What are the management strategies for a patient with a history of stroke or transient ischemic attack (TIA), including acute treatment and secondary prevention?

Stroke Management: Acute Treatment and Secondary Prevention

Immediate Triage and Risk Stratification

All patients presenting within 48 hours of stroke or TIA symptoms—particularly those with motor weakness, speech disturbance, or other focal neurological deficits—require immediate emergency department referral with advance stroke team notification. 1, 2 This is a medical emergency, not an outpatient problem. The stroke recurrence risk reaches 5% at 2 days and up to 10% in the first week, with approximately half occurring within the first 48 hours. 3, 1, 4

High-Risk Features Mandating Immediate Hospitalization

• ABCD2 score ≥4 (8% stroke risk at 2 days vs. 1% for score <4) 3, 1, 4
• Crescendo TIAs (multiple, increasingly frequent episodes)—these mandate immediate hospitalization under all circumstances 1, 2
• Symptomatic carotid stenosis >50% 4, 2
• Known cardiac embolic source (atrial fibrillation) 2
• Symptom duration >1 hour at presentation 4, 2
• Known hypercoagulable state 4, 2

The ABCD2 tool should be used at initial healthcare contact to guide management intensity, but it supplements rather than replaces comprehensive evaluation. 3, 1, 4

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Acute Diagnostic Workup (Within 24 Hours)

Brain Imaging

• CT or MRI brain imaging within 24 hours to exclude hemorrhage, identify acute infarction, and rule out stroke mimics 3, 1
• MRI with diffusion-weighted imaging (DWI) is superior to CT, showing 77% sensitivity within 3 hours versus only 16% for CT, and detects silent cerebral infarctions in up to 31% of TIA patients 1, 2
• For acute stroke patients who are candidates for IV thrombolysis (0-4.5 hour window), either noncontrast CT or MRI is recommended 3

Vascular Imaging

• CT angiography from aortic arch to vertex should be performed immediately at the time of initial brain CT for patients being considered for endovascular therapy 3, 1, 4
• Urgent carotid duplex ultrasound within 24 hours for all patients with carotid territory symptoms who are potential candidates for revascularization 3, 1, 4
• Vascular imaging of the head and neck should be performed to evaluate stroke mechanism and assess future stroke risk 3

Laboratory and Cardiac Evaluation

• ECG without delay in all patients to identify atrial fibrillation or other cardioembolic sources 3, 1, 4
• Full blood count, electrolytes, renal function, fasting lipids, glucose level 3
• Selected patients may require chest X-ray, syphilis serology, vasculitis screen, prothrombotic screen 3

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Acute Treatment for Ischemic Stroke

Thrombolytic Therapy

Intravenous alteplase (rt-PA) should be administered within 3-4.5 hours of symptom onset in patients satisfying specific inclusion and exclusion criteria, under the authority of a specialist physician with expert knowledge of stroke management. 3, 1 Thrombolysis should only be undertaken in hospitals with appropriate infrastructure, facilities, and protocols for acute blood pressure management. 3

Antiplatelet Therapy

• Aspirin 150-300 mg should be given as soon as possible after symptom onset (within 48 hours) if CT/MRI excludes hemorrhage 3, 1
• Dual antiplatelet therapy (aspirin plus clopidogrel) initiated within 24 hours and continued for 3 weeks reduces stroke risk from 7.8% to 5.2% (HR 0.66) in patients with minor stroke and high-risk TIA 1
• The routine use of anticoagulation (e.g., intravenous unfractionated heparin) in unselected patients following ischemic stroke/TIA is not recommended 3

Surgical Intervention for Ischemic Stroke

Selected patients (18-60 years) with significant middle cerebral artery infarction should be urgently referred to a neurosurgeon for consideration of hemicraniectomy within 48 hours of symptom onset. 3 This substantially reduces death and disability in patients with extensive hemispheric infarcts. 3

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Management of Intracerebral Hemorrhage (ICH)

• Surgery is not more beneficial for ICH than medical care overall, but may be considered for superficial ICH <1 cm from surface (craniotomy) or deep ICH (stereotactic surgery) 3
• ICH due to anticoagulation should be urgently reversed 3
• Surgery may be considered in patients with cerebellar hemisphere hemorrhage diameter >3 cm 3

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Secondary Prevention Strategies

Blood Pressure Management

All patients after stroke or TIA, whether normotensive or hypertensive, should receive blood pressure lowering therapy unless contraindicated by symptomatic hypotension. 3 Commencement of new blood pressure lowering therapy may occur before discharge or within the first week after stroke or TIA. 3 Antihypertensive treatment reduces recurrent stroke by approximately 30-40%, with effects related to the degree of blood pressure lowering achieved. 3

Lipid Management

Lipid lowering therapy via a statin is beneficial for all people with stroke or TIA and should be commenced before discharge, as this is associated with greater adherence at 3 months post-stroke. 3

Antiplatelet Therapy for Secondary Prevention

• Long-term antiplatelet therapy should be prescribed to all people with ischemic stroke or TIA who are not prescribed anticoagulation 3
• Low-dose aspirin and modified-release dipyridamole should be prescribed to all people with ischemic stroke or TIA who do not have concomitant acute coronary disease 3
• Aspirin alone or clopidogrel alone may be used for those who do not tolerate aspirin plus dipyridamole 3
• The combination of aspirin plus clopidogrel is not recommended long-term in secondary prevention of cerebrovascular disease in patients without acute coronary disease or recent coronary stent 3

Anticoagulation for Secondary Prevention

Anticoagulation therapy should be used in all people with ischemic stroke or TIA who have atrial fibrillation, cardioembolic stroke from valvular heart disease, or recent myocardial infarction, unless contraindicated. 3 The decision to commence anticoagulation should be made before discharge. 3 For patients with TIA, anticoagulation should begin once CT or MRI has excluded intracranial hemorrhage. 3

Carotid Revascularization

Carotid endarterectomy should be undertaken as soon as possible after the event (ideally within 2 weeks) in the following patients: 3, 1

• Symptomatic carotid stenosis 70-99% (NASCET criteria) if surgery can be performed by a specialist surgeon with low perioperative mortality/morbidity 3
• Symptomatic carotid stenosis 50-69% in select patients (considering age, gender, comorbidities) if surgery can be performed with very low perioperative mortality/morbidity 3
• Carotid endarterectomy is not recommended for <50% symptomatic stenosis 3
• Carotid angioplasty and stenting should not routinely be considered for symptomatic stenosis but may be an alternative in certain circumstances 3

The benefit of carotid endarterectomy is greatly diminished beyond 2 weeks after symptom onset because the highest recurrent ischemic event risk is in this early period. 4

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Lifestyle Modifications

Patients should receive individualized interventions delivered using behavioral techniques (educational or motivational counseling) targeting: 3

• Smoking cessation 3
• Low-salt and Mediterranean diet 3
• Regular aerobic physical activity 3
• Avoiding excessive alcohol consumption 3
• Weight loss where appropriate 3

Programs that use theoretical models of behavior change, proven techniques, and multidisciplinary support are needed—simple advice or brochures are insufficient. 3

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Stroke Unit Care and Multidisciplinary Management

All acute stroke patients should be admitted to a stroke unit with access to multidisciplinary assessment documented within 2 days of admission. 3 Rapid assessment and immediate treatment in specialized stroke centers reduces 90-day stroke risk by 80%, from historical rates of 10-20% down to 2-3%. 1, 4, 2

Prevention and Management of Complications

Complications such as deep venous thrombosis, pyrexia, pressure ulcers, falls, and pain should be actively prevented to reduce impediment to normal recovery. 3 Glucose levels >8 mmol/l predict poor prognosis and should be treated. 5 Both high and low blood pressure levels relate to poor prognosis, though target levels have not been defined in clinical trials. 5 Hyperthermia should be treated early, and oxygen therapy is recommended for <92% O2 saturation. 5

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Critical Pitfalls to Avoid

• Never discharge patients with crescendo TIAs under any circumstances 1, 2
• Do not delay carotid imaging in anterior circulation TIAs, as urgent revascularization may be needed 1, 2
• Do not rely solely on ABCD2 scores for disposition decisions—they supplement but do not replace comprehensive evaluation 1, 4
• Do not attempt outpatient workup for patients with known high-risk features (symptomatic carotid stenosis >50%, atrial fibrillation, hypercoagulable state) 2
• Never discharge without confirming outpatient follow-up arrangements 1