What is the management for a patient with an aborted stroke and no evidence of ischemia?

Management of Aborted Stroke with No Evidence of Ischemia

For patients with aborted stroke symptoms and no evidence of ischemia on imaging, aspirin 160-300 mg should be initiated within 48 hours of symptom onset, followed by daily low-dose aspirin (81 mg) for secondary prevention.

Definition and Clinical Context

An aborted stroke refers to a situation where a patient presents with stroke-like symptoms that resolve quickly, with no evidence of ischemia on neuroimaging. This differs from a transient ischemic attack (TIA) in that there is complete absence of ischemic changes on imaging.

Initial Evaluation

1. Neurological Assessment

   • Perform a standardized stroke scale assessment (NIHSS or CNS) to document resolution of symptoms 1
   • Document the timing of symptom onset and resolution

2. Immediate Imaging

   • Non-contrast CT or MRI brain imaging should be completed immediately to confirm absence of ischemia 1, 2
   • Vascular imaging (CTA or MRA from aortic arch to vertex) should be performed concurrently to identify potential causes 1

3. Laboratory Evaluation

   • Complete blood work including electrolytes, glucose, CBC, coagulation studies (INR, aPTT), creatinine, eGFR, and troponin 1
   • Note: Do not delay treatment decisions while awaiting lab results unless specifically indicated (e.g., INR for patients on warfarin) 1

Management Algorithm

Immediate Management (First 48 Hours)

1. Antiplatelet Therapy

   • Initiate aspirin 160-300 mg as soon as possible (within 48 hours of symptom onset) 1, 3
   • This dose is sufficient to achieve rapid inhibition of thromboxane biosynthesis 4
   • For patients who cannot swallow, administer aspirin per rectum 4
   • Avoid anticoagulation therapy as urgent anticoagulation is not recommended for preventing early recurrent stroke or improving outcomes after acute ischemic stroke (Class III; Level of Evidence A) 1

2. Blood Pressure Management

   • Monitor blood pressure but avoid aggressive lowering as it may be compensatory to maintain cerebral perfusion 1, 2
   • If treatment is necessary (diastolic >120 mmHg or systolic >220 mmHg), use easily titrated agents like labetalol that have minimal vasodilatory effects on cerebral blood vessels 1

3. Supportive Care

   • Ensure adequate oxygenation (maintain O2 saturation >94%) 2
   • Maintain euvolemia with isotonic solutions (0.9% saline) 2
   • Position patient to reduce aspiration risk (semi-recumbent) 2

Secondary Prevention

1. Antiplatelet Therapy

   • Continue aspirin at a lower maintenance dose (81 mg daily) for long-term secondary prevention 1, 2
   • Alternative options include:
     • Clopidogrel 75 mg daily (consider if aspirin allergy) 5
     • Combination of aspirin and extended-release dipyridamole 5

2. Risk Factor Modification

   • Identify and address modifiable risk factors (hypertension, diabetes, hyperlipidemia, smoking) 2
   • Consider statin therapy regardless of baseline lipid levels

Special Considerations

1. Diagnostic Uncertainty

   • If clinical suspicion for ischemia remains high despite negative imaging, consider:
     • Repeat MRI with diffusion-weighted imaging within 24-48 hours
     • Extended cardiac monitoring to detect paroxysmal atrial fibrillation

2. Cautions and Contraindications

   • Avoid prasugrel in patients with prior stroke or TIA (Class III: Harm) 1
   • Do not initiate anticoagulant therapy within 24 hours of thrombolytic therapy if it was administered 1

3. Common Pitfalls

   • Failing to perform adequate vascular imaging to identify potential stroke mechanisms
   • Delaying antiplatelet therapy while awaiting additional testing
   • Aggressively lowering blood pressure, which may compromise cerebral perfusion

Monitoring and Follow-up

1. Short-term Follow-up

   • Monitor for recurrent symptoms within the first 48 hours
   • Assess for medication side effects, particularly bleeding complications

2. Long-term Follow-up

   • Schedule follow-up within 1-2 weeks to review test results and adjust secondary prevention strategies
   • Consider cognitive assessment if indicated 2
   • Initiate early rehabilitation if any residual deficits are present 2

The evidence strongly supports early aspirin therapy in patients with suspected ischemic events, even when imaging shows no evidence of established infarction. This approach reduces the risk of recurrent ischemic events without significantly increasing hemorrhagic complications 3, 6.