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Last Updated: 3/28/2014  

Stroke and Transient Ischemic Attack

Prevention
  • Prevent stroke by controlling hypertension, encouraging smoking cessation, using statins in patients at increased risk, and treating patients with AF with aspirin, warfarin, or dabigatran based on stroke risk.

Diagnosis
  • Look for elements of the history and physical exam that suggest the type, extent, and anatomical location of the lesion.

  • Perform cranial CT or MRI (within 20 minutes of arrival in emergency department, if possible).

  • Obtain vascular studies such as carotid ultrasonography, CT angiography, or MR angiography, typically within 1 to 3 days of initial stroke.

  • Obtain an echocardiogram if vascular study results are unrevealing and embolism is suspected.

Therapy
  • In patients seen within 3 hours of suspected stroke onset (and some seen between 3 and 4.5 hours of symptom onset), consider immediate therapy with iv rtPA to reverse cerebrovascular damage.

  • Begin adjunctive antiplatelet therapy in patients with acute stroke within the first 48 hours. Delay antiplatelet or anticoagulant therapy if patient has received rtPA until 24 hours after rtPA is given.

  • Admit patients with stroke to a dedicated stroke unit and manage BP and comorbidities.

  • Institute antiplatelet therapy for secondary stroke prevention in patients with TIA or stroke.

  • Strongly consider referring patients with nondisabling stroke or TIA in the past 6 months due to internal carotid stenosis greater than 70% for carotid endarterectomy.

  • Consider anticoagulation for secondary stroke prevention in patients after TIA or completed stroke due to high-risk sources of cardioembolism, but not due to most other causes of stroke.

DOI: 10.7326/d114
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Disclosures:
James C. Grotta, MD received grants from AstraZeneca, Novo Nordisk, Boehringer-Ingelheim. Ji Chong, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Deborah Korenstein, MD, FACP, Editor in Chief, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Richard B. Lynn, MD, FACP, Editor, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
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