After 7 and 90 days of treatment, we studied the effect of picotamide, a thromboxane synthase inhibitor (450 and 900 mg/day), aspirin (150 mg/day), and aspirin plus picotamide (150 and 450 mg/day respectively) on platelet aggregation, evaluated in platelet rich plasma of 48 patients affected by ischemic stroke. Platelet aggregation, induced by collagen (1.0 and 2.0 micrograms/ml) and adenosine diphosphate (1.0 and 10 micrograms/L), was significantly increased in patients in comparison with healthy controls. Aspirin (150 mg/day) reduced collagen-induced platelet aggregation (1.0 microgram/ml) after 7 days of treatment. Picotamide (450 mg/day) reduced platelet aggregation induced by both concentrations of collagen, while the higher dose (900 mg/day) had no significant effect. Aspirin plus picotamide reduced the aggregation induced by 1.0 microgram/ml collagen and by 10 mumol/L adenosine diphosphate after 90 days of therapy. This study has shown that patients during the acute phase of stroke are characterized by an increased in vitro platelet aggregation. Aspirin may be beneficial in the acute phase of the cerebral ischemic event. Picotamide and picotamide plus aspirin could be useful for reducing platelet aggregation in long term treatment.