I. GENERAL: ALL PATIENTS

A. Management

1. CT/MRI at some time in hospitalization to R/O tumor, hemorrhage; always obtain before anticoagulation,
rTPA treatment.
2. CBC, platelet count, ESR, VDRL, HATTS/MHA-TP acutely; fasting lipid studies, 2 hour pc glucose/glycosylated HgB during convalescent phase
3. Vigorous hydration; adequate nutrition
4. Aggressive control of hyperglycemia 5. Cautious control of hypertension acutely: treat only to keep BP below 190/110, avoid hypotension at all costs; definitive control of BP chronically
6. Aspiration precautions (bedside aspiration test; if positive, diet modification; eating & drinking only while sitting on side of bed or in chair)
7. Regimen to prevent constipation
8. Neurochecks: frequency defined by how results will alter treatment
9. Assure adequate sleep from day 1, prevent sun-downing (low dose doxepin, trazodone or lorazepam titrated upward to efficacy)
10. Consider subcutaneous heparin 5,000 units bid in patients with significant motoric deficit for prophylaxis of deep venous thrombosis
11. Orient patients with neglect with attended hemispace toward room
12. Appropriate rehabilitation: PT, OT, Speech therapy, initiated as soon as possible
13. Counseling on risk factor reduction/elimination, especially smoking
14. Counsel family on effect of stroke on cognitive and emotional function, personality
15. Estimate rehabilitation potential and likelihood that patient will be able to return home, and initiate discharge planning.
16. Assess carefully for depression and treat aggressively as indicated.
17. Appropriate preparation of home and provision of ambulatory appliances for patients with gait disorders.
18. Avoid or discontinue anticonvulsants, benzodiazepines, neuroleptics, alpha-1 blockers (prazocin, terazocin, doxazocin), and alpha-2 agonists (clonidine), drugs with anticholinergic effects: these drugs inhibit neural plasticity.

B. Clinically define event:

Lacune versus large vessel
Anterior versus posterior circulation
Cardiogenic versus artery to artery embolic

II. DIAGNOSTIC EVALUATION

A. Patients with minor noncardiogenic anterior circulation event of uncertain type (large vessel vs lacune)(probability of large vessel event in this circumstance is 67%)

1. MRI day 4 or later: examine lenticulostriate endzone, look for subinsular slit infarct.
2. MRA/Duplex (MRA preferred): stenosis > 50% suggests large vessel

B. Patients with history, symptoms or signs of heart disease

1. Transthoracic echocardiogram
2. Holter monitor
3. If A fib/ventricular mural thrombus, MRA/Duplex (MRA preferred) to help determine whether clot originated in heart or carotid.

C. Patients with high probability of minor large vessel anterior circulation event, noncardiogenic, with potential willingness to undergo endarterectomy:

1. Screen with MRA. Use duplex scan only if MRA contraindicated (e.g., cardiac pacemaker, metal in head).
2. Cerebral angiography if MRA suggests >50% stenosis.

D. Patients with lateral medullary or superior cerebellar infarction: monitor level of consciousness and neuro exam closely for first 48 hours for evidence of life threatening mass effect from cerebellar edema.

E. All patients under age 45; patients under 65 without risk factors for stroke or evidence of atheromatous disease.

1. Arterial thrombosis: Anticardiolipin antibody; lupus anticoagulant; prothrombin G20210A polymorphism Venous thrombosis/paradoxical embolism: Protein S; Protein C; antithrombin III; activated protein C resistance; prothrombin G20210A polymorphism; anticardiolipin antibody; lupus anticoagulant.
2. Hemoglobin electrophoresis (Afro-Americans)
3. Peripheral smear; serial platelet counts; fibrin split products
4. Inquire regarding drug abuse; urine drug screen
5. Lumbar puncture
6. Transthoracic echocardiogram; if non-diagnostic, obtain transesophageal echocardiogram with bubble study.
7. High quality MRA of intracranial and extracranial vessels; consider cerebral angiography

F. Hemorrhage

1. Subarachnoid: CT If CT negative, LP Confirmed: angiography
2. Lobar intracerebral, basal ganglia/thalamus/pons without history of hypertension: Follow-up MRI at 2 months
3. BG/thalamus/pons with history of hypertension: Initial CT/MRI only
4. Hemorrhagic stroke: Treat as ischemic infarction
5. All: Clotting studies

G. Suspected sinus thrombosis/cerebral venous thrombosis (patients without risk factors for stroke; subacute as opposed to ictal onset; seizures at onset; CT/MRI abnormalities in posterior parasagittal region; otitis; history of recurrent peripheral venous thrombosis; known antiphospholipid antibodies, anti-thrombin III deficiency, protein C, S deficiency, activated protein C resistance syndrome, prothrombin G20210A variant, Behçets disease, SLE, post-partum state; high pressure on LP)

1. MRA/MR venogram
2. LP
3. Appropriate serologic studies
4. If pseudotumor cerebri presentation: serial visual perimetry

H. Recurrent TIA

1. ? Migraine: Stereotyped; minutes to hours duration; post-ictal malaise; prominent sensory symptoms splitting the midline, involving some fingers but not others, or sensory march; visual alteration (shimmering; scintillations; fortification spectra, central or wandering blobs; sense of looking through shattered glass)
2. ? Simple partial seizure: Stereotyped, minutes in duration, many recurrences, no migrainous features
3. ? Lacunar TIA: Stereotyped, pure sensory, pure motor or sensorimotor, < 10 episodes total, 1-2/day.

III. TREATMENT

A. All infarcts

1. If less than 3 hours since ictus, moderate to severe deficit, and not already on heparin or coumadin and no contraindications: consider rTPA
2. If mild to moderate artery to artery thromboembolic infarct or lacunar infarct, 3 days since ictus: consider low molecular weight heparin (Enoxaparin 1mg/kg SQ bid)) for 10 days to reduce probability of recurrence.

B. Suspected lacunar infarction:

Risk factor control
Aspirin 25mg + dipyridamole 200mg SR (Aggrenox) bid
HMG-CoA reductase inhibitor, even in normocholesteremic subjects, (for total cholesterol >170; LDL cholesterol >140)
ACE inhibitor/Angiotensin II receptor blocker
Clopidogrel indefinitely if aspirin hypersensitive
Consider B6 50mg/day + folate 3mg/day.

C. Suspected artery to artery thrombo-embolism

Risk factor control
Carotid endarterectomy ASAP if TIA, minor stroke
Anterior circulation: Consider LMW heparin for first 10 days
Posterior circulation, multisector (basilar thrombosis/bilateral vertebral thrombosis): consider anticoagulation (low molecular weight heparin) for 3 weeks
Dissection (anterior or posterior circulation): consider anticoagulation (LMW heparin, then coumadin) for 4-6 months
Chronic treatment all strokes:

Risk factor control
Aspirin 25mg + dipyridamole 200mg SR (Aggrenox) bid
HMG-CoA reductase inhibitor, even in normocholesteremic subjects
ACE inhibitor/Angiotensin II receptor blocker
Clopidogrel if aspirin hypersensitive

Repeated sudden declines in cognitive function: consider empiric trial of anticonvulsant for presumptive focal seizures
Consider B6 50mg/day + folate 3mg/day.

D. Suspected cardiogenic embolism

Acute anticoagulation
Cardiovert atrial fibrillation if possible.

If successful, Holter monitor q6months to confirm persistent sinus rhythm

Long term anticoagulation:

A fib:

Ventricular mural thrombus: assume 5%/year stroke risk
Dilated cardiomyopathy: indefinite anticoagulation
Paradoxical embolism (PFO), atrial septal aneurysm, clot in atrial appendage without A fib: 6 months but consider indefinite anticoagulation.

Aspirin: stroke occurrence reduced 25% (compared with 75% with warfarin).

D. Hemorrhage

1. Subarachnoid: Referral to state-of-the-art neurosurgical center within hours.
2. Lobar: Supportive care with special vigilance for sundowning, partial seizures. Consider surgical evacuation if single lobe with cerebral herniation threatened, or if cerebellar hemorrhage with declining level of consciousness and threatened upward herniation.
3. Basal ganglia, thalamus, brainstem: supportive