›Dual antiplatelet therapy (DAPT) for minor stroke or high-risk TIA
›Aspirin 81 mg + clopidogrel 75 mg daily for 21 days
›Then single antiplatelet agent indefinitely
›For NIHSS <=3 and high-risk TIA (ABCD2 >=4)
›Clopidogrel 75 mg daily — alternative for aspirin-intolerant patients
›Cardioembolic stroke — anticoagulation
›Atrial fibrillation identified as source
›Direct oral anticoagulants (DOAC) preferred over warfarin for non-valvular AF
›Timing of initiation: typically 4-14 days post-stroke depending on stroke size
›Large infarct: delay to reduce hemorrhagic transformation risk
›Other cardioembolic sources
›Mechanical heart valve — warfarin target INR 2.5-3.5
›LV thrombus — anticoagulation 3-6 months
›Anticoagulation for basilar artery atherosclerosis
›Evidence limited for anticoagulation over antiplatelet in non-cardioembolic basilar stenosis
›Warfarin not routinely recommended over antiplatelet for intracranial stenosis
Blood pressure management
›Acute phase BP management
›Non-thrombolysis candidate — permissive hypertension
›Allow BP up to 220/120 mmHg for first 24 hours
›Avoid aggressive lowering — may worsen ischemia in penumbral territory
›Thrombolysis candidate — pre-treatment target
›Reduce to <185/110 mmHg before alteplase administration
›Labetalol 10-20 mg IV bolus — first-line agent
›Nicardipine infusion 5 mg/hour, titrate by 2.5 mg/hour every 5-15 minutes to maximum 15 mg/hour
›Post-thrombolysis BP control
›Target <180/105 mmHg for 24 hours post-alteplase
›Frequent monitoring: every 15 minutes for 2 hours, then every 30 minutes for 6 hours
›Secondary prevention BP target
›Target <130/80 mmHg for secondary prevention
›ACE inhibitor or ARB preferred — evidence for recurrence reduction
›Initiated or restarted after acute phase stabilization
Secondary prevention pharmacotherapy
›High-intensity statin therapy
›Atorvastatin 40-80 mg daily — first-line for atherosclerotic stroke
›Target LDL <1.8 mmol/l for secondary prevention
›Rosuvastatin 20-40 mg daily as alternative
›Statin initiation in acute phase
›Initiate or continue statin in hospital
›Statin discontinuation associated with worse outcomes
›Glucose and metabolic management
›Acute glucose target: 7.8-10 mmol/l
›Hyperglycemia worsens ischemic injury
›Avoid hypoglycemia — threshold <3.9 mmol/l requires treatment
›Long-term diabetes management
›Target HbA1c <7% for secondary prevention
›DVT prophylaxis
›Intermittent pneumatic compression devices for immobile patients
›Initiate within 24 hours of admission
›LMWH when safe — timing depends on hemorrhage risk
›Early mobilization when neurologically stable
Rehabilitation and supportive care
›Dysphagia management
›Modified texture diet per speech therapy evaluation
›IDDSI (International Dysphagia Diet Standardisation Initiative) framework
›Thickened liquids if thin liquid aspiration demonstrated
›Nasogastric tube feeding if unsafe to swallow
›PEG consideration for prolonged dysphagia >4 weeks
›Diplopia management
›Eye patching of one eye for binocular diplopia relief
›Alternate eyes to prevent amblyopia
›Prism glasses — referral to neuro-ophthalmology if persistent
›Expected recovery: most isolated abducens palsies resolve with treatment of underlying cause
›Facial palsy management
›Eye protection — artificial tears and eye patching for incomplete eye closure
›Corneal exposure risk with LMN CN VII palsy
›Ophthalmology referral for significant lagophthalmos
›Facial rehabilitation exercises — physiotherapy
›Rehabilitation therapies
›Physiotherapy — early mobilization, gait training for contralateral hemiplegia
›Occupational therapy — upper limb function and ADL retraining
›Speech-language pathology — dysphagia and dysarthria