From the Guidelines
When faced with worsening ischemic stroke on imaging, immediate medical intervention is crucial, and the patient should be considered for reperfusion therapies, including IV alteplase and mechanical thrombectomy, if they meet the eligibility criteria, as evidenced by the 2018 guidelines for the early management of patients with acute ischemic stroke 1. For eligible patients within the appropriate time window (typically up to 4.5 hours from symptom onset for IV thrombolysis or up to 24 hours for thrombectomy in selected cases), reperfusion therapies should be considered.
Key Considerations
- Administer IV alteplase at 0.9 mg/kg (maximum 90 mg) with 10% as bolus and remainder over 60 minutes if the patient meets criteria.
- For large vessel occlusions with salvageable penumbra, mechanical thrombectomy should be pursued, using imaging criteria such as those from the DAWN or DEFUSE 3 trials to select patients 1.
- Blood pressure management is critical - maintain systolic BP below 180 mmHg after thrombolysis using agents like labetalol (10-20 mg IV) or nicardipine (5 mg/hr IV, titrated).
- Provide supportive care including airway management, maintaining normoglycemia (blood glucose 140-180 mg/dL), and normothermia.
- Initiate antithrombotic therapy (aspirin 325 mg initially, then 81 mg daily) once hemorrhage is excluded and after the thrombolysis window.
Imaging and Eligibility
- All patients with suspected acute stroke should undergo brain imaging with NCCT or MRI, and those with suspected acute ischemic stroke who arrive within 4.5 h and are potentially eligible for intravenous thrombolysis should undergo immediate brain imaging with non-contrast CT (NCCT) without delay to determine eligibility for thrombolysis 1.
- For patients with suspected acute ischemic stroke who arrive within 6 h and are potentially eligible for EVT, immediate brain imaging non-contrast CT and CT angiography (CTA) without delay, from arch-to-vertex including the extra- and intra-cranial circulation, should be performed to identify large vessel occlusions eligible for endo-vascular thrombectomy 1. The goal of these interventions is to restore blood flow, limit infarct expansion, and prevent secondary injury by maintaining physiological parameters within optimal ranges for brain tissue preservation, as supported by the Canadian Stroke Best Practice Recommendations for Acute Stroke Management 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Worsening Ischemic Stroke on Imaging: Management Options
- For patients with acute ischemic stroke, administration of IV tissue plasminogen activator (tPA) is recommended if treatment is initiated within 3 hours of clearly defined symptom onset 2, 3.
- For patients with acute ischemic stroke of > 3 hours but < 4.5 hours, clinicians are suggested not to use IV tPA 2, 3.
- For patients with acute stroke onset of > 4.5 hours, the use of IV tPA is recommended against 2.
- Early aspirin therapy is recommended for patients with acute ischemic stroke who are not receiving thrombolysis 2, 3.
- Prophylactic low-dose subcutaneous heparin or low-molecular-weight heparins are recommended for patients with acute ischemic stroke and restricted mobility 2, 3.
Imaging Changes and Clinical Deterioration
- Clinical worsening is a known complication following acute ischemic stroke, and imaging changes such as edema, extension of infarct, hemorrhage, herniation, and midline shift may occur 4.
- However, patients who deteriorate are no more likely to have imaging changes than those who have a stable clinical course 4.
- Appearance of herniation, both subfalcine and uncal, is the only specific imaging change associated with clinical deterioration 4.
Thrombolytic Therapy in Specific Patient Populations
- For patients with acute ischemic stroke and NIHSS ≤5 screened with MRI, IV tissue plasminogen activator is safe 5.
- For Chinese patients with mainly mild posterior circulation stroke who did not receive thrombectomy, alteplase administered 4.5 to 24 hours after stroke onset resulted in a higher frequency of functional independence at 90 days than standard medical care 6.