From the Guidelines
Acute stroke treatment requires immediate medical attention to minimize brain damage, with intravenous tissue plasminogen activator (tPA, alteplase) being the primary medication for ischemic strokes, administered at 0.9 mg/kg (maximum 90 mg) with 10% given as a bolus and the remainder over 60 minutes, within 4.5 hours of symptom onset 1. For eligible patients with large vessel occlusions, mechanical thrombectomy can be performed up to 24 hours after symptom onset. Hemorrhagic strokes require different management, including blood pressure control with medications like labetalol or nicardipine, reversal of anticoagulation if applicable, and possible neurosurgical intervention. All stroke patients should receive supportive care including:
- Airway management
- Blood pressure monitoring (target <185/110 mmHg for ischemic strokes receiving tPA)
- Glucose control
- Temperature management After the acute phase, secondary prevention includes:
- Antiplatelet therapy (aspirin 81-325 mg daily, clopidogrel 75 mg daily, or combination therapy depending on stroke type) 1
- Statins
- Blood pressure management
- Lifestyle modifications Early rehabilitation should begin as soon as the patient is medically stable to maximize functional recovery. Time is critical in stroke treatment as "time is brain" – approximately 1.9 million neurons die each minute during a stroke, making rapid assessment and treatment essential for better outcomes. The most recent and highest quality studies, such as those published in 2020 1, support the use of tPA and mechanical thrombectomy in the treatment of acute ischemic stroke, and emphasize the importance of rapid treatment and supportive care.
From the Research
Acute Stroke Treatment Overview
- Acute ischemic stroke treatment primarily involves thrombolysis with intravenous alteplase, which is approved in most countries 2.
- The effectiveness of thrombolysis depends on the time elapsed between stroke onset and treatment initiation, with benefits decreasing over time 2, 3.
- Symptomatic intracranial hemorrhage (SICH) is a significant risk associated with thrombolysis, occurring in around 3% of cases 2, 4.
Treatment Options and Considerations
- Intravenous alteplase remains the only approved thrombolytic agent for acute ischemic stroke, but research is ongoing to develop new agents with improved safety and efficacy 3.
- Tenecteplase has emerged as a potential alternative to alteplase due to its ease of administration and reported efficacy in patients with large vessel occlusion 3.
- Intra-arterial thrombolysis and mechanical thrombectomy are also being explored as treatment options, particularly in cases where intravenous thrombolysis is not effective or suitable 3, 5, 6.
Management and Outcome
- Prompt diagnosis and early correction of coagulopathy are crucial in managing SICH caused by systemic thrombolysis with alteplase 4.
- Prehospital and emergency stroke care, including the use of emergency medical services protocols and advanced imaging techniques, play a critical role in minimizing the impact of acute ischemic stroke 5, 6.
- Secondary prevention strategies, such as short-term use of dual antiplatelet therapy, are also important in preventing recurrent stroke 6.