Post-Stroke Management¶

VERSION: 1.0 CREATED: January 31, 2026 STATUS: Approved

DIAGNOSIS: Post-Stroke Management

ICD-10: I69.30 (Sequelae of cerebral infarction, unspecified), I69.398 (Other sequelae of cerebral infarction), I69.351 (Hemiplegia following cerebral infarction), I69.320 (Aphasia following cerebral infarction), I69.310 (Cognitive deficits following cerebral infarction), I69.10 (Sequelae of intracerebral hemorrhage, unspecified), Z86.73 (Personal history of transient ischemic attack and cerebral infarction without residual deficits)

CPT CODES: 70553 (MRI brain), 93306 (echocardiogram), 93880 (carotid duplex), 93224-93227 (Holter/event monitor), 33267 (PFO closure), 97110-97542 (rehabilitation therapies), 96132 (neuropsychological testing), 99213-99215 (outpatient E/M)

SYNONYMS: Post-stroke care, post-stroke management, stroke secondary prevention, stroke recovery, stroke rehabilitation, post-cerebral infarction management, post-CVA management, stroke follow-up, stroke aftercare, post-stroke complications, chronic stroke care, stroke survivorship

SCOPE: Comprehensive post-stroke care from hospital discharge through long-term outpatient management. Covers secondary stroke prevention (antiplatelet, anticoagulation, statin, BP management), post-stroke rehabilitation, management of post-stroke complications (spasticity, depression, central pain, fatigue, cognitive decline, seizures, pseudobulbar affect), medication optimization, functional recovery monitoring, and return to activities. Excludes acute stroke management (see Acute Ischemic Stroke, ICH templates), acute rehabilitation admission protocols, and TIA workup (see TIA template).

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Fasting lipid panel (CPT 80061)	-	STAT	ROUTINE	-	Baseline for statin optimization; LDL target <70 for secondary prevention; reassess after statin initiation; triglycerides and HDL	LDL <70 mg/dL (SPARCL/TST trials); TC <200; TG <150; HDL >40 (M) / >50 (F)
HbA1c (CPT 83036)	-	STAT	ROUTINE	-	Diabetes is major modifiable risk factor; screen all stroke patients; pre-diabetes identification	<7% for most; <6.5% if newly diagnosed; >6.5% → diabetes management
CBC with differential (CPT 85025)	STAT	STAT	ROUTINE	-	Anemia (worsens ischemia); polycythemia (thrombotic risk); baseline for anticoagulation; infection screening	Normal; Hgb >10; plt >100K for anticoagulation; >50K for antiplatelet
CMP (BMP + LFTs) (CPT 80053)	STAT	STAT	ROUTINE	-	Renal function (medication dosing); electrolytes; hepatic function (statin monitoring); glucose	Normal; creatinine for DOAC dosing; LFTs for statin safety
TSH (CPT 84443)	-	ROUTINE	ROUTINE	-	Atrial fibrillation workup; thyroid disease as vascular risk factor; hypothyroidism contributes to hyperlipidemia	Normal; hyperthyroidism → AF; hypothyroidism → lipid control
Fasting glucose (CPT 82947)	STAT	STAT	ROUTINE	-	Diabetes screening; acute hyperglycemia management; target glucose 140-180 inpatient	<126 fasting; >126 → diabetes workup
PT/INR (CPT 85610)	STAT	STAT	ROUTINE	-	If on warfarin; baseline coagulation; hemorrhagic conversion monitoring	INR 2-3 for AF (unless mechanical valve: 2.5-3.5); stable monthly
Urinalysis with microalbumin (CPT 81003, 82043)	-	ROUTINE	ROUTINE	-	Renal function; microalbuminuria is independent cardiovascular risk marker; hypertensive nephropathy	Normal; microalbuminuria → aggressive BP and metabolic control

1B. Extended Workup (Second-line)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Lipoprotein(a) [Lp(a)] (CPT 83695)	-	-	ROUTINE	-	Independent cardiovascular risk factor; elevated in 20% of population; if elevated, more aggressive lipid lowering	<50 nmol/L; elevated → maximize statin + consider PCSK9i; Lp(a)-specific therapies in development
ApoB (CPT 82172)	-	-	ROUTINE	-	Better predictor of residual cardiovascular risk than LDL alone; target for patients on statins with LDL at goal	<70 mg/dL (or <50 in very high risk); elevated → intensify lipid therapy
Homocysteine (CPT 83090)	-	ROUTINE	ROUTINE	-	Hyperhomocysteinemia as vascular risk factor; B12/folate deficiency; treat with B vitamins	<15 μmol/L; elevated → B12, folate, B6 supplementation
Urine albumin/creatinine ratio (CPT 82043/82570)	-	-	ROUTINE	-	Quantify proteinuria; chronic kidney disease staging; cardiovascular risk stratification	<30 mg/g (normal); 30-300 → microalbuminuria; >300 → overt nephropathy
BNP or NT-proBNP (CPT 83880)	-	ROUTINE	ROUTINE	-	Heart failure screening; AF-associated cardiomyopathy; elevated in cardioembolic stroke	Normal; elevated → echocardiogram; HF management
Vitamin D, 25-OH (CPT 82306)	-	-	ROUTINE	-	Deficiency associated with worse stroke outcomes and depression; common in post-stroke patients with limited mobility	>30 ng/mL; deficient → supplement
Free T4 (CPT 84439)	-	ROUTINE	ROUTINE	-	If TSH abnormal; thyroid function affects AF and cardiovascular risk	Normal

1C. Rare/Specialized (Refractory or Atypical)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Hypercoagulable panel (CPT 85300-85306, 86235, 86147)	-	-	EXT	-	Young stroke (<50) without clear etiology; recurrent stroke on appropriate therapy; protein C, protein S, antithrombin III, factor V Leiden, prothrombin G20210A, antiphospholipid antibodies	Normal; positive → hematology referral; may change anticoagulation strategy
Antiphospholipid antibody panel (CPT 86235, 86147)	-	-	EXT	-	Recurrent stroke; young patient; pregnancy loss history; livedo reticularis; lupus anticoagulant, anticardiolipin, anti-β2-glycoprotein I (confirm at 12 weeks)	Negative; positive (confirmed at 12 weeks) → anticoagulation per APS guidelines
JAK2 mutation (CPT 81270)	-	-	EXT	-	Polycythemia vera or essential thrombocythemia as stroke etiology in young patients with elevated Hgb/Hct or platelets	Negative; positive → hematologic malignancy workup
MTHFR genotyping (CPT 81291)	-	-	EXT	-	Hyperhomocysteinemia evaluation; limited clinical utility for treatment decisions (treat homocysteine regardless)	Common variants (C677T, A1298C); treatment same regardless
Fabry disease screening (alpha-galactosidase A) (CPT 82657)	-	-	EXT	-	Young stroke without risk factors; can present with cryptogenic stroke; treatable with enzyme replacement	Normal activity; deficient → confirmatory genetic testing

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI brain with DWI (follow-up) (CPT 70553)	-	ROUTINE	ROUTINE	-	Follow-up MRI at 3-6 months post-stroke to assess infarct evolution, hemorrhagic transformation, and new lesions; baseline for comparison	Infarct maturation; no new lesions; hemorrhagic transformation assessment; chronic changes	MRI-incompatible implants
Carotid duplex ultrasound (CPT 93880)	-	STAT	ROUTINE	-	All ischemic stroke patients need carotid evaluation; re-evaluate annually if stenosis present; post-CEA/CAS surveillance	<50% stenosis (medical management); 50-69% (consider CEA if symptomatic); ≥70% (CEA/CAS recommended if symptomatic)	None
Transthoracic echocardiogram (TTE) (CPT 93306)	-	URGENT	ROUTINE	-	Cardioembolic source evaluation; LV function; valvular disease; atrial septal abnormalities; intracardiac thrombus	Normal; LV thrombus → anticoagulation; reduced EF → anticoagulation if <30%; valvular disease → cardiology	None
12-lead ECG (CPT 93000)	STAT	STAT	ROUTINE	-	AF detection; QTc monitoring; MI screening; baseline before antiarrhythmics	Normal sinus rhythm; AF → anticoagulation; other arrhythmia → cardiology	None
Holter monitor (24-48h) (CPT 93224)	-	ROUTINE	ROUTINE	-	Paroxysmal AF detection; 24-48h capture; initial cardiac rhythm monitoring post-stroke	Normal sinus rhythm; paroxysmal AF → anticoagulation; other arrhythmia	None

2B. Extended¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Extended cardiac monitoring (30-day event monitor) (CPT 93228)	-	-	ROUTINE	-	If 24-48h Holter negative and cryptogenic stroke; 30-day monitor detects ~12% additional AF; CRYSTAL-AF data	AF detection (even brief episodes ≥30 sec warrant anticoagulation consideration)	Skin irritation; compliance
Implantable loop recorder (ILR) (CPT 33285)	-	-	ROUTINE	-	Cryptogenic stroke with negative 30-day monitor; long-term AF detection (up to 3 years); CRYSTAL-AF showed 30% AF detection at 3 years	AF detection; any atrial arrhythmia → anticoagulation decision	Device infection risk; MRI conditional
Transesophageal echocardiogram (TEE) with bubble study (CPT 93312/93315)	-	URGENT	ROUTINE	-	PFO evaluation (present in 25% of population, ~50% of cryptogenic stroke <60 years); left atrial appendage thrombus; aortic arch atheroma	PFO with right-to-left shunt → closure consideration if age <60 and cryptogenic; LAA thrombus → anticoagulation; aortic atheroma → antiplatelet/statin	Esophageal stricture; recent esophageal surgery
CTA/MRA head and neck (CPT 70496/70544)	-	URGENT	ROUTINE	-	Intracranial stenosis evaluation; vertebral artery assessment; follow-up vascular imaging at 3-6 months post-stroke	Stable or improved stenosis; new stenosis → medication optimization; hemodynamically significant → interventional consideration	Contrast allergy (CTA); MRI incompatibility (MRA)
CT perfusion or MR perfusion (CPT 70496/70553)	-	ROUTINE	-	-	If symptomatic intracranial stenosis; assess hemodynamic significance; guide intervention	Normal perfusion despite stenosis (compensated) vs decreased perfusion (symptomatic)	Contrast; cooperation

2C. Rare/Specialized¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
PFO closure evaluation (cardiac catheterization) (CPT 93462)	-	-	EXT	-	Age <60 with cryptogenic stroke and PFO on TEE with moderate-to-large shunt or atrial septal aneurysm; CLOSE/REDUCE/RESPECT trials	PFO anatomy suitable for closure; shunt size; atrial septal aneurysm	Catheterization risks; active infection
Cerebral angiography (DSA) (CPT 36224)	-	EXT	EXT	-	Intracranial stenosis characterization; vasculitis evaluation; pre-intervention planning; when non-invasive imaging inconclusive	Degree and length of stenosis; collateral circulation; dissection flap; vasculitis pattern	Invasive; contrast; stroke risk ~0.5%

3. TREATMENT¶

3A. Secondary Prevention (Antiplatelet/Anticoagulation)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Aspirin	PO	First-line antiplatelet for non-cardioembolic ischemic stroke; lifelong secondary prevention	81 mg daily :: PO :: daily :: 81 mg PO daily (preferred); 325 mg for first 3 weeks with minor stroke/TIA per CHANCE/POINT then reduce to 81 mg; lifelong	Active GI bleeding; aspirin allergy; thrombocytopenia <50K	GI symptoms; bleeding signs; annual CBC	STAT	STAT	ROUTINE	-
Clopidogrel	PO	Alternative to aspirin if aspirin-intolerant; DAPT with aspirin for 21 days after minor stroke/TIA (CHANCE/POINT protocol)	75 mg daily :: PO :: daily :: 75 mg PO daily; 300 mg loading dose for acute minor stroke; DAPT: aspirin 81 mg + clopidogrel 75 mg x 21 days then clopidogrel monotherapy	Active bleeding; CYP2C19 poor metabolizer (reduced efficacy — consider ticagrelor); thrombocytopenia	Bleeding signs; CYP2C19 genotyping if available; platelet function testing rarely needed	STAT	STAT	ROUTINE	-
Aspirin + Clopidogrel (DAPT — short-term)	PO	Dual antiplatelet x 21 days for minor ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4) per CHANCE/POINT trials	81 mg aspirin + 75 mg clopidogrel daily x 21 days :: PO :: daily :: Aspirin 81 mg + clopidogrel 75 mg (with 300 mg clopidogrel load) x 21 days from onset; then monotherapy (aspirin or clopidogrel); DO NOT continue DAPT beyond 21-90 days (increases bleeding without benefit)	Major bleeding; planned surgery; thrombocytopenia	Bleeding signs closely x 21 days; GI prophylaxis with PPI if high GI risk	STAT	STAT	ROUTINE	-
Ticagrelor + Aspirin (DAPT — alternative)	PO	Alternative DAPT for minor stroke/TIA per THALES trial; does NOT require CYP2C19 metabolism	90 mg BID ticagrelor + 81 mg aspirin daily x 30 days :: PO :: BID :: Ticagrelor 180 mg load then 90 mg BID + aspirin 81 mg x 30 days; then switch to monotherapy; alternative when clopidogrel resistance suspected	Active bleeding; history of ICH; severe hepatic impairment; concurrent strong CYP3A4 inhibitors	Bleeding; dyspnea (common, usually benign); bradycardia; liver function	STAT	STAT	ROUTINE	-
Apixaban	PO	Anticoagulation for stroke with AF; preferred DOAC for most patients; superior to warfarin (ARISTOTLE trial)	5 mg BID; 2.5 mg BID :: PO :: BID :: 5 mg BID standard; reduce to 2.5 mg BID if ≥2 of: age ≥80, weight ≤60 kg, creatinine ≥1.5; start 2-14 days after stroke depending on infarct size (1-3-6-12 day rule)	Active major bleeding; severe hepatic impairment; mechanical heart valve; pregnancy	Renal function q6 months; CBC annually; bleeding signs; Xa level if needed (not routine)	-	ROUTINE	ROUTINE	-
Rivaroxaban	PO	Anticoagulation for stroke with AF; once-daily dosing advantage; ROCKET-AF data	20 mg daily; 15 mg daily :: PO :: daily :: 20 mg PO daily with dinner (food enhances absorption); reduce to 15 mg daily if CrCl 15-50 mL/min; timing per infarct size	Active major bleeding; CrCl <15; severe hepatic impairment (Child-Pugh C); mechanical valve	Renal function q6 months; CBC annually; bleeding signs	-	ROUTINE	ROUTINE	-
Dabigatran	PO	Anticoagulation for stroke with AF; RE-LY trial; reversible with idarucizumab	150 mg BID; 110 mg BID :: PO :: BID :: 150 mg BID standard; 110 mg BID if age ≥80 or concurrent P-gp inhibitor; CrCl 30-50: 150 mg BID acceptable; avoid if CrCl <30	CrCl <30; mechanical valve; active bleeding	Renal function q6 months (renal elimination); thrombin time or ecarin clotting time if needed; idarucizumab for reversal	-	ROUTINE	ROUTINE	-
Warfarin	PO	Anticoagulation for mechanical heart valve; alternative when DOACs contraindicated; AF in severe renal failure	Individualized per INR :: PO :: daily :: Start 5 mg daily (2.5 mg if elderly, low weight, liver disease); adjust to INR 2-3 (2.5-3.5 for mechanical valve); check INR 2-3 days after start, then weekly until stable, then monthly	Active major bleeding; pregnancy (teratogenic); severe hepatic failure; non-adherence (requires monitoring)	INR q1-4 weeks (target 2-3); dietary vitamin K counseling; drug interactions; bridge plan for procedures	-	ROUTINE	ROUTINE	-

3B. Symptomatic Treatments (Post-Stroke Complications)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Sertraline	PO	Post-stroke depression (affects 30-50% of stroke survivors); FLAME trial showed improved motor recovery; first-line SSRI	25 mg daily; 50 mg daily; 100 mg daily; 200 mg daily :: PO :: daily :: Start 25 mg daily; increase by 25-50 mg q1-2wk; target 50-200 mg daily; FLAME trial used 20 mg fluoxetine — either SSRI effective	Concurrent MAOIs; caution with anticoagulants (increased bleeding risk with SSRIs)	Suicidality first 4 weeks; bleeding risk with anticoagulants; serotonin syndrome; hyponatremia (especially elderly)	-	ROUTINE	ROUTINE	-
Escitalopram	PO	Post-stroke depression; well tolerated; alternative SSRI	5 mg daily; 10 mg daily; 20 mg daily :: PO :: daily :: Start 5-10 mg daily; max 20 mg; well tolerated in elderly stroke patients	Concurrent MAOIs; QT prolongation; max 10 mg in elderly per FDA	QTc if elderly or QT risk; suicidality; hyponatremia	-	ROUTINE	ROUTINE	-
Baclofen	PO	Post-stroke spasticity; GABA-B agonist; first-line for focal or generalized spasticity	5 mg TID; 10 mg TID; 20 mg TID :: PO :: TID :: Start 5 mg TID; increase by 5 mg/dose q3 days; target 10-20 mg TID; max 80 mg/day; taper slowly (withdrawal seizures)	Abrupt discontinuation (withdrawal syndrome with seizures, hallucinations); renal impairment (reduce dose)	Sedation; weakness (balance with spasticity reduction); renal function	-	ROUTINE	ROUTINE	-
Tizanidine	PO	Post-stroke spasticity; alpha-2 agonist; alternative or adjunct to baclofen; less weakness but more sedation	2 mg qHS; 4 mg TID; 8 mg TID :: PO :: TID :: Start 2 mg qHS; increase by 2 mg q3-7 days; target 4-8 mg TID; max 36 mg/day; sedating — use at bedtime initially	Concurrent ciprofloxacin or fluvoxamine (CYP1A2 inhibitors increase levels 10x); hepatic impairment	LFTs at baseline, 1, 3, 6 months (hepatotoxicity); sedation; hypotension; dry mouth	-	ROUTINE	ROUTINE	-
OnabotulinumtoxinA (Botox)	IM	Focal post-stroke spasticity not adequately controlled with oral agents; upper or lower limb; reduces spasticity and improves function	Individualized per muscle :: IM :: per protocol :: Upper limb: biceps 100-200 units, flexor digitorum 30-50 units per site; lower limb: gastrocnemius 150-300 units; effect onset 1-2 weeks; duration 3-4 months; repeat q3 months	Infection at injection site; generalized neuromuscular disease (MG, ALS); concurrent aminoglycosides	Excessive weakness; dysphagia if cervical muscles injected; antibody development (rare)	-	ROUTINE	ROUTINE	-
Gabapentin	PO	Central post-stroke pain (thalamic pain syndrome); neuropathic pain; also helps insomnia	100 mg TID; 300 mg TID; 600 mg TID; 900 mg TID :: PO :: TID :: Start 100-300 mg qHS; increase by 300 mg q3-7 days; target 300-900 mg TID; max 3600 mg/day; renal dosing	Renal impairment (dose adjust); respiratory depression with opioids	Sedation; dizziness; peripheral edema; renal function	-	ROUTINE	ROUTINE	-
Pregabalin	PO	Central post-stroke pain; alternative to gabapentin; scheduled dosing (no TID)	25 mg BID; 75 mg BID; 150 mg BID; 300 mg BID :: PO :: BID :: Start 25-75 mg BID; increase by 75 mg q1wk; target 150-300 mg BID; max 600 mg/day; renal dosing	Renal impairment; Class V controlled substance; angioedema (rare)	Sedation; weight gain; dizziness; peripheral edema; renal function	-	ROUTINE	ROUTINE	-
Amitriptyline	PO	Central post-stroke pain; insomnia; alternative when gabapentinoids insufficient; TCA class	10 mg qHS; 25 mg qHS; 50 mg qHS; 75 mg qHS :: PO :: QHS :: Start 10 mg qHS; increase by 10-25 mg q1wk; target 25-75 mg qHS; max 150 mg/day; use cautiously in elderly	Cardiac conduction abnormalities; recent MI; urinary retention; glaucoma; elderly (falls, anticholinergic effects)	ECG (QTc, conduction); anticholinergic effects; orthostatic hypotension; sedation	-	ROUTINE	ROUTINE	-
Dextromethorphan-quinidine (Nuedexta)	PO	Pseudobulbar affect (PBA) — involuntary laughing/crying; occurs in 15-25% of stroke survivors; significantly impacts quality of life	20/10 mg capsule daily x 7 days; then BID :: PO :: BID :: 20 mg dextromethorphan/10 mg quinidine: 1 capsule daily x 7 days then 1 capsule BID; only FDA-approved treatment for PBA	Concurrent MAOIs; QT prolongation; concurrent quinidine; CYP2D6 substrates with narrow therapeutic index; AV block	QTc at baseline and after steady state; hepatic function; serotonin syndrome risk with concurrent serotonergic drugs	-	ROUTINE	ROUTINE	-
Modafinil	PO	Post-stroke fatigue (affects 30-70% of survivors); not responsive to treating depression alone; wakefulness-promoting agent	100 mg daily; 200 mg daily :: PO :: daily :: Start 100 mg each morning; may increase to 200 mg daily; take in morning to avoid insomnia; Schedule IV	Severe hepatic impairment; history of angioedema with modafinil; concurrent hormonal contraceptives (reduces efficacy)	Blood pressure; psychiatric symptoms; insomnia; headache; reduces efficacy of hormonal contraceptives	-	ROUTINE	ROUTINE	-
Levetiracetam	PO	Post-stroke seizures (5-10% incidence; higher with cortical involvement and hemorrhagic stroke); preferred ASM post-stroke	500 mg BID; 750 mg BID; 1000 mg BID :: PO :: BID :: Start 500 mg BID; increase by 500 mg q1-2wk; target 500-1000 mg BID; max 3000 mg/day; no hepatic interactions with stroke medications	Renal impairment (dose adjust)	Psychiatric effects (irritability); renal function; not recommended for primary prophylaxis (only after seizure occurs)	STAT	STAT	ROUTINE	-

3C. Vascular Risk Factor Management¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Atorvastatin	PO	High-intensity statin for all ischemic stroke patients; SPARCL trial demonstrated 16% stroke risk reduction with LDL <70; TST trial supports LDL <70	40 mg daily; 80 mg daily :: PO :: daily :: Start 40-80 mg daily; target LDL <70 mg/dL; 80 mg preferred for secondary prevention; take any time of day	Active liver disease; pregnancy; concurrent strong CYP3A4 inhibitors at high doses	LFTs at baseline and 3 months; CK if myalgia; lipid panel q3-6 months until at goal then annually	-	STAT	ROUTINE	-
Rosuvastatin	PO	High-intensity statin alternative to atorvastatin; may be more potent for LDL lowering; non-CYP3A4 metabolism	20 mg daily; 40 mg daily :: PO :: daily :: Start 20 mg daily; may increase to 40 mg; max 40 mg; preferred if CYP3A4 drug interactions a concern	Active liver disease; pregnancy; severe renal impairment (max 10 mg if CrCl <30)	Same as atorvastatin; Asian patients: start 5-10 mg (increased rosuvastatin levels)	-	STAT	ROUTINE	-
Ezetimibe	PO	Add-on to statin if LDL not at goal on maximum statin; IMPROVE-IT trial showed benefit	10 mg daily :: PO :: daily :: 10 mg PO daily; can add to any statin; no dose adjustment needed	Severe hepatic impairment (when combined with statin); hypersensitivity	Lipid panel q3 months after starting until at goal; LFTs with statin combination	-	ROUTINE	ROUTINE	-
PCSK9 inhibitor (evolocumab or alirocumab)	SC	LDL not at goal despite max statin + ezetimibe; FOURIER trial (evolocumab) showed stroke reduction; Lp(a) elevated	Evolocumab 140 mg q2wk; alirocumab 75 mg q2wk :: SC :: q2wk :: Evolocumab 140 mg SC q2 weeks or 420 mg monthly; alirocumab 75 mg SC q2wk (may increase to 150 mg); self-injection training	Hypersensitivity	Lipid panel q3 months; injection site reactions; cost/insurance coverage	-	-	ROUTINE	-
Lisinopril	PO	First-line ACE inhibitor for post-stroke BP management; target BP <130/80 (SPRINT-like targets for secondary prevention)	5 mg daily; 10 mg daily; 20 mg daily; 40 mg daily :: PO :: daily :: Start 5 mg daily; increase by 5-10 mg q1-2wk; target BP <130/80; max 40 mg	Bilateral renal artery stenosis; angioedema history; pregnancy; hyperkalemia	BMP within 2 weeks of starting (creatinine, potassium); BP; cough (switch to ARB if intolerable)	-	ROUTINE	ROUTINE	-
Losartan	PO	ARB for post-stroke BP management; alternative if ACE inhibitor not tolerated (cough); LIFE trial showed stroke reduction	25 mg daily; 50 mg daily; 100 mg daily :: PO :: daily :: Start 25-50 mg daily; increase by 25-50 mg q2-4wk; target BP <130/80; max 100 mg	Bilateral renal artery stenosis; pregnancy; hyperkalemia	BMP within 2 weeks; BP; less cough than ACEi	-	ROUTINE	ROUTINE	-
Amlodipine	PO	Calcium channel blocker for post-stroke BP management; add-on to ACEi/ARB; good in elderly; evidence from ASCOT	2.5 mg daily; 5 mg daily; 10 mg daily :: PO :: daily :: Start 2.5-5 mg daily; increase by 2.5-5 mg q1-2wk; max 10 mg; well tolerated in elderly	Severe aortic stenosis; hypotension	BP; peripheral edema (common); HR	-	ROUTINE	ROUTINE	-
Chlorthalidone	PO	Thiazide-like diuretic for post-stroke BP management; more potent and longer-acting than HCTZ; evidence from ALLHAT	12.5 mg daily; 25 mg daily :: PO :: daily :: Start 12.5 mg daily; increase to 25 mg if needed; max 25 mg; take in morning	Hyponatremia; hypokalemia; gout; sulfonamide allergy (relative)	BMP (sodium, potassium, creatinine) at 2 weeks and q3-6 months; uric acid; glucose	-	ROUTINE	ROUTINE	-
Metformin	PO	First-line for type 2 diabetes in post-stroke patients; cardiovascular benefit; weight neutral	500 mg daily; 500 mg BID; 1000 mg BID :: PO :: BID :: Start 500 mg daily with meals; increase by 500 mg q1-2wk; target 1000 mg BID; max 2550 mg/day; extended-release for GI tolerability	eGFR <30; metabolic acidosis; heavy alcohol use; contrast dye (hold 48h)	BMP q3-6 months; HbA1c q3 months until <7% then q6 months; B12 annually (depletion)	-	ROUTINE	ROUTINE	-
Empagliflozin	PO	SGLT2 inhibitor for diabetes with cardiovascular benefit; reduces MACE and heart failure; renoprotective	10 mg daily; 25 mg daily :: PO :: daily :: Start 10 mg daily; may increase to 25 mg; take in morning; cardiovascular and renal benefit independent of HbA1c	eGFR <20 (for glucose lowering); recurrent UTI/genital infections; type 1 DM	BMP; eGFR; genital infections; volume status; ketoacidosis risk (rare)	-	ROUTINE	ROUTINE	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU
Physical therapy for gait training, balance, strength, and fall prevention — begin inpatient and continue outpatient; most recovery occurs in first 3-6 months but improvement continues	-	STAT	ROUTINE	-
Occupational therapy for ADL retraining, upper extremity function, adaptive equipment, and energy conservation	-	STAT	ROUTINE	-
Speech-language pathology for aphasia, dysarthria, cognitive-communication deficits, and swallow evaluation (dysphagia screening before oral intake)	-	STAT	ROUTINE	-
Neuropsychological testing at 3-6 months post-stroke for cognitive assessment; vascular cognitive impairment screening; guide rehabilitation goals	-	-	ROUTINE	-
Cardiology referral for AF management, PFO closure evaluation (if age <60 + cryptogenic stroke + PFO), heart failure management, or complex antithrombotic decisions	-	URGENT	ROUTINE	-
Rehabilitation medicine (physiatry) for comprehensive rehabilitation program coordination; inpatient rehab evaluation if moderate-severe deficits	-	URGENT	ROUTINE	-
Psychiatry or psychology referral for post-stroke depression not responding to SSRI within 6-8 weeks; anxiety; PTSD; adjustment disorder	-	ROUTINE	ROUTINE	-
Social work for discharge planning, community resources, disability documentation, caregiver support, and financial assistance	-	ROUTINE	ROUTINE	-
Neurology follow-up in 1-2 weeks post-discharge for medication reconciliation, imaging review, and secondary prevention optimization; then q3-6 months	-	ROUTINE	ROUTINE	-
Driving evaluation by occupational therapist and neurology clearance when appropriate; varies by deficit and state law	-	-	ROUTINE	-
Vascular surgery or neurointerventional referral if symptomatic carotid stenosis ≥50% for CEA/CAS evaluation	-	URGENT	ROUTINE	-

4B. Patient Instructions¶

Recommendation	ED	HOSP	OPD
Learn and recognize stroke warning signs (FAST: Face drooping, Arm weakness, Speech difficulty, Time to call 911); call 911 immediately if any symptom recurs — do not drive yourself	ROUTINE	ROUTINE	ROUTINE
Take all medications as prescribed; DO NOT stop antiplatelet, anticoagulant, or statin medications without consulting your neurologist — stopping these medications significantly increases recurrent stroke risk	ROUTINE	ROUTINE	ROUTINE
Monitor blood pressure at home twice daily (morning and evening) using validated automatic cuff; keep a log and bring to all appointments; target <130/80	-	ROUTINE	ROUTINE
Do not drive until cleared by your neurologist; stroke can affect vision, reaction time, and judgment; formal driving evaluation may be required	-	ROUTINE	ROUTINE
Participate actively in all prescribed rehabilitation therapies (PT, OT, speech); most recovery occurs in first 3-6 months but improvement can continue for years	-	ROUTINE	ROUTINE
Report new mood changes, persistent sadness, loss of interest, or involuntary crying/laughing to your neurologist — post-stroke depression and pseudobulbar affect are common and treatable	-	ROUTINE	ROUTINE
Maintain a medication list including all prescriptions, doses, and schedule; bring to every medical visit and keep a copy in your wallet	-	ROUTINE	ROUTINE
If on anticoagulation (apixaban, rivaroxaban, warfarin): report any unusual bleeding (gums, nosebleed, blood in urine/stool, easy bruising); carry anticoagulant alert card	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Smoking cessation is the single most important lifestyle modification; reduces recurrent stroke risk by 50%; offer nicotine replacement, varenicline, or bupropion; referral to cessation program	-	ROUTINE	ROUTINE
Mediterranean-style or DASH diet: rich in fruits, vegetables, whole grains, fish, olive oil; limit sodium to <2300 mg/day (1500 mg if hypertensive); limit processed foods and red meat	-	ROUTINE	ROUTINE
Regular aerobic exercise: 30 minutes of moderate-intensity exercise (walking, swimming, cycling) 5 days/week; adapted to functional level; reduces stroke recurrence by 20-25%	-	ROUTINE	ROUTINE
Limit alcohol to ≤1 drink/day for women, ≤2 drinks/day for men; heavy alcohol increases hemorrhagic stroke risk; complete abstinence preferred if AF or liver disease	-	ROUTINE	ROUTINE
Weight management: target BMI 18.5-25; waist circumference <40" (men) / <35" (women); even modest weight loss (5-10%) improves vascular risk factors	-	-	ROUTINE
Diabetes management: target HbA1c <7% (individualize for elderly); regular glucose monitoring; medication adherence; annual diabetic screening (eyes, feet, kidneys)	-	ROUTINE	ROUTINE
Sleep apnea screening (present in 50-70% of stroke patients); STOP-BANG questionnaire; polysomnography if positive; CPAP improves vascular outcomes	-	ROUTINE	ROUTINE

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Recurrent ischemic stroke	New focal deficit; DWI-positive on MRI; may be same or different vascular territory; reassess etiology	MRI/DWI (new acute infarct); vascular imaging; cardiac evaluation
Hemorrhagic transformation of existing infarct	Headache; worsening deficit; on anticoagulation/antiplatelet; typically occurs days 3-7 post-stroke	CT head (hemorrhage within infarct territory); manage anticoagulation
Post-stroke seizure	New seizure (focal or generalized); may mimic stroke (Todd paralysis); typically occurs within first year	EEG; MRI (no new infarct on DWI); seizure semiology
Post-stroke depression/apathy	Reduced motivation; flat affect; cognitive slowing; may mimic cognitive decline from vascular dementia	PHQ-9; neuropsychological testing; SSRI trial
Vascular cognitive impairment	Progressive cognitive decline; executive dysfunction; gait disturbance; strategic infarct dementia	Neuropsychological testing; MRI (strategic infarcts, white matter disease); exclude Alzheimer overlap
Central post-stroke pain	Contralateral burning/stinging pain; allodynia; typically thalamic stroke; onset weeks-months post-stroke	Clinical diagnosis; MRI (thalamic infarct); exclude other pain causes
Deconditioning / orthostatic hypotension	Weakness and fatigue from prolonged bed rest; orthostatic symptoms; not focal	Orthostatic vitals; functional assessment; PT evaluation
Medication side effects	Cognitive slowing; fatigue; sedation from post-stroke medications; overlap with stroke sequelae	Medication review; trial dose reduction; timing of symptoms

6. MONITORING PARAMETERS¶

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Blood pressure	Home BID; each visit	<130/80 per AHA/ASA	Add/increase antihypertensives; lifestyle modifications; renal artery evaluation if resistant	STAT	STAT	ROUTINE	-
LDL cholesterol	6 weeks after statin start; q3-6 months until goal; annually	<70 mg/dL	Intensify statin; add ezetimibe; PCSK9i if still above goal	-	ROUTINE	ROUTINE	-
HbA1c	q3 months until <7%; then q6 months	<7% (individualize)	Intensify diabetes treatment; add second agent; endocrine referral	-	ROUTINE	ROUTINE	-
INR (if on warfarin)	Weekly until stable; then q2-4 weeks	2.0-3.0 (2.5-3.5 for mechanical valve)	Adjust warfarin dose; assess diet/drug changes; bridge if needed	-	ROUTINE	ROUTINE	-
Renal function (BMP)	2 weeks after ACEi/ARB start; q6 months	Stable creatinine; K <5.0	Cr rise >30% → evaluate; K >5.5 → reduce ACEi/ARB or add K-lowering	-	ROUTINE	ROUTINE	-
PHQ-9 (depression screening)	Each visit for first year; annually thereafter	<5	≥10 → SSRI initiation or adjustment; ≥15 → psychiatry referral	-	ROUTINE	ROUTINE	-
Carotid imaging	6 months after CEA/CAS; annually if stenosis present	Stable or improved stenosis	Progressive stenosis → reassess intervention	-	-	ROUTINE	-
Functional status (mRS, NIHSS)	Each neurology visit; baseline → 3mo → 6mo → 1yr	Improving or stable	Plateau or decline → optimize rehabilitation; evaluate for depression or recurrence	-	ROUTINE	ROUTINE	-
Swallow function	Before first PO intake; SLP evaluation if dysphagia	Safe oral diet	Failed screen → modified diet; SLP evaluation; VFSS/FEES	-	STAT	ROUTINE	-
Weight / BMI	Each visit	BMI 18.5-25	Nutritional counseling; exercise prescription; medication review (weight-gaining meds)	-	ROUTINE	ROUTINE	-

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge home	Stable neurologic exam; safe swallow; ambulates with appropriate assistance; medications optimized; follow-up arranged; caregiver available if needed; home PT/OT if not yet outpatient
Inpatient rehabilitation	Moderate-severe deficits requiring 3+ hours of therapy daily; medical stability; motivation and ability to participate; expected functional improvement
Skilled nursing facility	Medical complexity requiring nursing care; unable to tolerate 3h/day therapy; awaiting home modifications
Admit to hospital (from outpatient)	Suspected recurrent stroke; hemorrhagic transformation; uncontrolled BP despite oral agents; medication adverse effects requiring monitoring
Outpatient follow-up schedule	Neurology 1-2 weeks post-discharge → 3 months → 6 months → annually; PCP q1-3 months for risk factor management; rehab therapies 3-5x/week

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
DAPT (aspirin + clopidogrel) x 21 days for minor stroke/high-risk TIA reduces recurrent stroke	Class I, Level A (RCTs)	Wang et al. NEJM 2013 (CHANCE); Johnston et al. NEJM 2018 (POINT)
High-intensity statin with LDL <70 for secondary stroke prevention	Class I, Level A	Amarenco et al. NEJM 2006 (SPARCL); Amarenco et al. NEJM 2020 (TST)
Apixaban superior to warfarin for stroke prevention in AF	Class I, Level A	Granger et al. NEJM 2011 (ARISTOTLE)
BP target <130/80 for secondary stroke prevention	Class I, Level A	AHA/ASA Guidelines 2021
PFO closure for cryptogenic stroke age <60 with moderate-large shunt	Class I, Level A (RCTs)	Mas et al. NEJM 2017 (CLOSE); Søndergaard et al. NEJM 2017 (REDUCE)
SSRIs improve post-stroke depression and may improve motor recovery	Class I, Level B	Chollet et al. Lancet Neurol 2011 (FLAME)
Early mobilization and rehabilitation improve outcomes post-stroke	Class I, Level A	AHA/ASA Rehab Guidelines 2016
Implantable loop recorder detects 30% AF at 3 years in cryptogenic stroke	Class I, Level B	Sanna et al. NEJM 2014 (CRYSTAL-AF)
Sleep apnea highly prevalent post-stroke; CPAP may improve outcomes	Class II, Level B	Brown et al. Stroke 2013
Mediterranean diet reduces recurrent cardiovascular events	Class I, Level A	Estruch et al. NEJM 2018 (PREDIMED)

CHANGE LOG¶

v1.0 (January 31, 2026) - Initial template creation - Comprehensive post-stroke management covering secondary prevention (antiplatelet, anticoagulation, statins, BP management), post-stroke complications (spasticity, depression, pain, fatigue, PBA, seizures), rehabilitation referrals, and risk factor optimization

APPENDIX A: Post-Stroke Secondary Prevention Checklist¶

APPENDIX B: Timing of Anticoagulation After Ischemic Stroke (for AF)¶

The "1-3-6-12 day rule" guides DOAC initiation based on infarct size:

Infarct Size	NIHSS	Start DOAC	Rationale
TIA (no infarct)	0	Day 1	No hemorrhagic transformation risk
Small infarct (<1.5 cm)	1-4	Day 3	Low HT risk
Moderate infarct (1.5-5 cm)	5-15	Day 6	Moderate HT risk; bridging not recommended
Large infarct (>5 cm or >1/3 MCA)	>15	Day 12	High HT risk; repeat imaging before starting

Notes: - Repeat CT/MRI before starting DOAC for large infarcts to exclude hemorrhagic transformation - These are guidelines, not absolute rules — individualize based on clinical judgment - Bridging with heparin is generally NOT recommended (HAEST, RAF-NOAC data) - If high recurrence risk and large infarct, consider aspirin bridge until DOAC timing