Management of Ischemic Stroke

Initial Assessment and Imaging

• Non-contrast CT has identified a posterior cerebral artery territory infarct, which is crucial for distinguishing between hemorrhagic and ischemic stroke 1
• Further vascular imaging with CTA or MRA should be performed to evaluate the severity of stenosis and identify any additional intracranial or extrathoracic vascular lesions 2, 3
• When symptoms suggest posterior cerebral or cerebellar ischemia, MRA or CTA is recommended over ultrasound for evaluation of vertebral arteries 4

Secondary Stroke Prevention

Antiplatelet Therapy

• Administer aspirin 75-325 mg daily as part of initial management for secondary prevention 3, 5
• In patients with ischemic stroke or TIA with obstructive or nonobstructive extracranial cerebrovascular atherosclerosis, antiplatelet therapy is recommended 3

Blood Pressure Management

• Antihypertensive treatment is recommended to maintain blood pressure below 140/90 mmHg 2, 3
• For patients with symptomatic extracranial carotid or vertebral atherosclerosis, antihypertensive treatment should be carefully managed to avoid exacerbating cerebral ischemia 3

Lipid Management

• Statin therapy is recommended for all patients with extracranial carotid or vertebral atherosclerosis to reduce LDL cholesterol below 100 mg/dL 3, 6
• For patients with atherosclerotic ischemic stroke, it is reasonable to target LDL-C reduction of at least 50% or a target level of <70 mg/dL for maximum benefit 6, 7
• High-intensity statin therapy is recommended for patients with ischemic stroke and LDL-C >100 mg/dL 7

Lifestyle Modifications

• Smoking cessation is strongly advised with appropriate counseling and pharmacological support 3, 6, 8
• The American Heart Association recommends smoking cessation interventions including counseling, nicotine replacement products, and oral medications 9
• Alcohol reduction is strongly recommended, with complete cessation being preferable 6, 7, 8
• At least 30 minutes of moderate-intensity physical exercise 1-3 times per week should be encouraged as tolerated 6, 9

Follow-up Care

• Serial non-invasive imaging of the extracranial vertebral arteries is reasonable to assess progression of atherosclerotic disease 4
• Regular monitoring of lipid levels 1-3 months after treatment initiation, followed by assessments every 3-12 months 7
• The American Stroke Association recommends a transdisciplinary team approach for comprehensive management, especially if diabetes is present 7