • 99 Yasaka M, Yamaguchi T, Oita J. et al. Clinical features of recurrent embolization in acute cardioembolic stroke. Stroke 1993; 24: 1681-5.
    CrossrefPubMedGoogle Scholar
  • 100 Yatsu FM, Mohr JP. Anticoagulation therapie for cardiogenic emboli to brain. Neurology 1982; 32: 274-5.
    CrossrefPubMedGoogle Scholar
  • 101 Yatsu FM, Becker C, McLeroy KR. et al. Community hospital-based stroke programs: North Carolina, Oregon and New York. I: Goals, objectives and data collection procedures. Stroke 1986; 17: 276-84.
    CrossrefPubMedGoogle Scholar
  • 102 Yatsu FM, Hart RG, Mohr JP, Grotta JC. Anticoagulation of embolic strokes of cardiac origin: An update. Neurology 1988; 38: 314-6.
    CrossrefPubMedGoogle Scholar