What is the recommended treatment for a patient with ischemic stroke symptoms that began a couple of weeks ago?

Treatment for Ischemic Stroke Symptoms That Began Weeks Ago

For a patient whose ischemic stroke symptoms began a couple of weeks ago, the focus is entirely on secondary prevention with long-term antithrombotic therapy—acute interventions like thrombolysis and thrombectomy are no longer applicable beyond the first hours to days after symptom onset. 1, 2

Why Acute Treatments Are Not Applicable

The window for acute stroke interventions has long passed:

• Intravenous thrombolysis (tPA) is only effective within 3-4.5 hours of symptom onset 1, 2
• Endovascular thrombectomy must be initiated within 6 hours (groin puncture), with uncertain benefit beyond this timeframe 1

At weeks post-stroke, the treatment paradigm shifts entirely to secondary stroke prevention and rehabilitation 3.

Secondary Prevention Strategy: Determine Stroke Mechanism First

The choice of antithrombotic therapy depends critically on whether the stroke was cardioembolic (particularly from atrial fibrillation) versus noncardioembolic 1, 4:

For Noncardioembolic Ischemic Stroke

Antiplatelet therapy is indicated, NOT anticoagulation 1, 4:

• Aspirin 75-100 mg daily, clopidogrel 75 mg daily, or aspirin 25 mg/extended-release dipyridamole 200 mg twice daily are all appropriate first-line options 1
• Clopidogrel or aspirin/dipyridamole combination are preferred over aspirin monotherapy for superior efficacy 1
• Dual antiplatelet therapy (aspirin plus clopidogrel) is NOT recommended long-term beyond 21-90 days due to excess bleeding risk 1, 3

Since symptoms began weeks ago, the patient is beyond the window for short-term dual antiplatelet therapy (which should be initiated within 12-24 hours and continued for 21-90 days for minor strokes) 1. Therefore, single antiplatelet therapy should be used 1, 3.

For Cardioembolic Stroke (Atrial Fibrillation)

Oral anticoagulation is strongly indicated 1, 4:

• Direct oral anticoagulants (DOACs) are preferred over warfarin: apixaban, dabigatran, edoxaban, or rivaroxaban 4, 5
• Anticoagulation should typically be initiated within 1-2 weeks after stroke onset 1, 5
• At weeks post-stroke, if anticoagulation has not yet been started, it should be initiated now after confirming no hemorrhagic transformation on brain imaging 5

The timing algorithm based on stroke severity (TIA: 1 day, mild: 3 days, moderate: 6-8 days, severe: 12-14 days) is designed for the acute/subacute period 5. At weeks post-event, repeat brain imaging (CT or MRI) should be obtained to exclude hemorrhagic transformation before starting anticoagulation 5.

Critical Diagnostic Steps at This Stage

Before selecting therapy, ensure:

1. Brain imaging has been performed to confirm ischemic (not hemorrhagic) stroke 2
2. Cardiac evaluation completed: 12-lead ECG and cardiac monitoring to detect atrial fibrillation 2
3. Vascular imaging (carotid ultrasound or CTA) to assess for significant stenosis 1
4. Risk factor assessment: blood pressure, lipids, diabetes screening 3

Additional Secondary Prevention Measures

Beyond antithrombotic therapy 3:

• High-intensity statin therapy regardless of baseline cholesterol 3
• Blood pressure control with target <130/80 mmHg 3
• Diabetes management if present 3
• Lifestyle modifications: smoking cessation, diet, exercise 3

Rehabilitation and Chronic Sequelae Management

At weeks post-stroke, rehabilitation should be well underway 3:

• Physical therapy for mobility and balance deficits 3
• Speech therapy for aphasia or dysphagia 3
• Occupational therapy for activities of daily living 3
• Screen for and treat post-stroke depression, which is common 3

Common Pitfall to Avoid

Do not use anticoagulation for noncardioembolic stroke—this is a critical error that increases bleeding risk without benefit 1, 4. The stroke mechanism must be determined before selecting antithrombotic therapy.