What is the management approach for acute ischemic stroke?

From the Guidelines

Emergency stroke management requires immediate action to minimize brain damage, and the most effective approach is to administer intravenous tissue plasminogen activator (tPA) within 4.5 hours of symptom onset, followed by mechanical thrombectomy within 24 hours for large vessel occlusions, as recommended by the most recent guidelines 1. The initial assessment of a suspected stroke patient should involve the FAST evaluation: checking for Facial drooping, Arm weakness, Speech difficulties, and Time to call emergency services. Once at the hospital, rapid neuroimaging (CT or MRI) will determine if the stroke is ischemic (caused by a clot) or hemorrhagic (caused by bleeding). For ischemic strokes, intravenous tPA may be administered at a dose of 0.9 mg/kg (maximum 90 mg), with 10% given as a bolus and the remainder over 60 minutes, as supported by the American Heart Association/American Stroke Association guidelines 1. Mechanical thrombectomy may be performed within 24 hours for large vessel occlusions, with a combined endovascular therapy approach using stent-retrievers and aspiration being the most effective way to achieve fast first-pass complete reperfusion, as recommended by the Journal of the American College of Cardiology 1. For hemorrhagic strokes, blood pressure control is crucial, targeting systolic BP <140-160 mmHg using medications like labetalol (10-20 mg IV) or nicardipine (5 mg/hour IV, titrated by 2.5 mg/hour). Reversal of anticoagulation may be necessary using protamine sulfate for heparin, vitamin K and prothrombin complex concentrate for warfarin, or specific reversal agents for DOACs. Supportive care includes maintaining oxygen saturation >94%, normal blood glucose (140-180 mg/dL), and preventing complications like aspiration pneumonia. Early mobilization and rehabilitation should begin as soon as the patient is stable. Time is critical in stroke management, as "time is brain" - approximately 1.9 million neurons die each minute during an acute ischemic stroke. Some key points to consider in emergency stroke management include:

• Rapid patient transfer and diagnosis
• Avoiding time-consuming imaging methods and overly selective treatment selection criteria
• Using a combined endovascular therapy approach for mechanical thrombectomy
• Organizing existing systems of care and pre-hospital transfer systems to diagnose and treat patients as fast as possible.

From the Research

Emergency Stroke Management

• The goal of emergency stroke management is to minimize brain damage and improve patient outcomes 2, 3, 4, 5.
• Intravenous thrombolysis with alteplase is recommended for patients with acute ischemic stroke within 4.5 hours of symptom onset 2, 6.
• Mechanical thrombectomy can be considered for patients with acute middle cerebral artery or carotid occlusions within a 6-hour time window 2.
• Antiplatelet agents, such as aspirin, are recommended for patients with ischemic stroke, but should be delayed for 24 hours if thrombolysis is performed or contemplated 2.
• Urgent anticoagulation is not recommended for ischemic stroke patients, but may be considered for secondary prevention in patients with a high risk of cardioembolism 2.

Patient Selection and Treatment

• Patient selection for intravenous thrombolysis and mechanical thrombectomy is crucial, and should be based on individual patient characteristics and risk factors 2, 6.
• Imaging selection strategies, such as MRI DWI-FLAIR mismatch, can help identify patients who may benefit from intravenous thrombolysis or mechanical thrombectomy 6.
• Relative and absolute contraindications to alteplase should be carefully considered before initiating treatment 6.

Pre-Hospital and Emergency Care

• Pre-hospital care, including emergency medical services protocols, can help identify patients with stroke and triage them to centers capable of delivering appropriate treatment 4, 5.
• Emergency clinicians should remain current with the newest treatment algorithms and provide expeditious and high-quality care to stroke patients 3, 5.
• Initial evaluation of the patient with history, examination, and imaging is critical in determining the best course of treatment 5.