Acute Ischemic Stroke Management
For acute ischemic stroke, immediately administer IV alteplase 0.9 mg/kg (maximum 90 mg) within 4.5 hours of symptom onset, with 10% as a bolus over 1 minute and the remainder over 60 minutes, while simultaneously evaluating for endovascular thrombectomy in large vessel occlusions 1.
Time-Critical Reperfusion Strategy
The cornerstone of acute management is rapid reperfusion through two complementary pathways:
Intravenous Thrombolysis
- Alteplase remains the standard thrombolytic with high-quality evidence supporting its use within 4.5 hours 1, 2
- Tenecteplase is emerging as an alternative, though alteplase has more established evidence 3, 2
- Do not delay treatment to pursue additional diagnostic studies beyond essential non-contrast CT to exclude hemorrhage 1
- For wake-up strokes (last known normal >4.5 hours ago), use MRI DWI-FLAIR mismatch to identify candidates for thrombolysis 2
Endovascular Thrombectomy
- Standard of care for large vessel occlusions in both anterior and posterior circulation 3
- Evaluate immediately and simultaneously with thrombolysis consideration—do not delay one for the other
- Treatment windows have expanded beyond traditional timeframes based on advanced imaging selection 3
Critical Monitoring Protocol
After alteplase administration, follow this strict monitoring schedule 1:
- First 2 hours: BP and neurological assessments every 15 minutes
- Next 6 hours: Every 30 minutes
- Until 24 hours: Hourly assessments
- Target BP: Maintain SBP ≤180 mmHg and DBP ≤105 mmHg
- Admit to intensive care or dedicated stroke unit 1
Management of Complications
If Symptomatic Intracranial Hemorrhage Develops 1:
- Stop alteplase immediately
- Obtain emergent non-contrast head CT
- Send CBC, PT/INR, aPTT, fibrinogen, type and cross-match
- Administer cryoprecipitate 10 units over 10-30 minutes (repeat if fibrinogen <200 mg/dL)
- Consider tranexamic acid 1000 mg IV over 10 minutes OR ε-aminocaproic acid 4-5 g over 1 hour
- Consult hematology and neurosurgery emergently
Delay Invasive Procedures 1:
- Nasogastric tubes
- Indwelling bladder catheters
- Intra-arterial pressure catheters
- Only place if patient cannot be safely managed without them
Post-Thrombolysis Care
- Obtain follow-up CT or MRI at 24 hours before starting any anticoagulants or antiplatelet agents 1
- Manage blood pressure, glucose, temperature, and oxygenation to optimize cerebral protection 4
- Screen for dysphagia before oral intake 5
- Begin early secondary prevention planning 4
Common Pitfalls to Avoid
The 2018 AHA/ASA guidelines 1 explicitly warn against delaying treatment for additional diagnostic workup beyond essential imaging. The most recent 2026 updates 5 reinforce this time-critical approach while expanding eligibility criteria and introducing pediatric considerations. The key error is hesitation—stroke is a time-dependent emergency where "time is brain." Every 15-minute delay in treatment reduces the likelihood of good functional outcome.
The European Stroke Organisation guidelines 2 provide concordant high-quality evidence supporting this aggressive early intervention approach, particularly emphasizing appropriate patient selection through rapid clinical and imaging assessment rather than exhaustive testing that delays treatment.