What are the next steps before discharging a patient with a small acute basal ganglia infarct on MRI?

Management of Small Acute Basal Ganglia Infarct Before Discharge

Before discharging a patient with a small acute basal ganglia infarct on MRI, you must complete a comprehensive stroke workup including vascular imaging, cardiac evaluation, and initiate secondary stroke prevention measures, with discharge only appropriate if no high-risk features are identified. 1, 2

Mandatory Pre-Discharge Workup

Vascular Imaging

• Obtain noninvasive cervicocephalic vessel imaging (MRA, CTA, or carotid ultrasound/transcranial Doppler) to identify large artery atherosclerosis, particularly carotid stenosis ≥50%. 1 This directly impacts whether the patient requires urgent admission for carotid intervention versus outpatient management.

• If significant stenosis is identified, the patient requires admission to a stroke unit rather than discharge. 1

Cardiac Evaluation

• Perform electrocardiography immediately to screen for atrial fibrillation or other arrhythmias that would necessitate anticoagulation rather than antiplatelet therapy. 1

• Obtain at least transthoracic echocardiography, particularly when no cause is identified by other workup elements. 1 Depending on local resources, this may be arranged as outpatient if the cardiac evaluation is otherwise normal. 1

• Consider prolonged cardiac monitoring (inpatient telemetry or Holter monitor) if the etiology remains unclear after initial imaging and ECG. 1

Laboratory Assessment

• Complete routine blood tests including complete blood count with platelets, chemistry panel, hemoglobin A1C, PT/PTT, and fasting lipid panel. 1 These identify modifiable risk factors requiring immediate intervention.

Criteria That Mandate Admission Rather Than Discharge

You should hospitalize rather than discharge if ANY of the following are present: 1

• Abnormal brain DWI-MRI showing additional acute cerebral infarctions beyond the known basal ganglia lesion
• Large artery atherosclerosis on vascular imaging (such as internal carotid artery stenosis)
• Abnormal cardiac evaluation suggesting cardioembolic source
• Recurrent episodes (crescendo TIAs)
• Inability to provide expedited outpatient follow-up

Secondary Stroke Prevention Measures Required Before Discharge

Antiplatelet Therapy

• Initiate aspirin as first-line antiplatelet agent for indefinite use. 2 This should be started before discharge unless contraindicated or anticoagulation is indicated.

Blood Pressure Management

• Target blood pressure <130/80 mmHg, using diuretics and/or ACE inhibitor as the optimal regimen. 2, 3 For acute ischemic stroke, permissive hypertension up to 220/120 mmHg is acceptable in the hyperacute phase unless thrombolysis was given. 3

• Initiate or adjust antihypertensive medications before discharge with clear BP targets documented. 2

Lipid Management

• Start statin therapy with target LDL cholesterol <100 mg/dL. 1, 2 This should be prescribed at discharge regardless of baseline lipid levels.

Diabetes Management

• If diabetic, ensure tight glycemic control with target HbA1c <7%. 2

Critical Discharge Instructions

Provide both written and verbal instructions covering the following return precautions: 4

• Worsening headache or new severe headache
• Increased confusion or altered mental status
• New or worsening weakness or numbness in arms/legs
• Vision changes
• Seizure activity
• Worsening balance or coordination
• Any new neurological symptoms

Educate the patient to call 9-1-1 if symptoms are unimproved or worsening 5 minutes after onset. 1 Patients rarely remember verbal discharge instructions, so written documentation is essential. 1

Mandatory Follow-Up Arrangements

• Schedule neurology follow-up within 2 weeks to review completed workup results and optimize secondary stroke prevention. 1

• Arrange outpatient completion of any pending studies (such as echocardiography if not done inpatient). 1

Common Pitfalls to Avoid

• Do not discharge without completing vascular imaging. Undiagnosed carotid stenosis ≥50% requires urgent intervention and would make discharge inappropriate. 1

• Do not assume small size equals low risk. Basal ganglia infarcts, even when small, can predict poor outcomes if associated with large vessel occlusion or if additional workup reveals high-risk features. 5

• Inadequate blood pressure control is a critical error. Epidemiological data shows continual reduction in cardiovascular events down to BP 120/80 mmHg, so aggressive BP management is essential. 2

• Do not discharge patients on anticoagulation or with bleeding disorders without ensuring contrast-enhanced imaging has excluded hemorrhagic transformation. 1