From the Guidelines
Post-tPA management for acute ischemic stroke requires intensive monitoring and specific interventions to minimize complications, with a focus on maintaining blood pressure below 180/105 mmHg and avoiding anticoagulants, antiplatelets, and invasive procedures for 24 hours post-tPA, as recommended by the 2018 guidelines for the early management of patients with acute ischemic stroke 1.
Key Management Strategies
- Patients should be admitted to an ICU or stroke unit for at least 24 hours with neurological assessments every 15 minutes for 2 hours, then every 30 minutes for 6 hours, and hourly thereafter.
- Blood pressure must be maintained below 180/105 mmHg, typically using IV labetalol (10-20 mg over 1-2 minutes, repeated every 10-20 minutes) or nicardipine infusion (5-15 mg/hour) 1.
- Avoid anticoagulants, antiplatelets, and invasive procedures for 24 hours post-tPA.
- Monitor for hemorrhagic transformation with immediate CT if neurological deterioration occurs.
- Manage complications promptly—for intracranial hemorrhage, stop antithrombotics, consider cryoprecipitate (10 units), tranexamic acid (1g IV), or fresh frozen plasma.
- Angioedema may require airway management, diphenhydramine (50 mg IV), famotidine (20 mg IV), and methylprednisolone (125 mg IV).
Antiplatelet Therapy
- After 24 hours, if imaging shows no hemorrhage, initiate antiplatelet therapy (typically aspirin 81-325 mg daily) 1.
Additional Considerations
- Supplemental oxygen should be provided to maintain oxygen saturation >94% (Class I; Level of Evidence C) 1.
- Sources of hyperthermia (temperature >38°C) should be identified and treated, and antipyretic medications should be administered to lower temperature in hyperthermic patients with stroke (Class I; Level of Evidence C) 1.
- Hypoglycemia (blood glucose <60 mg/dL) should be treated in patients with acute ischemic stroke (Class I; Level of Evidence C) 1.
- Hypovolemia should be corrected with intravenous normal saline, and cardiac arrhythmias that might be reducing cardiac output should be corrected (Class I; Level of Evidence C) 1.
From the Research
Post TNK Management
The management of patients post tissue plasminogen activator (tPA) for acute ischemic stroke involves several key principles, including:
- Airway and ventilation management
- Hemodynamic and fluid optimization
- Fever and glycemic control
- Management of anticoagulation, antiplatelet, and thromboprophylaxis therapy
- Control of seizures and surgical interventions for malignant middle cerebral artery and cerebellar infarctions 2
Management Guidelines
The European Stroke Organisation, the American Stroke Association, and the U.K. National Institute for Health and Care Excellence provide general guidelines for the management of acute ischemic stroke, which include:
- Care on a stroke unit
- Intravenous tissue plasminogen activator within 4.5 hours of stroke onset
- Aspirin within 48 hours of stroke onset
- Decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction 2, 3
Secondary Prevention
Secondary prevention of ischemic stroke includes:
- Optimization of chronic disease management (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia)
- Nonpharmacologic lifestyle interventions (e.g., diet changes, exercise, substance use counseling)
- Pharmacologic interventions, such as dual antiplatelet therapy with aspirin and clopidogrel for minor noncardioembolic ischemic strokes and high-risk transient ischemic attacks 4
Rehabilitation
Rehabilitation involves a multidisciplinary, multimodal approach that includes:
- Physical therapy
- Speech therapy
- Treatment of chronic pain and poststroke depression
- Management of poststroke problems with mobility, balance, cognition, dysphagia, and depression 4