What is the most appropriate management for a patient presenting 12 hours after stroke symptoms with resolved weakness, stable vitals, and imaging showing mild to moderate occlusion?

Management of Stroke Presenting at 12 Hours with Resolved Symptoms

The most appropriate management is observation (Option D), with initiation of antiplatelet therapy and secondary stroke prevention measures. This patient does not meet criteria for acute reperfusion therapies given the 12-hour presentation window, symptom resolution (suggesting transient ischemic attack or minor stroke), and only mild-to-moderate occlusion on imaging.

Rationale for Excluding Acute Reperfusion Therapies

tPA is Not Indicated

• IV alteplase is contraindicated beyond 4.5 hours from symptom onset in standard practice, though the EXTEND trial showed benefit up to 9 hours in highly selected patients with perfusion imaging demonstrating salvageable tissue 1
• This patient's symptoms have resolved, indicating either a TIA or very minor stroke with excellent collateral flow, making the risk-benefit ratio of thrombolysis unfavorable 2
• The Canadian Stroke Best Practice guidelines specify that tPA should only be extended beyond 4.5 hours in exceptional circumstances with advanced imaging selection 2

Mechanical Thrombectomy is Not Indicated

• Endovascular therapy (EVT) requires a functionally significant deficit at presentation 2
• The 2024 ESO/ESMINT guidelines for basilar artery occlusion specify that patients with NIHSS ≥10 benefit most from EVT, while those with NIHSS <10 show no clear benefit 2
• For anterior circulation strokes, the 2018 Canadian guidelines recommend EVT for patients with small-to-moderate ischemic core (ASPECTS ≥6) and proximal large vessel occlusions causing disabling deficits 2
• This patient has resolved weakness and no ongoing neurological symptoms, making them ineligible for EVT regardless of the mild-to-moderate occlusion seen on imaging 2
• The time window (12 hours) would require advanced perfusion imaging to demonstrate salvageable tissue for EVT consideration, but the resolved symptoms make this moot 2, 3

Appropriate Management Strategy

Immediate Actions

• Complete diagnostic workup including cardiac monitoring for 24-72 hours to detect atrial fibrillation, echocardiography, and complete neurovascular imaging 4
• Initiate antiplatelet therapy within 24 hours of symptom onset—aspirin 160-325 mg is the standard approach for patients not receiving thrombolysis 2, 4
• The Canadian guidelines specify that early aspirin therapy (within 48 hours) reduces risk of early recurrent ischemic stroke, with 7 fewer recurrent strokes per 1000 patients treated 2

Secondary Prevention

• Dual antiplatelet therapy (clopidogrel 75 mg + aspirin 75 mg) for 21 days should be considered for minor stroke or high-risk TIA, based on the CHANCE and POINT trials showing reduced 90-day stroke recurrence 2
• Statin therapy should be initiated for long-term secondary prevention 5
• Blood pressure management should begin within 24 hours, though permissive hypertension is initially warranted 4, 5

Monitoring and Supportive Care

• VTE prophylaxis with intermittent pneumatic compression devices and pharmacologic prophylaxis (enoxaparin or unfractionated heparin) unless contraindicated 2, 4
• Swallowing assessment before any oral intake to prevent aspiration 2, 4
• Early mobilization within 24 hours if clinically stable, which decreases post-stroke complications 2

Critical Pitfall to Avoid

Do not pursue aggressive reperfusion therapy in patients with resolved symptoms, even if imaging shows vascular occlusion 2. The presence of a mild-to-moderate occlusion with symptom resolution suggests excellent collateral circulation and completed compensation. The risks of thrombolysis (6.2% symptomatic ICH) or thrombectomy (11-14% procedural complications) far outweigh potential benefits in this clinical scenario 2, 1.

The key distinction is that reperfusion therapies are indicated for ongoing, disabling neurological deficits, not for radiographic findings alone 2, 3. This patient's clinical stability and symptom resolution make observation with aggressive secondary prevention the evidence-based approach.