Dipyridamole should be added to this patient's medication regimen. She had a small subcortical infarction despite taking daily aspirin before the stroke. The combination of aspirin and dipyridamole has been shown to be superior to aspirin alone in reducing the risk of recurrent stroke.

The combination of aspirin and clopidogrel versus aspirin alone in patients with small subcortical infarcts (lacunes) was associated with increased mortality without the benefit of reducing the risk of recurrent stroke in the Secondary Prevention of Small Subcortical Strokes (SPS3) trial. Similarly, in the Management of Atherothrombosis with Clopidogrel in High-Risk Patients with Recent Transient Ischemic Attacks or Ischemic Stroke (MATCH) trial, the combination of dual antiplatelet agents was associated with an increased risk of hemorrhagic complications that offset any potential clinical benefit. The combination of aspirin and clopidogrel thus has limited utility in the secondary prevention of stroke.

Ticlopidine is not first-line treatment for secondary stroke prevention. Although superior to aspirin in preventing a second stroke, ticlopidine is associated with the serious adverse effects of agranulocytosis and thrombotic thrombocytopenic purpura and thus is considered a second-line agent.

Warfarin should not be substituted for aspirin because no evidence of atrial fibrillation or other high-risk cardioembolic sources of stroke was detected in this patient.