Save the Penumbra: Acute Management of Ischemic Cerebrovascular Disease-Slides

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The presentation "Save The Penumbra: Management of Acute Cerebrovascular Disease" by CPT Madison Paul, MD, focuses on current approaches to ischemic stroke care, emphasizing reperfusion strategies, antiplatelet therapy, and anticoagulation management. Stroke remains the fifth leading cause of death and a major source of disability, disproportionately affecting African American patients who face earlier and recurrent strokes.<br /><br />Key ischemic stroke types include large vessel occlusion, cardioembolic stroke, small vessel occlusion, and strokes of other or undetermined causes. Timely reperfusion is critical; intravenous thrombolysis with tissue plasminogen activator (tPA) is most effective within 4.5 hours of symptom onset. Alteplase remains the only FDA-approved agent, although tenecteplase is gaining attention for easier administration. Mechanical thrombectomy is indicated within 24 hours for eligible patients with anterior circulation large vessel occlusion and specified clinical criteria.<br /><br />For transient ischemic attacks (TIA) or minor stroke (ABCD2 score ≥4 or NIHSS ≤3), dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended within 72 hours of symptoms to reduce recurrence risk, generally continued for 21-90 days.<br /><br />In patients with cardioembolic stroke due to non-valvular atrial fibrillation (NVAF), direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, or rivaroxaban are preferred, including in obese patients, while warfarin remains standard for valvular atrial fibrillation. Initiation is recommended within 4-14 days post-stroke. Adding antiplatelet therapy to DOACs is generally not supported. Ongoing cardiac monitoring is advised to detect atrial fibrillation in cryptogenic strokes.<br /><br />Post-tPA care involves close blood pressure and neurological monitoring with a BP goal of 180/105 mmHg, withholding antiplatelets and anticoagulants for 24 hours, and vigilance for neurological changes.<br /><br />Overall, emerging data favors individualized timely reperfusion, evidence-based antithrombotic regimens, and adherence to evolving guidelines to optimize outcomes in acute cerebrovascular disease management.

Keywords

acute cerebrovascular disease

ischemic stroke

reperfusion strategies

antiplatelet therapy

anticoagulation management

transient ischemic attack

mechanical thrombectomy

direct oral anticoagulants

tissue plasminogen activator

atrial fibrillation