All patients with new-onset strokes should be admitted for further evaluation, education, and early rehabilitation. Patients with anterior circulation strokes should be evaluated for surgically correctable lesions and observed for any progression in their symptoms. Patients with vertebrobasilar strokes should be admitted for observation and possible heparinization.
Patients with new-onset TIAs should be evaluated for possible cardiac sources of TIAs or high-grade stenosis in the carotid arteries. The incidence of stroke after TIA in high-risk patients may be as high as 20 to 25 percent in the first year, with the greatest incidence in the first month. Because of the proven efficacy of carotid endarterectomy, patients should be admitted unless high-grade stenosis of the carotid artery can be ruled out in the emergency department. Patients without high-grade stenosis may be safely discharged on antiplatelet therapy with close follow-up.
Patients with a prior history of an anterior circulation stroke who have been previously studied, who present with a minor, completed (less than 24 h old), recurrent stroke or TIA, and who have a reliable support system may be discharged home after an appropriate emergency department workup. The use of aspirin, ticlopidine, or clopidogrel should be discussed with the family physician or neurologist, and follow-up within 48 h should be arranged. The patient and family members should be given clear instructions to return for further medical treatment if the patient experiences worsening of symptoms.
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