From the Guidelines
The treatment of ischemic stroke (cerebral infarction) requires immediate medical attention, with initial treatment focusing on restoring blood flow to the brain, often through intravenous thrombolysis with tissue plasminogen activator (tPA) if the patient arrives within 4.5 hours of symptom onset, as recommended by the most recent guidelines 1. The goal of treatment is to minimize morbidity, mortality, and improve quality of life.
- Initial assessment and management should prioritize determining the cause of stroke and evaluating the patient's eligibility for thrombolytic therapy or mechanical thrombectomy.
- For patients with large-vessel occlusion, endovascular treatment (EVT) is a critical component of care, with the goal of recanalization as quickly as possible to improve functional outcomes 1.
- Antiplatelet therapy, typically with aspirin, is started within 24-48 hours after stroke, unless contraindicated, to reduce the risk of recurrent stroke.
- Secondary prevention strategies include the use of antiplatelet agents, anticoagulants for patients with atrial fibrillation, and statins to lower cholesterol, as well as lifestyle modifications such as smoking cessation, limited alcohol consumption, regular exercise, and a balanced diet.
- Blood pressure management is crucial, targeting levels below 140/90 mmHg, and rehabilitation therapy should begin as soon as the patient is stable, including physical, occupational, and speech therapy tailored to specific deficits. The most recent guidelines emphasize the importance of prompt and effective treatment to improve outcomes in patients with acute ischemic stroke, with a focus on individualized care and consideration of the patient's underlying risk factors and comorbidities 1.
From the Research
Treatment for Cerebral Infarction (Stroke)
The primary treatment for acute ischemic stroke is thrombolysis with intravenous alteplase, which is approved in most countries 2, 3. This treatment is most effective when administered early, with the best outcomes achieved when initiated within 4.5 hours of symptom onset 2.
Thrombolysis
- Intravenous alteplase is the primary therapy for acute ischemic stroke 2, 3
- Early administration of alteplase improves functional outcome, with the sooner it is given, the greater the benefit 2
- Intra-arterial thrombolysis has a less extensive evidence base and is mostly unapproved for acute stroke 2
Anti-Platelet Therapy
- Early administration of anti-platelet therapy after alteplase does not improve outcome at 3 months and increases the risk of symptomatic intracranial hemorrhage (SICH) 4
- Current guidelines advise starting anti-platelet therapy 24 hours after alteplase 4, 5
- A meta-analysis found that early anti-platelet therapy after alteplase did not benefit acute ischemic stroke patients, but more clinical trials and statistical evidence are needed 5
Dosing of Alteplase
- Different doses of alteplase (0.6 mg/kg and 0.9 mg/kg) can improve neurological function and living ability of patients with acute ischemic stroke 6
- Future studies need to broaden the sample size to study the safety of low and standard doses of alteplase in patients with acute cerebral infarction 6
Safety and Efficacy
- Intravenous thrombolytic therapy with alteplase is effective and safe in the treatment of acute ischemic stroke, with no persistent adverse reactions after treatment 6
- The risk of SICH is around 3% with intravenous alteplase, and initiating treatment after 4.5 hours increases mortality and reverses the risk-benefit balance 2