How should an acute ischemic brain infarct be managed?

Management of Acute Brain Infarct (Acute Ischemic Stroke)

For acute ischemic stroke, immediately initiate IV alteplase (0.9 mg/kg, max 90 mg) if the patient presents within 4.5 hours of symptom onset and has no contraindications, while simultaneously evaluating for mechanical thrombectomy if large vessel occlusion is suspected. 111

Immediate Assessment and Imaging

Upon arrival, obtain emergent non-contrast head CT to exclude hemorrhage. Do not delay treatment to pursue additional diagnostic studies if the patient is within the therapeutic window 1. The time of onset is defined as when the patient was last known to be neurologically normal, not when symptoms were discovered 11.

Reperfusion Therapy Algorithm

Intravenous Thrombolysis

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) over 60 minutes, with 10% given as bolus over 1 minute 11:

• Within 4.5 hours: Standard indication (Class I, Level A)
• 4.5-24 hours: May be considered with advanced imaging showing salvageable tissue 23

The 2026 guidelines have expanded eligibility beyond rigid time windows toward tissue-based selection using advanced neuroimaging 24.

Mechanical Thrombectomy

Mechanical thrombectomy with stent retrievers is recommended over intra-arterial thrombolysis as first-line therapy for large vessel occlusions 1. This applies to:

• Anterior circulation strokes up to 24 hours with salvageable tissue
• Basilar artery occlusion 23
• Medium vessel occlusions (per 2026 updates) 54

Critical Monitoring Protocol

After alteplase administration 11:

• First 2 hours: BP and neurological assessments every 15 minutes
• Next 6 hours: Every 30 minutes
• Until 24 hours: Hourly assessments
• Target BP: Keep SBP ≤180 mmHg and DBP ≤105 mmHg
• Admit to intensive care or stroke unit

If severe headache, acute hypertension, nausea, vomiting, or neurological worsening occurs, immediately stop alteplase and obtain emergency head CT 11.

Antiplatelet Therapy

Administer aspirin 160-300 mg within 24-48 hours of stroke onset 1. Key timing considerations:

• If alteplase given: Delay aspirin for 24 hours, but may consider earlier if substantial benefit from concomitant conditions outweighs risk
• Minor stroke: Dual antiplatelet therapy (aspirin + clopidogrel) for 21 days started within 24 hours can be beneficial for secondary prevention up to 90 days (Class IIa) 1
• Do NOT use aspirin as substitute for alteplase or thrombectomy (Class III: No Benefit) 1

Management of Hemorrhagic Complications

If symptomatic intracranial bleeding occurs within 24 hours of alteplase 11:

1. Stop alteplase immediately
2. Obtain CBC, PT/INR, aPTT, fibrinogen, type and cross-match
3. Emergency non-contrast head CT
4. Cryoprecipitate: 10 units over 10-30 minutes; additional dose if fibrinogen <200 mg/dL
5. Tranexamic acid 1000 mg IV over 10 minutes OR ε-aminocaproic acid 4-5 g over 1 hour
6. Consult hematology and neurosurgery
7. Supportive care: BP control, ICP management, temperature and glucose control

Special Populations and Contraindications

The 2026 guidelines have modified the approach to contraindications 4:

• Small/moderate unruptured aneureurysms (<10 mm): IV alteplase is reasonable (Class IIa) 1
• 1-10 cerebral microbleeds on MRI: Treatment reasonable (Class IIa) 1
• >10 microbleeds: Uncertain benefit, increased hemorrhage risk (Class IIb) 1
• Recent non-STEMI or right/inferior STEMI: Treatment reasonable (Class IIa) 1
• Concurrent acute MI: Use cerebral ischemia dose followed by PCI if indicated (Class IIa) 1

Critical Pitfalls to Avoid

1. Do not delay treatment for additional diagnostic studies if within therapeutic window 1
2. Do not use glycoprotein IIb/IIIa antagonists (abciximab) - potentially harmful (Class III: Harm) 1
3. Do not use ticagrelor over aspirin for acute minor stroke (Class III: No Benefit) 1
4. Delay invasive procedures (NG tubes, Foley catheters, arterial lines) for 24 hours if patient can be safely managed without them 11
5. Obtain follow-up CT/MRI at 24 hours before starting anticoagulants or antiplatelet agents 11

Emerging Evidence

Recent trials support tenecteplase as an alternative to alteplase with practical workflow advantages, particularly in centers with transfer delays 23. The shift from time-based to tissue-based (penumbra-guided) treatment selection represents the most significant paradigm change in acute stroke management 24.