How to Order Management in Acute Ischemic Stroke (AIS) and Transient Ischemic Attack (TIA)

A table summarizing the drugs and doses used in Acute Ischemic Stroke (AIS) and Transient Ischemic Attack (TIA) management, focusing on Dual Antiplatelet Therapy (DAPT) and other key medications:

Medication	Indication	Dosage	Duration
Alteplase (tPA)	Acute Ischemic Stroke (AIS)	0.9 mg/kg (Max: 90 mg); 10% IV bolus, 90% over 60 mins	Single dose within 4.5 hours
Aspirin	DAPT for AIS/TIA	Initial: 160-325 mg daily	21 days in combination with Clopidogrel
Clopidogrel	DAPT for AIS/TIA	Loading: 300 mg, then 75 mg daily	21 days in combination with Aspirin
Aspirin (monotherapy)	Post-DAPT or monotherapy for TIA	75-100 mg daily	Long-term
Clopidogrel (monotherapy)	Post-DAPT or monotherapy for TIA	75 mg daily	Long-term
Atorvastatin	High-intensity statin therapy	40-80 mg daily	Long-term
Rosuvastatin	High-intensity statin therapy	20-40 mg daily	Long-term
Warfarin	Atrial fibrillation with stroke/TIA	Adjust to INR 2.0-3.0	Long-term with monitoring
DOACs (e.g., Apixaban)	Atrial fibrillation with stroke/TIA	Apixaban: 5 mg twice daily	Long-term
IV Normal Saline (0.9%)	Supportive care (hydration)	1000 mL or as needed	Based on clinical assessment
Paracetamol (Acetaminophen)	Fever/Pain management	500-1000 mg every 4-6 hours	As needed (Max: 4 g/day)

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Management of Acute Ischemic Stroke (AIS) and Transient Ischemic Attack (TIA) follows an evidence-based approach, focusing on rapid diagnosis, reperfusion therapies, and secondary prevention. Here’s a detailed guide covering both conditions and the dosage considerations:

Acute Ischemic Stroke (AIS) Management

1. Initial Assessment and Imaging:

   • CT Scan or MRI: Non-contrast CT is used to rule out hemorrhagic stroke, while MRI helps confirm ischemic stroke.

   • NIH Stroke Scale (NIHSS): Assesses stroke severity and helps determine the treatment plan.

2. Reperfusion Therapy:

   • Intravenous Thrombolysis (tPA – Alteplase): Administered within 4.5 hours of symptom onset.

     • Dosage: 0.9 mg/kg (maximum dose: 90 mg). Give 10% as an initial bolus over 1 minute, followed by the remaining 90% over 60 minutes via continuous IV infusion.

   • Endovascular Thrombectomy: Recommended for patients with large vessel occlusion (LVO) within 24 hours of stroke onset (based on advanced imaging).

3. Antiplatelet Therapy Dual Antiplatelet Therapy (DAPT):

   • Aspirin: 160-325 mg/day within 24-48 hours of stroke onset if thrombolysis is not given.

   • Clopidogrel (for dual antiplatelet therapy): Consider adding Clopidogrel 75 mg daily for 21 days in patients with minor stroke or TIA (per guidelines).

4. Anticoagulation:

   • For atrial fibrillation (AF) or other cardioembolic causes, long-term anticoagulation with Warfarin (target INR: 2.0-3.0) or DOACs (e.g., Apixaban, Dabigatran) is recommended after acute stabilization.

5. Management of Hypertension:

   • Avoid aggressive blood pressure lowering during the acute phase unless systolic BP > 220 mmHg or diastolic BP > 120 mmHg. If thrombolysis is administered, lower BP to < 185/110 mmHg before thrombolysis and maintain < 180/105 mmHg for 24 hours afterward.

6. Supportive Care:

   • IV fluids: Normal saline to avoid dehydration.

   • DVT Prophylaxis: Intermittent pneumatic compression devices.

   • Monitoring: Continuous cardiac and respiratory monitoring to detect complications such as arrhythmias or aspiration.
     

Transient Ischemic Attack (TIA) Management

1. Risk Stratification:

   • Use the ABCD² Score (Age, Blood Pressure, Clinical features, Duration of symptoms, Diabetes) to assess the risk of subsequent stroke.

2. Antiplatelet Therapy Dual Antiplatelet Therapy (DAPT):

   • Aspirin 160-325 mg/day is the first-line therapy.

   • Consider adding Clopidogrel (75 mg daily) for dual antiplatelet therapy, especially in the first 21 days post-TIA, if there's a high risk of recurrent ischemic events.

3. Blood Pressure Management:

   • Aim for a target BP < 140/90 mmHg. First-line agents include ACE inhibitors or thiazide diuretics.

4. Statin Therapy:

   • High-intensity statins such as Atorvastatin 40-80 mg daily or Rosuvastatin 20-40 mg daily to lower LDL cholesterol to < 70 mg/dL.

5. Anticoagulation:

   • If TIA is due to atrial fibrillation, start anticoagulation therapy with DOACs or Warfarin after ruling out hemorrhage.

6. Carotid Revascularization:

   • In patients with carotid artery stenosis (70-99%), carotid endarterectomy or stenting is recommended to prevent future strokes.
     

Long-term Management and Secondary Prevention

• Lifestyle Modifications: Encourage smoking cessation, regular physical activity, and a Mediterranean-style diet.

• Monitoring: Regular follow-up to monitor for recurrent strokes and manage comorbidities such as hypertension, diabetes, and hyperlipidemia.
  

Conclusion

Both AIS and TIA require prompt intervention to prevent further neurologic damage and recurrence. In AIS, timely administration of tPA or thrombectomy significantly improves outcomes, while secondary prevention in both conditions revolves around antiplatelet therapy, statin use, and lifestyle modifications.