- The goal of this care guideline is to minimize stroke-related admissions and length of stay.
- For patients with new persistent deficits, with last known well within 24 h, proceed with an acute stroke pathway. Otherwise, may proceed with the pathway below.
- For any patient with suspected TIA or stroke, consult neurology.
- Screen for COVID-19 related risk factors:
High Risk Symptoms
- Perform and document NIHSS
- Diagnostic studies:
- Labs: CBC, BMP, PT/INR, fibrinogen, lipid panel, HgbA1C, ESR, CRP, troponin
- Consider: NT-proBNP, blood cultures, UA, urine/serum toxicology, COVID-19 testing if indicated above
- Hypercoagulation panel could be considered in select patients.
- EKG, keep on telemetry for duration of hospitalization (ok to travel off monitor)
- CT/CTA head and neck preferred
- Consider Carotid US
- Consider MRI/MRA head and neck
- Consider CT or MR venography
Discharge criteria checklist
- Clinical and Laboratory
❑ Adult with low-risk TIA (ABCD2 ≤ 3)
Non-disabling stroke (e.g. No dysphagia, encephalopathy, gait instability, severe limb weakness, severe neglect/visual deficit).
❑ No fluctuating neurological deficits or recurrent TIAs in the past month.
❑ No clinical concern for high recurrence risk stroke etiology (e.g. endocarditis, hypercoagulability of malignancy, giant cell arteritis).
❑ No concern for stroke mimics (e.g. meningoencephalitis, seizure, cerebral amyloid angiopathy-related spells).
❑ No medical instability (e.g. rapid AFib, severe hypertension, respiratory distress
❑ No psychosocial limitations compromising rapid virtual F/U (language barrier, internet access, psychiatric comorbidities)
❑ Head CT shows no evidence of hemorrhage or significant edema.
❑ No evidence for significant (>50%) stenosis or embolic occlusion of the ‘culprit’ artery
❑ No evidence for cerebral arteriopathy (e.g. vasculitis, RCVS, Moyamoya)
❑ No evidence of cervical arterial dissection
❑ TTE is reassuring or deemed not necessary by neurology consultant
TTE indicated during hospitalization
- Even if Discharge Criteria are met, the patient may be admitted per the discretion of neurology, OR if the recommended post-discharge tests or follow-up cannot be arranged within a suitable time frame.
- COVID-19 positive patients with TIA/minor stroke will be admitted to the COVID-19 unit with neurology consult team follow-up.
- Neurology consultant will determine appropriate management, including antiplatelet / anticoagulation therapy, statin, and blood pressure recommendations.
- Cardiac Evaluation:
- Additional TTE or TEE with contrast
- Cardiac monitoring with 30 day MCT or implanted loop monitor
- Additional stroke mechanism evaluation, determined per neurology
- Lower extremity vascular ultrasound, pelvic MRV, CT venogram
- CT chest/abdomen/pelvis