Acute Stroke

Immediate Treatment of Stroke

Reperfusion (Time=Brain)

tPA

• Window for any tPA is 4.5 hours from known onset of symptoms. Overall it increases ICH but the overall benefit prevails in this time period.
• Indications for tPA are simple: (1) ischemic stroke causing a measurable neurological deficit, (2) time between 0 and 4.5 hours before beginning treatment, (3) adult
• Contraindications are more complex:

Endovascular thrombectomy

Adjunct Treatment

Secondary Prevention of Stroke

Address Comorbidities

• hypertension
• dyslipidemia.md
• diabetes mellitus.md
• smoking
• extracranial carotid artery stenosis
• intracranial carotid artery stenosis
• atrial fibrillation
• patent foramen ovale closure

High-Risk Transient Ischemic Attack or Minor Stroke

In these patients (TIA with ABCD >= 4, minor stroke with NIHSS less than or equal to 3), dual anti-platelet therapy is warranted as per several recent trials (CHANCE[^1], POINT[^2] for clopidogrel and THALES[^3] for ticagrelor).

[^1]: Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C, Wang C, Li H, Meng X, Cui L, Jia J. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med. 2013 Jul 4;369:11-9. [^2]: Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, Kim AS, Lindblad AS, Palesch YY. Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA. New England Journal of Medicine. 2018 Jul 19;379(3):215-25. [^3]: Johnston SC, Amarenco P, Denison H, Evans SR, Himmelmann A, James S, Knutsson M, Ladenvall P, Molina CA, Wang Y. Ticagrelor and aspirin or aspirin alone in acute ischemic stroke or TIA. New England Journal of Medicine. 2020 Jul 16;383(3):207-17.

Antiplatelet monotherapy as maintenance can be one of three accepted regimens:

1. ASA 81 mg once daily
2. Clopidogrel 75 mg once daily
   1. CAPRIE trial
3. ASA + dipyridamole
   1. ESPS II, ESPRIT, and PRoFESS trials