What are the guidelines for managing ischemic stroke?

From the Guidelines

The management of ischemic stroke requires rapid assessment and treatment to minimize brain damage, and according to the most recent guidelines from 2018 1, patients with suspected stroke should receive immediate neuroimaging (CT or MRI) to confirm diagnosis and exclude hemorrhage. For eligible patients presenting within 4.5 hours of symptom onset, intravenous alteplase (tPA) should be administered at 0.9 mg/kg (maximum 90 mg), with 10% given as bolus and the remainder over 60 minutes. Some key points to consider in the management of ischemic stroke include:

• Urgent evaluation and treatment, with a focus on protecting the airway, breathing, and circulation (life support) 1
• The use of intravenous rtPA (0.9 mg/kg; maximum 90 mg) for carefully selected patients who can receive the medication within 3 hours of onset of stroke 1
• The consideration of mechanical thrombectomy for patients with large vessel occlusion presenting within 24 hours 1
• Secondary prevention measures, including antiplatelet therapy with aspirin (initial dose 325 mg, then 81 mg daily), or clopidogrel (75 mg daily), or combination therapy in select cases 1
• High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) regardless of baseline cholesterol levels 1
• Blood pressure management targets <140/90 mmHg in most patients, using medications like ACE inhibitors or ARBs 1
• Anticoagulation with direct oral anticoagulants (apixaban, dabigatran, edoxaban, or rivaroxaban) or warfarin (target INR 2-3) for patients with atrial fibrillation 1
• Carotid revascularization for patients with significant carotid stenosis 1
• Rehabilitation beginning as soon as the patient is medically stable, with therapy tailored to specific deficits 1 These interventions are critical because prompt reperfusion therapy salvages penumbral tissue, while secondary prevention measures significantly reduce recurrence risk by addressing underlying pathophysiological mechanisms like atherosclerosis, thromboembolism, and hypertension.

From the Research

Guidelines for Managing Ischemic Stroke

The management of ischemic stroke involves several guidelines to ensure effective treatment and minimize complications. Some key points to consider include:

• Intravenous tissue plasminogen activator (IV tPA) is a recommended treatment for acute ischemic stroke, with the most benefit seen when administered within 3 hours of symptom onset 2, 3.
• The use of IV tPA within 4.5 hours of symptom onset may also be beneficial in selected patients, although this is considered an off-label use in the United States 4.
• Endovascular treatment, such as intraarterial thrombolysis or mechanical thrombectomy, may be considered for patients who are ineligible for IV tPA or have persistent large-artery occlusion, although the evidence for its efficacy is limited 5.
• The time from stroke symptom onset to treatment is crucial, and optimal care should include community education and standardized protocols to guide immediate patient assessment and triage to medical centers with capability for efficient neurologic assessment, brain imaging, drug administration, and specialized postthrombolysis care 6.

Key Considerations for IV tPA Administration

Some key considerations for IV tPA administration include:

• Patient selection: IV tPA is most beneficial for patients with acute ischemic stroke who can be treated within 3 hours of symptom onset and have no contraindications to therapy 2, 3.
• Time to treatment: The time from stroke symptom onset to IV tPA administration is critical, with the most benefit seen when treatment is initiated as soon as possible 6.
• Dosage and administration: The recommended dosage of IV tPA is 0.9 mg/kg, with a maximum dose of 90 mg 3.
• Monitoring and follow-up: Patients who receive IV tPA should be closely monitored for signs of complications, such as intracranial hemorrhage, and should receive follow-up care to assess their response to treatment 6.

Endovascular Treatment Options

Endovascular treatment options, such as intraarterial thrombolysis or mechanical thrombectomy, may be considered for patients who are ineligible for IV tPA or have persistent large-artery occlusion. However, the evidence for the efficacy of these treatments is limited, and they should only be used in selected patients 5. Some key considerations for endovascular treatment include:

• Patient selection: Endovascular treatment may be considered for patients who are ineligible for IV tPA or have persistent large-artery occlusion 5.
• Time to treatment: The time from stroke symptom onset to endovascular treatment is critical, with the most benefit seen when treatment is initiated as soon as possible 5.
• Technical considerations: Endovascular treatment requires specialized equipment and trained personnel, and should only be performed at medical centers with experience in these procedures 5.