What is the treatment for cerebral infarction (stroke)?

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, typically through intravenous thrombolysis with tissue plasminogen activator (tPA) if the patient arrives within 4.5 hours of symptom onset, or mechanical thrombectomy for large vessel occlusions within 24 hours, as recommended by the most recent guidelines 1.

Key Treatment Approaches

• Intravenous thrombolysis with tPA within 4.5 hours of symptom onset
• Mechanical thrombectomy for large vessel occlusions within 24 hours
• Antiplatelet therapy, usually with aspirin 325mg initially, followed by 81mg daily maintenance, or clopidogrel 75mg daily in some cases, as suggested by previous guidelines 1
• Statins, such as atorvastatin 40-80mg daily, to lower cholesterol and stabilize plaques
• Blood pressure management, targeting levels below 140/90 mmHg, using medications such as ACE inhibitors, ARBs, or calcium channel blockers

Rehabilitation and Lifestyle Modifications

• Rehabilitation, beginning as soon as the patient is stable, including physical, occupational, and speech therapy tailored to specific deficits
• Lifestyle modifications, including smoking cessation, limited alcohol consumption, regular exercise, and a Mediterranean or DASH diet, as recommended by guidelines 1

Importance of Prompt Treatment

• Every 30-min delay in recanalization decreases the chance of a good functional outcome by 8% to 14% 1
• Urgent evaluation and treatment are crucial to improve outcomes and reduce the risk of recurrent strokes, as emphasized by the American Heart Association and American Stroke Association 1

From the Research

Treatment Options for Cerebral Infarction (Stroke)

• The primary therapy for acute ischemic stroke is thrombolysis with intravenous alteplase, which is approved in most countries 2.
• Early administration of alteplase improves functional outcome, with the greatest benefit seen when treatment is initiated soon after symptom onset 2, 3.
• The risk of bleeding, including symptomatic intracranial hemorrhage (SICH), is a concern with alteplase treatment, with a risk of around 3% 2.
• Intra-arterial thrombolysis has a less extensive evidence base and is mostly unapproved for acute stroke 4.

Administration of Aspirin

• Early administration of intravenous aspirin in patients treated with alteplase for acute ischemic stroke does not improve outcome at 3 months and increases the risk of SICH 5.
• Current guidelines advise starting antiplatelet therapy 24 hours after alteplase treatment 5.

Dosing of Alteplase

• Different doses of alteplase (0.6 mg/kg and 0.9 mg/kg) have been shown to improve neurological function and living ability in patients with acute ischemic stroke 6.
• Further studies are needed to determine the safety of low and standard doses of alteplase in patients with acute cerebral infarction 6.

Timing of Treatment

• Treatment with alteplase is most effective when initiated within 4.5 hours of symptom onset 2, 4.
• Initiating treatment after 4.5 hours increases mortality and reverses the risk-benefit balance 2.