Acute ischemic stroke and TIA: workup and management
Sudden focal neurological deficit. Time is brain: establish last known well, check glucose, get a non-contrast CT (with CT angiography for large-vessel occlusion), and decide quickly on thrombolysis and thrombectomy. TIA needs urgent workup because early stroke risk is high.
Working diagnosis
Adult · US guidelines
Draft · awaiting physician review
01Orient
What's new in the evidence
- 2026 AHA/ASA acute ischemic stroke guideline: tenecteplase 0.25 mg/kg (max 25 mg) and alteplase are both Class I within 4.5 hours; tenecteplase is simpler to give (FDA-approved for stroke in 2025)
- Treat any disabling deficit within 4.5 hours; non-disabling minor stroke gets dual antiplatelet therapy instead of thrombolysis
- Extended-window thrombolysis 4.5–9 hours or wake-up stroke with imaging mismatch (Class 2a); large-core thrombectomy (ASPECTS 3–5) and basilar thrombectomy (NIHSS ≥10) within 24 hours
- Do not target SBP <140 mmHg after successful thrombectomy (may harm); intensive glucose control to 80–130 is not recommended
- OPTIMAS (2024): a DOAC started within 4 days of AF-related stroke was noninferior to delayed start; INSPIRES (2023): DAPT up to 72 hours for presumed atherosclerotic minor stroke
Differential diagnoses
- Acute ischemic stroke (can't miss)
- Intracerebral or subarachnoid hemorrhage (can't miss)
- Hypoglycemia (can't miss: check glucose first)
- Seizure with postictal (Todd) paralysis
- Complicated migraine
- Functional neurological disorder
- Space-occupying lesion, aortic dissection with neurological signs
02Assess
Risk scores and decision tools
- NIH Stroke Scale
- ASPECTS on CT
- ABCD² for TIA risk
- Last known well time and imaging mismatch for extended windows
Key history questions
- Last known well time (exact)
- Deficits and their progression
- Anticoagulants and last dose; recent surgery, bleeding, head trauma
- Seizure at onset, migraine history
- Vascular risk factors, atrial fibrillation
Examination findings
- NIH Stroke Scale
- Blood pressure in both arms; glucose
- Cortical signs (aphasia, neglect, gaze deviation) suggesting large-vessel occlusion
- Irregular pulse, carotid bruit, murmur
03Investigate
Initial investigations
- Point-of-care glucose
- Non-contrast CT head immediately
- CT angiography head and neck (and CT perfusion when selecting late-window thrombectomy)
- CBC, BMP, coagulation, troponin, ECG
Advanced investigations
- MRI brain
- Echocardiogram; telemetry or ambulatory monitoring for atrial fibrillation
- Lipid panel, HbA1c
04Treat
Immediate management
- Thrombolysis within 4.5 hours of last known well for disabling deficits: tenecteplase 0.25 mg/kg (max 25 mg) or alteplase 0.9 mg/kg (max 90 mg)
- BP <185/110 before and <180/105 for 24 hours after thrombolysis; do not push SBP below 140 after thrombectomy
- Mechanical thrombectomy for large-vessel occlusion up to 24 hours in selected patients, including large cores and basilar occlusion
- Not receiving reperfusion: permit BP up to 220/120 in the first 48–72 hours unless other indications
First-line treatment
- Aspirin within 24–48 hours (after 24 hours if thrombolysed)
- Minor stroke (NIHSS ≤3) or high-risk TIA: clopidogrel 300–600 mg load plus aspirin, then 21 days of DAPT; ticagrelor-aspirin for 30 days is an alternative
- High-intensity statin; swallow screen before oral intake
- AF: start a DOAC early (within about 4 days for minor-moderate strokes) when bleeding risk allows
Second-line treatment
- Carotid endarterectomy or stenting for symptomatic 70–99% stenosis, ideally within 2 weeks
- Decompressive hemicraniectomy for malignant MCA infarction in selected patients
Specialist referrals
- Stroke team or neurology immediately
- Neurointerventional for thrombectomy
- Vascular surgery for carotid stenosis; rehabilitation services
05Disposition
Admission criteria
- All acute strokes
- TIA with high risk (ABCD² ≥4, crescendo symptoms, AF, carotid stenosis) or incomplete workup
Safe discharge criteria
- Low-risk TIA with rapid outpatient workup (within 24–48 hours) and antiplatelet started
Follow-up timing
- Stroke clinic within 2 weeks; primary care for risk factors
Patient instructions
- BE FAST: call 911 immediately for new symptoms
- Driving restrictions per state law
Monitoring
- Neuro checks and BP every 15 minutes for 2 hours after thrombolysis, then less often
- Glucose 140–180 mg/dL; treat fever
Clinical pearls and pitfalls
- Do not delay CT for labs other than glucose
- Wake-up stroke: MRI DWI–FLAIR mismatch can select patients for thrombolysis
- Long-term BP goal usually <130/80 mmHg
RefGuidelines and landmark evidence
- GuidelineAHA/ASA – Guideline for the Early Management of Acute Ischemic Stroke (2026)PubMed
- TrialAcT: tenecteplase vs alteplase for acute ischemic stroke (2022)PubMed
- TrialOPTIMAS: timing of DOAC after AF-related stroke (2024)PubMed
- TrialINSPIRES: DAPT up to 72 hours after ischemic stroke (2023)PubMed
- TrialNINDS rt-PA trial: alteplase for acute ischemic stroke (1995)PubMed
- TrialDAWN: thrombectomy 6 to 24 hours after stroke (2018)PubMed
- TrialPOINT: clopidogrel plus aspirin after minor stroke or high-risk TIA (2018)PubMed
For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.