Acute Stroke Management
For acute ischemic stroke, administer IV alteplase 0.9 mg/kg (max 90 mg) within 4.5 hours of symptom onset, or tenecteplase as an alternative, followed by endovascular thrombectomy (EVT) for large vessel occlusions up to 24 hours in selected patients; for hemorrhagic stroke, rapidly lower systolic blood pressure to approximately 140 mmHg. 1, 2
Initial Diagnosis and Triage
Perform immediate CT or MRI to differentiate ischemic from hemorrhagic stroke—this is the critical first step that determines all subsequent management 3. The imaging must be completed rapidly as door-to-needle time should be ≤30 minutes for thrombolysis 2.
For ischemic stroke, obtain CT angiography or MR angiography to identify large vessel occlusions that may benefit from EVT 1. Advanced imaging with CT perfusion can extend treatment windows by identifying salvageable tissue even beyond traditional time limits 4.
Acute Ischemic Stroke: Reperfusion Therapy
Intravenous Thrombolysis
Administer alteplase 0.9 mg/kg (maximum 90 mg total) with 10% given as IV bolus over 1 minute and remaining 90% infused over 60 minutes 2. This dosing is fundamentally different from myocardial infarction protocols—a critical pitfall to avoid 2.
The 2026 AHA guidelines now recognize tenecteplase as an acceptable alternative to alteplase, offering simplified single-bolus administration with comparable safety and efficacy 4, 1, 5. This represents a significant practice update from the 2018 recommendations.
Time windows:
- Standard window: within 4.5 hours of symptom onset 1, 6
- Extended window: may be considered beyond 4.5 hours in selected patients using advanced neuroimaging to identify salvageable tissue 4, 1
Key contraindications to address:
- Do NOT give thrombolysis to patients on direct oral anticoagulants (DOACs) unless specialized testing confirms safe drug levels and reversal agents are available 2
- Blood pressure must be <185/110 mmHg before initiating thrombolysis 2, 1
Endovascular Thrombectomy (EVT)
EVT should be performed for large vessel occlusions up to 24 hours from symptom onset in carefully selected patients 3, 1. The evidence strongly supports:
- EVT is indicated whether or not the patient received IV thrombolysis 2
- Patients eligible for both IV thrombolysis and EVT should receive IV thrombolysis first (bridging therapy), which can be initiated while preparing for EVT 2, 7
- Time windows: up to 8 hours for anterior circulation as standard, up to 24 hours with favorable imaging, and potentially 12-24 hours for posterior circulation strokes 6, 1
Blood Pressure Management
Acute Ischemic Stroke WITHOUT Reperfusion Therapy
Do NOT routinely lower blood pressure unless systolic BP ≥220 mmHg or diastolic BP ≥120 mmHg 8, 6. If treatment is required, reduce BP by only approximately 15% within the first 24 hours 8. Aggressive BP lowering can worsen outcomes by reducing perfusion to ischemic penumbra.
Acute Ischemic Stroke WITH Reperfusion Therapy
Maintain BP <185/110 mmHg before thrombolysis and <180/105 mmHg for 24 hours after treatment 2, 8, 1. Use IV calcium channel blockers (preferred in Japanese guidelines) or other rapidly titratable agents 8.
Acute Intracerebral Hemorrhage (ICH)
Rapidly but carefully lower systolic BP to approximately 140 mmHg 8. All major guidelines (AHA, ESC, ESH, JSH) converge on this target. Critical caveats:
- Avoid overshoot below target
- Minimize BP variability
- Be particularly cautious when baseline SBP >220 mmHg 8
Antithrombotic Therapy
Acute Phase (First 24-48 Hours)
For ischemic stroke NOT receiving thrombolysis: start aspirin 160-325 mg within 48 hours 9, 5.
For ischemic stroke receiving thrombolysis: delay aspirin or any antithrombotic for 24 hours 9, 6. Perform repeat brain imaging at 24 hours before starting antiplatelet therapy 9.
Do NOT use:
- Glycoprotein IIb/IIIa inhibitors 9
- Urgent full-dose anticoagulation with heparin or LMWH for acute stroke treatment 9
Secondary Prevention (After Acute Phase)
For minor ischemic stroke or high-risk TIA: initiate short-term dual antiplatelet therapy (DAPT) to reduce early recurrence 4, 1, 5. This represents updated evidence from recent trials.
For cardioembolic stroke: start oral anticoagulation 5. Timing depends on infarct size:
- Small infarcts with high embolic risk: can start immediately or within first days 9
- Large infarcts: delay anticoagulation and decide timing case-by-case due to hemorrhagic transformation risk 9
For cerebral venous thrombosis: use therapeutic-dose heparin even if concomitant intracranial hemorrhage is present 9. This is a critical exception where anticoagulation is given despite bleeding.
Additional Acute Management
Supportive Care Targets
- Hyperglycemia: Treat glucose >155 mg/dL 6, 1
- Fever: Use antipyretics if temperature >37.5°C 6
- Blood pressure in non-reperfusion candidates: Only treat if >185/105 mmHg 6
Complications
Malignant cerebral edema: Consider decompressive hemicraniectomy 6.
Symptomatic ICH after thrombolysis: There is insufficient evidence for routine use of cryoprecipitate, FFP, prothrombin complex concentrates, tranexamic acid, or platelet transfusions—decisions must be individualized 2, 7.
Early Rehabilitation and Stroke Unit Care
All stroke patients must be admitted to a stroke unit 2, 6. This is standard of care with proven mortality and morbidity reduction. Start rehabilitation as early as possible 6.
Critical Pitfalls to Avoid
- Wrong alteplase dosing: The 0.9 mg/kg stroke protocol differs completely from MI dosing 2
- Giving thrombolysis to DOAC patients: Unless specialized testing/reversal available 2
- Aggressive BP lowering in acute ischemic stroke: Can worsen outcomes by reducing penumbral perfusion 8
- Starting antiplatelets within 24 hours of thrombolysis: Increases bleeding risk 9
- Withholding anticoagulation in cerebral venous thrombosis due to hemorrhage: Anticoagulation is still indicated 9