Stroke and Transient Ischemic Attack (TIA)
Stroke and Transient Ischemic Attack (TIA)
Treatment
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Select acute ischemic stroke treatment
The 2026 AHA/ASA Acute Ischemic Stroke Guideline supports rapid reperfusion assessment based on disabling symptoms, timing, imaging, and contraindications. A low NIHSS score alone should not exclude treatment when the deficit is disabling.
Approach | Clinical use |
|---|---|
IV thrombolysis | Alteplase or tenecteplase within 4.5 hours in eligible patients with disabling deficits. Selected unknown-onset or 4.5–9-hour presentations may qualify using advanced imaging. |
Mechanical thrombectomy | Urgent evaluation for eligible large-vessel occlusion, including selected patients up to 24 hours. Eligibility now includes some large-core infarcts and basilar occlusions; a small core is not a universal requirement. |
Antiplatelet treatment | For nondisabling noncardioembolic presentations, short-term DAPT may be appropriate after hemorrhage is excluded. It does not replace reperfusion in an otherwise eligible disabling stroke. |
Do not wait for response to IV thrombolysis before arranging thrombectomy. Use local stroke-team protocols for agent dosing, contraindications, blood pressure thresholds, and interfacility transfer.
Supportive care
- Protect recovery: Provide stroke-unit care, swallow screening before oral intake, oxygen for hypoxemia, and management of fever and glucose. Avoid hypoglycemia and routine intensive glucose lowering.
- Manage BP by treatment pathway: Reperfusion eligibility and hemorrhage risk determine acute targets. Avoid routine intensive systolic lowering to <140 mm Hg after IV thrombolysis or thrombectomy; chronic prevention targets do not apply to the hyperacute phase.
- Prevent complications: Monitor for hemorrhagic transformation and edema. Provide appropriate VTE prevention, rehabilitation assessment, and early discharge planning.
Match ongoing treatment to the subtype
The 2021 AHA/ASA Secondary Stroke Prevention Guideline anchors cause-specific care after ischemic stroke or TIA. Revisit the diagnosis when new rhythm, cardiac, or vascular findings emerge. For additional clinician education, visit the VLN learning hub.
Mechanism | Antithrombotic and procedural approach |
|---|---|
Noncardioembolic stroke or TIA | Long-term single antiplatelet therapy: aspirin, clopidogrel, or aspirin–extended-release dipyridamole. Select by tolerance, bleeding risk, cost, and adherence. |
Minor noncardioembolic stroke or high-risk TIA | Eligible patients benefit from early aspirin plus clopidogrel, usually for 21 days, then a single agent. Classic criteria include NIHSS ≤3 or ABCD² ≥4; selected broader presentations need protocol-based assessment. Avoid routine long-term DAPT. |
Symptomatic atherosclerotic disease | Severe intracranial stenosis may warrant DAPT for up to 90 days plus intensive risk management; stenting is not first-line. Assess symptomatic carotid stenosis for revascularization based on severity, timing, anatomy, and procedural risk. |
Cardioembolic stroke | For AF, oral anticoagulation when appropriate; eligible patients generally use a DOAC. Warfarin remains necessary for mechanical valves or moderate-or-greater mitral stenosis and may be chosen for affordability. Start timing depends on infarct size, hemorrhagic transformation, and clinical status. Other cardiac sources require source-specific management. |
Other or undetermined causes | Treat the established cause. Consider PFO closure only in carefully selected patients, generally age 18–60 with nonlacunar stroke and suitable PFO features, after exclusion of alternative causes. Do not empirically anticoagulate ESUS. |
After IV thrombolysis, generally defer antithrombotics until 24-hour follow-up imaging excludes hemorrhage. Combining anticoagulation with antiplatelets usually requires a separate indication and an explicit duration plan.
Hemorrhagic stroke
Use the 2022 AHA/ASA ICH Guideline for smooth, individualized BP control, prompt anticoagulant reversal, and neurocritical/neurosurgical assessment. Deterioration, cerebellar mass effect, or hydrocephalus requires urgent escalation. For aneurysmal SAH, the 2023 AHA/ASA Aneurysmal SAH Guideline emphasizes early aneurysm treatment, enteral nimodipine, and monitoring for delayed cerebral ischemia. Neither pathway follows routine ischemic-stroke antithrombotic treatment.
Resources & References
Clinical tools and patient education
Guidelines and supporting sources
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