What is the management approach for subacute ischemic stroke?

Subacute Ischemic Stroke Management

For patients in the subacute phase (beyond 48 hours but within days to weeks after stroke onset), management centers on secondary prevention with antiplatelet therapy, aggressive risk factor modification, stroke unit care with early rehabilitation, and prevention of complications—not acute reperfusion therapies.

Antiplatelet Therapy for Secondary Prevention

• Initiate aspirin 160-325 mg daily if not already started, as this reduces recurrent ischemic stroke, death, and dependency 1
• For patients with minor non-cardioembolic stroke or high-risk TIA who are within 21-30 days of onset, dual antiplatelet therapy (aspirin plus clopidogrel) is superior to monotherapy, then transition to single antiplatelet therapy 2, 3
• Continue single antiplatelet therapy (aspirin or clopidogrel) indefinitely for non-cardioembolic strokes 3, 4
• Do not use glycoprotein IIb/IIIa inhibitors, as they increase mortality without benefit 1

Blood Pressure Management in Subacute Phase

• Avoid aggressive blood pressure lowering in the subacute phase, particularly in watershed or hypoperfusion-related strokes, as adequate perfusion pressure is critical 5
• For most patients not receiving thrombolysis, only treat blood pressure if systolic >220 mmHg or diastolic >120 mmHg 1, 6
• Gradually resume or initiate antihypertensive medications for long-term control after the acute vulnerability period, typically after several days 1
• In exceptional cases with documented hypotension causing neurological deterioration, vasopressors may be used with close monitoring 5

Stroke Unit Care and Complication Prevention

• Admit all patients to a geographically defined stroke unit with specialized interdisciplinary staff, as this improves mortality and functional outcomes 5, 6
• Perform swallowing assessment before allowing any oral intake to prevent aspiration pneumonia 5, 6
• Use intermittent pneumatic compression devices for deep vein thrombosis prophylaxis in patients who cannot receive anticoagulation 5
• Initiate early mobilization when neurologically stable 5
• Monitor and treat fever (temperature >38°C) as it worsens outcomes 5
• Avoid indwelling bladder catheters when possible due to infection risk 6

Secondary Prevention and Risk Factor Modification

• Initiate high-intensity statin therapy regardless of baseline cholesterol levels 5, 3
• Aggressively control hypertension with target <140/90 mmHg (or <130/80 mmHg for diabetics) after the acute phase 3, 4
• Optimize diabetes management with target HbA1c <7% 3
• Provide smoking cessation counseling and pharmacotherapy if applicable 3
• Evaluate for carotid stenosis; if ≥70% symptomatic stenosis is identified, urgent carotid revascularization (endarterectomy or stenting) should be performed within 2 weeks 5

Cardioembolic Stroke Considerations

• If atrial fibrillation or other cardioembolic source is identified, initiate oral anticoagulation rather than antiplatelet therapy 2, 3
• Direct oral anticoagulants (DOACs) are preferred over warfarin for non-valvular atrial fibrillation due to lower bleeding risk and no need for INR monitoring 2, 3
• Timing of anticoagulation initiation depends on infarct size: small infarcts can start at 3-4 days, moderate at 5-7 days, large at 10-14 days 3

Rehabilitation and Functional Recovery

• Begin comprehensive rehabilitation assessment early, including physical therapy, occupational therapy, and speech therapy as needed 3, 4
• Screen for and treat poststroke depression, which occurs in approximately 30% of patients 3
• Address cognitive impairment, dysphagia, mobility limitations, and chronic pain through multidisciplinary rehabilitation 3

Critical Pitfalls to Avoid

• Do not aggressively lower blood pressure in watershed or hemodynamic strokes, as these result from hypoperfusion and require adequate perfusion pressure 5
• Do not use routine therapeutic anticoagulation in acute non-cardioembolic stroke, as it increases hemorrhagic risk without proven benefit 5, 6
• Do not use volume expansion, vasodilators, or induced hypertension strategies outside clinical trials, as they are associated with serious complications without established benefit 1
• Do not perform emergency carotid endarterectomy in the hyperacute setting due to high risk of hemorrhagic transformation 1