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Management of TIA and Stroke

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PART 1: TRANSIENT ISCHEMIC ATTACK (TIA)

Definition

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Step 1 - Risk Stratification: ABCD² Score

• 0-3 = Low risk (1% stroke risk in 48 h)
• 4-5 = Moderate risk (4.1% at 48 h)
• ≥6 = High risk (8% at 48 h; 17-22% at 3 months)

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Step 2 - Immediate Evaluation

• Non-contrast CT head - to rule out hemorrhage
• MRI brain (DWI preferred) - detects infarction in TIA mimics
• CT/MR angiography - evaluate carotid and intracranial vessels
• ECG - detect atrial fibrillation
• Echocardiogram - evaluate for cardioembolic source
• Carotid Doppler/imaging
• Labs: CBC, coagulation screen, glucose, lipids, HbA1c - Adams and Victor's Principles of Neurology

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Step 3 - Disposition (Admit vs. Outpatient)

• Admit to hospital if: ABCD² ≥ 4, DWI-positive lesion, suspected cardioembolism, high-grade carotid stenosis, or first TIA within 24-48 hours
• Rapid outpatient TIA clinic within 24 hours may be used for low-risk patients - ROSEN's Emergency Medicine

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Step 4 - Antithrombotic Therapy

• Dual antiplatelet therapy (DAPT): Aspirin + Clopidogrel started within 24 hours, continued for 21 days, followed by single antiplatelet long-term
  • Based on pooled analysis of POINT and CHANCE trials - DAPT reduced major ischemic events vs. aspirin alone
  • Major hemorrhage risk increases slightly: 0.2% (aspirin alone) vs. 0.9% (DAPT)
  • Alternative: Aspirin + Ticagrelor (180 mg load, then 90 mg BID) showed similar benefit with less genetic heterogeneity in platelet inhibition - Harrison's 22E; ROSEN's Emergency Medicine

Note on CYP2C19: ~30% of people (especially Asians) carry a CYP2C19 loss-of-function variant causing poor clopidogrel metabolism. Ticagrelor avoids this issue. - Harrison's 22E

• Anticoagulation (NOAC preferred; warfarin if mechanical valve)
• Immediate anticoagulation considered except when bleeding risk exceeds benefit or CHA₂DS₂-VASc = 0 (men) / 1 (women) with self-terminating AF - ROSEN's Emergency Medicine

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Step 5 - Revascularization

• Carotid endarterectomy (CEA) or carotid artery stenting (CAS) if ipsilateral high-grade carotid stenosis (>70%) is the likely cause
• CEA is most beneficial when performed within 2 weeks of the TIA - Bradley & Daroff's Neurology; Adams & Victor's

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Step 6 - Secondary Prevention (Long-term)

• Antiplatelet therapy (single agent after 21 days of DAPT)
• Statin therapy (target LDL < 70 mg/dL)
• Antihypertensive therapy
• Diabetes management (tight glycemic control)
• Smoking cessation, weight reduction, exercise
• Anticoagulation if AF is identified

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PART 2: ACUTE ISCHEMIC STROKE

Step 1 - Prehospital Rapid Response

• ABC stabilization; O₂ only if SpO₂ < 95% (avoid routine supplementation in normoxic patients)
• IV access, cardiac monitor
• Avoid dextrose-containing fluids in normoglycemic patients (hyperglycemia worsens ischemia)
• Check blood glucose (hypoglycemia mimics stroke)
• Rapid transport; notify receiving ED early ("stroke alert")
• Target door-to-imaging ≤ 20 minutes - ROSEN's Emergency Medicine

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Step 2 - Emergency Department Time Targets (NINDS Guidelines)

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Step 3 - Immediate Investigations

• Non-contrast CT head (mandatory - rules out hemorrhage before thrombolysis)
• MRI with DWI (if available, more sensitive)
• CT Angiography - identify large vessel occlusion (LVO) for thrombectomy eligibility
• CT Perfusion - assess penumbra (salvageable tissue)
• Labs: CBC, PT/INR, aPTT, glucose, BMP, cardiac enzymes, type & screen
• ECG
• Chest X-ray

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Step 4 - Blood Pressure Management

• BP must be ≤ 185/110 mmHg before tPA administration
• Agents to lower BP if needed:
  • Labetalol 10-20 mg IV over 1-2 min (may repeat once)
  • Nicardipine infusion 5 mg/h (titrate up to 15 mg/h)
  • Clevidipine 1-2 mg/h IV

• Monitor BP every 15 min during infusion, then every 30 min for 6 h, then hourly for 16 h
• Target BP < 180/105 mmHg
• Systolic 180-230 or diastolic 105-120: Labetalol 10 mg IV q10-20 min (max 300 mg) or infusion
• Systolic > 230: Labetalol or Nicardipine; consider nitroprusside if uncontrolled

• Permissive hypertension - do not aggressively lower BP unless > 220/120 mmHg (to maintain penumbral perfusion) - ROSEN's Emergency Medicine

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Step 5 - Blood Glucose Control

• Treat hyperglycemia to target 140-180 mg/dL
• Avoid hypoglycemia (closely monitor)
• Persistent in-hospital hyperglycemia in the first 24 hours is associated with worse outcomes - ROSEN's Emergency Medicine

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Step 6 - IV Thrombolysis (IV Alteplase / tPA)

• Standard: within 3 hours of symptom onset (or last known well)
• Extended: 3-4.5 hours in selected patients

• Hemorrhage on CT
• Symptom onset > 4.5 hours (or unknown onset)
• BP > 185/110 after treatment attempts
• Platelet count < 100,000
• INR > 1.7 or anticoagulant use
• History of prior ICH, intracranial neoplasm
• Recent major surgery (< 14 days) or GI bleed (< 21 days)
• Recent stroke or head trauma (< 3 months)

Tenecteplase (0.25 mg/kg IV, max 25 mg, single bolus) is an emerging alternative - some guidelines now consider it non-inferior to alteplase and easier to administer.

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Step 7 - Mechanical Thrombectomy (Endovascular Treatment)

• ICA, M1, M2, basilar artery occlusions
• NIHSS ≥ 6 (functionally significant deficit)
• Pre-stroke mRS 0-1 (good baseline function)

• 0-6 hours: Standard window (based on DAWN, DEFUSE-3 trials)
• 6-24 hours: Extended window in selected patients with favourable imaging (perfusion mismatch)

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Step 8 - Antiplatelet Therapy (Non-cardioembolic stroke)

• Start Aspirin 325 mg within 24-48 hours of stroke onset (after ruling out hemorrhage and 24 h after tPA)
• For minor ischemic stroke (NIHSS ≤ 3) not receiving tPA: DAPT (aspirin + clopidogrel) for 21 days, then aspirin alone for long-term

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Step 9 - Anticoagulation (Cardioembolic stroke / AF)

• Atrial fibrillation: NOAC preferred (dabigatran, rivaroxaban, apixaban)
• Timing of anticoagulation after stroke is individualized based on stroke size and hemorrhagic risk
• For AF with minor stroke: may start anticoagulation within days; larger strokes: delay 2-4 weeks

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Step 10 - Admission and Monitoring

• All significant strokes: admit to stroke unit (evidence shows reduced mortality and dependency)
• ICU monitoring for ≥ 24 h if:
  • Large hemispheric stroke (risk of herniation/malignant edema)
  • Posterior fossa stroke
  • Post-tPA treatment
• Continuous cardiac monitoring for at least 24-48 hours to detect AF

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Step 11 - Management of Complications

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Step 12 - Hemorrhagic Stroke (ICH) Management

• No tPA (contraindicated)
• Strict BP control: Target SBP < 140 mmHg (INTERACT2 trial)
• Reverse any coagulopathy: FFP/PCC for warfarin, idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors
• Neurosurgical consultation:
  • Cerebellar hemorrhage > 3 cm: surgical evacuation (life-saving)
  • Hydrocephalus: EVD (external ventricular drain)
  • Lobar/basal ganglia ICH: surgical benefit is limited (STICH trials)
• ICP monitoring for large bleeds
• Avoid anticoagulants; restart antiplatelet/anticoagulant therapy only after ≥ 4 weeks based on risk-benefit

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Step 13 - Rehabilitation and Secondary Prevention

• Start early mobilization (within 24-48 h if hemodynamically stable)
• Multidisciplinary team: physiotherapy, OT, speech therapy
• Address all vascular risk factors:
  • Statins (high-intensity): atorvastatin 40-80 mg daily
  • Antihypertensives: ACE inhibitor + thiazide diuretic combination preferred
  • Antiplatelet or anticoagulant maintenance
  • Diabetes control, smoking cessation, alcohol reduction, diet, exercise
• Evaluate for depression (post-stroke depression is common)

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Summary: Key Time Targets

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