Acute Ischemic Stroke Management
Classification of Non-Hemorrhagic (Ischemic) Stroke
Ischemic strokes are classified by mechanism using the TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria, which divides them into five main categories: large-artery atherosclerosis, cardioembolism, small-vessel occlusion (lacunar), stroke of other determined etiology, and stroke of undetermined etiology. While the guidelines provided don't explicitly detail classification systems, understanding the mechanism is critical for determining secondary prevention strategies 1.
Acute Stroke Protocol and Treatment
Immediate Hospital Evaluation
All patients with suspected acute stroke must undergo brain imaging (CT or MRI) immediately upon hospital arrival before any specific treatment is initiated 2. The primary goals are to:
- Rule out hemorrhage
- Identify vessel occlusion location
- Assess salvageable brain tissue
Check capillary blood glucose immediately—hypoglycemia (glucose <60 mg/dL or 3.3 mmol/L) must be treated with IV dextrose before anything else 2.
Airway, Breathing, Circulation
- Intubate if airway is compromised or ventilation insufficient due to impaired alertness or bulbar dysfunction 2
- Provide supplemental oxygen only to maintain saturation ≥94% 2
- Correct hypotension and hypovolemia to maintain organ perfusion 2
Blood Pressure Management
Do NOT routinely lower blood pressure in acute ischemic stroke unless:
- SBP ≥220 mmHg or DBP ≥120 mmHg (without reperfusion therapy planned) 3, 1
- Patient is eligible for IV thrombolysis—then BP must be <185/110 mmHg before treatment and maintained <180/105 mmHg for 24 hours after 2
- Concomitant acute MI, aortic dissection, or preeclampsia/eclampsia exists 2
Cautious lowering means approximately 15% reduction over 24 hours—aggressive BP reduction can worsen outcomes 1.
Intravenous Thrombolysis (Alteplase)
Administer IV alteplase 0.9 mg/kg (maximum 90 mg) with 10% as bolus over 1 minute, remaining 90% over 60 minutes, to eligible patients within 4.5 hours of symptom onset or last known well 2, 4, 2.
Target door-to-needle time <60 minutes in 90% of patients, with median of 30 minutes 4.
Key Eligibility Points:
- Only glucose assessment must precede alteplase—do not delay for other labs 2
- Aspirin is NOT a substitute for thrombolysis and should not be given within 24 hours of alteplase 1
- Give alteplase even if mechanical thrombectomy is planned—do NOT wait to evaluate response before proceeding to thrombectomy 2
Extended Window Thrombolysis:
For wake-up strokes or unclear onset >4.5 hours from last known well, alteplase can be given within 4.5 hours of symptom recognition if MRI shows DWI-FLAIR mismatch 2.
Endovascular Thrombectomy (EVT)
Perform mechanical thrombectomy with stent retriever or direct aspiration for patients meeting ALL criteria:
- Age ≥18 years
- Pre-stroke mRS 0-1
- Internal carotid artery or MCA (M1) occlusion
- NIHSS ≥6
- ASPECTS ≥6
- Treatment initiated (groin puncture) within 6 hours of onset 2
Between 6-24 hours, EVT is recommended for patients with large vessel occlusion in anterior circulation who have salvageable tissue on advanced imaging (CT perfusion or DW-MRI showing core/perfusion mismatch) 2.
Obtain non-invasive angiography (CTA) for all patients with clinically suspected large vessel occlusion 2.
Antiplatelet Therapy
Administer aspirin 325 mg orally within 24-48 hours after stroke onset 1. This provides modest benefit primarily through prevention of early recurrent stroke 3, 1.
Do NOT give aspirin or other antiplatelets within 24 hours of IV thrombolysis due to increased bleeding risk 1.
Anticoagulation
Urgent anticoagulation (UFH or LMWH) is NOT recommended for acute ischemic stroke treatment—it does not prevent early recurrent stroke or improve outcomes and increases bleeding risk, especially in moderate-to-severe strokes 1.
Do NOT initiate anticoagulation within 24 hours of rtPA administration 1.
Indications for Hospitalization
Virtually all patients with acute ischemic stroke should be admitted to the hospital 1. The rationale is compelling:
- Approximately 25% of patients experience neurological worsening within the first 24-48 hours, and it's impossible to predict which patients will deteriorate 1
- Monitoring is essential after reperfusion therapy to detect and manage bleeding complications 1
- Early complications require prompt recognition and treatment 1
Stroke Unit Care
Patients must be admitted to a specialized stroke unit—a geographically defined hospital unit with beds exclusively for stroke patients, staffed by an interdisciplinary team with stroke expertise 4.
Stroke unit care reduces mortality (OR 0.76), death or institutionalization (OR 0.76), and death or dependency (OR 0.80) compared to general medical ward care 4.
The core team should include physicians, nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers, and clinical nutritionists, with additional support from pharmacists 4.
Patients should be admitted to the stroke unit within 24 hours of hospital arrival 4.
Goals of Hospitalization
- Observe for neurological changes requiring intervention
- Monitor for bleeding complications after thrombolysis
- Prevent and treat subacute complications (aspiration pneumonia, DVT, pressure ulcers, urinary tract infections)
- Initiate secondary prevention measures
- Begin rehabilitation
- Determine stroke etiology to guide long-term prevention 3, 1
Critical Pitfalls to Avoid
- Do not delay imaging or treatment for comprehensive lab work—only glucose is mandatory before alteplase 2
- Do not aggressively lower blood pressure in acute stroke without reperfusion therapy—this can extend infarct 3, 1
- Do not give aspirin as a substitute for thrombolysis in eligible patients 1
- Do not wait to assess thrombolysis response before proceeding to thrombectomy—both should proceed in parallel 2
- Do not use streptokinase or other thrombolytics—only alteplase is proven safe and effective 3
- Do not routinely anticoagulate acutely—no benefit and increased bleeding risk 1