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Management of Minor Stroke / TIA vs. Major Ischemic Stroke (Alteplase-Ineligible)

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PART 1: Minor Stroke and TIA

Definition

• TIA: Transient focal neurological deficit lasting <24 hours (typically <1 hour), with no evidence of acute infarction on imaging.
• Minor stroke: NIHSS score 0-5 (mild, often non-disabling deficit).

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Immediate Assessment - ABCD2 Score

• 0-3 = Low risk (1% stroke risk in 48h)
• 4-5 = Moderate risk (4.1% in 48h)
• ≥6 = High risk (8% in 48h)

• ROSEN's Emergency Medicine, p. 3434

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Why Alteplase is NOT given in Minor/Non-disabling Stroke

• Mild non-disabling stroke (NIHSS 0-5) within 3 hours
• Mild non-disabling stroke between 3-4.5 hours

• ROSEN's Emergency Medicine, p. 3173 (Table 87.5B)

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Antiplatelet Therapy (Cornerstone of Minor Stroke/TIA Management)

• Aspirin + Clopidogrel started within 24 hours of symptom onset
• Continued for 21 days, then transition to single antiplatelet
• Evidence: Pooled analysis of POINT and CHANCE trials showed early short-term DAPT significantly reduces major ischemic events vs. aspirin alone
• Risk of major hemorrhage is low but DAPT increases it from 0.2% to 0.9% vs. aspirin alone
• Benefit is confined to the first 21 days - beyond that, bleeding risk outweighs benefit
• In non-cardioembolic minor stroke (NIHSS ≤3) not receiving alteplase, DAPT for 21 days reduces recurrent ischemic stroke for up to 90 days

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New-Onset Atrial Fibrillation After TIA/Minor Stroke

• Start anticoagulation immediately (not antiplatelet) for cardioembolic source
• Exception: those with bleeding risk > benefit or CHA2DS2-VASc 0 in men / 1 in women with self-terminating paroxysmal AF

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General Supportive Care (applies to all strokes)

• Admit to stroke unit or ICU
• Monitor airway, prevent aspiration
• Supplemental O2 if SpO2 <94%
• Treat hyperthermia (worsens ischemic outcome)
• Blood glucose: target 140-180 mg/dL; treat hypoglycemia (<60 mg/dL) with IV dextrose
• Cardiac monitoring for ≥48 hours (12-lead ECG + troponin on admission)
• BP: generally do NOT aggressively lower in acute phase unless treating for thrombolysis

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PART 2: Major Ischemic Stroke - Alteplase Ineligible

Absolute Contraindications (Do NOT give alteplase)

• ROSEN's Emergency Medicine, Table 87.5 (p. 3172-3180); Tintinalli's Emergency Medicine, p. 2068

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Management of Major Stroke When Alteplase Cannot be Given

1. Mechanical Thrombectomy (if large vessel occlusion)

• For patients with proximal intracranial artery occlusion (ICA, M1, basilar)
• Eligible up to 6 hours from symptom onset; up to 24 hours in selected patients with perfusion imaging mismatch (DAWN/DEFUSE-3 criteria)
• NIHSS >6 generally used as threshold
• Patient should be functionally independent at baseline, life expectancy >3 months
• Thrombolysis should NOT be withheld just because thrombectomy is planned (give both if eligible for alteplase)

2. Blood Pressure Management (no thrombolysis scenario)

• Do NOT aggressively lower BP in acute ischemic stroke not receiving reperfusion therapy (no specific target)
• Permissive hypertension is acceptable - lowering BP can reduce cerebral blood flow to the penumbra
• Treat if BP is extremely high (>220/120 mmHg) or if there is another urgent indication

3. Antiplatelet Therapy

• Aspirin 325 mg within 24-48 hours of symptom onset (if no thrombolysis given, can start immediately)
• For larger non-cardioembolic strokes, single antiplatelet (aspirin or clopidogrel) is used for secondary prevention
• DAPT for 21 days applies specifically to minor stroke/TIA, NOT major stroke (increased bleeding risk in larger infarcts)

4. Anticoagulation (Cardioembolic Stroke)

• If the stroke is cardioembolic (AF, mechanical valve, etc.) and thrombolysis is contraindicated, anticoagulation is started after a safe interval (typically 2-14 days depending on infarct size) to prevent recurrence
• Early anticoagulation in large strokes risks hemorrhagic transformation

5. Neuroprotective/Supportive Measures

• Airway protection, aspiration prevention (swallowing assessment by speech pathology before oral intake)
• Head of bed >30 degrees to prevent aspiration
• Treat fever (antipyretics; mild hypothermia is protective; hyperthermia worsens outcome)
• Glucose management: target 140-180 mg/dL
• Cardiac monitoring ≥48 hours
• DVT prophylaxis once hemorrhagic transformation risk is acceptable
• Early physiotherapy, speech therapy, occupational therapy

6. Raised ICP Management (Large Infarct)

• Malignant MCA territory infarction: decompressive hemicraniectomy within 48 hours (especially in patients <60 years) can be life-saving
• Mannitol, head of bed elevation
• Avoid hypotonic fluids

7. Neurosurgical Consultation

• Cerebellar infarction with obstructive hydrocephalus: urgent suboccipital craniectomy
• Large cerebellar stroke: may need posterior fossa decompression

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Quick Summary Comparison Table

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• ROSEN's Emergency Medicine, Table 87.5, pp. 3161-3200
• Tintinalli's Emergency Medicine (AHA/ASA 2018/2019 Inclusion/Exclusion Criteria for Alteplase), p. 2068
• Bradley and Daroff's Neurology in Clinical Practice, General Management of Acute Ischemic Stroke, p. 1405
• Fuster and Hurst's The Heart, 15th ed., Antithrombotics for Secondary Stroke Prevention, p. 795