Acute Ischemic Stroke/ Transient Ischemic Attack (TIA)

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Acute Ischemic Stroke/ TIA

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Acute ischemic stroke/ TIA
–DDx includes: complicated migraines vs intracranial hemorrhage vs intracranial tumor vs intracranial abscess.
—ABCD score >3 so will admit and initiate stroke protocol with goal door-to-needle time of 60 minutes.
—Fingerstick glucose, EKG, troponin, CBC, electrolytes, troponin, CMP, UDS, HbA1c, Fasting Lipid Panel (FLP), TSH, and coagulation factors/hypercoagulable state (r/o blood disorders [thrombophilia/sickle cell/polycythemia vera]).
–Admit to stroke unit with telemetry or ICU for severe stroke.
–Plain CT head/ brain MRI.
-CTA head with contrast and CTA neck with contrast.
-Transthoracic echo (TTE) to assess for thrombus or vegetation, w/ bubble study to assess for PFO / atrial septal aneurysm.
-F/u CTA / MRA neck and brain. Discuss with neurology [CTA gives a better image and is preferred if normal kidney function since test requires contrast. Use MRA if poor kidney function].
-If unable to do CTA/ MRA, get B/L carotid U/S and Doppler.
-Neuro-check Q4hr.
–If last known baseline was within 3/4.5 hours, IV Alteplase.
–Neurology consult for Alteplase/ Tenecteplase/ Thrombolytics vs mechanical thrombectomy
—Inclusion and exclusion criteria reviewed.
—Monitor for orolingual angioedema following  IV Alteplase. 
–Permissive HTN of <220/120, otherwise BP less than 180/105 mmHg if thrombolysis anticipated. IV Labetalol 10-20 mg, or IV Nicardipine 5mg/hr, or Clevidipine 1-2 mg/hr IV, double dose of Clevidipine every 15 minutes as needed. Maximum dose 21 mg/hr.
–Target blood glucose within 140 to 180 range, avoid hypotonic fluids.
–ST/PT/OT.
–Neurosurgical consult for cerebral edema/hydrocephalus.
–Seizure precautions
–Aspirin+ Plavix+ Statin. DC Plavix after 21 days.
–Early DVT prophylaxis per neurology.
–Monitor for stroke extension, recurrent stroke, hemorrhagic transformation and brain edema.
–Risk factor modifications including: HTN, diabetes, HLD, and tobacco use prior to DC.