What are the treatment options for acute cerebral stroke (CVA)?

From the Guidelines

For patients with acute ischemic stroke, the primary treatment is intravenous thrombolysis with alteplase (tPA) administered at 0.9 mg/kg (maximum 90 mg) with 10% given as a bolus and the remainder over 60 minutes, which must be given within 4.5 hours of symptom onset, as recommended by the most recent guidelines 1. The management of patients with acute ischemic stroke is multifaceted, and indications for specific therapies vary among patients.

• The treatment options for acute stroke depend on the type of stroke and how quickly the patient receives medical attention.
• For ischemic strokes (caused by blood clots), intravenous thrombolysis with alteplase (tPA) is the primary treatment.
• For eligible patients presenting within 24 hours with large vessel occlusions, mechanical thrombectomy is recommended to physically remove the clot.
• Antiplatelet therapy with aspirin (325 mg initially, then 81 mg daily) is typically started within 24-48 hours after an ischemic stroke if thrombolysis is not given.
• For hemorrhagic strokes, treatment focuses on controlling blood pressure (typically maintaining systolic BP below 140-160 mmHg), reversing anticoagulation if applicable, and sometimes surgical intervention to relieve pressure or repair blood vessels.
• Supportive care for all stroke patients includes maintaining adequate oxygenation, managing blood glucose levels, preventing complications like deep vein thrombosis with intermittent pneumatic compression devices, and early mobilization when stable. The most recent guidelines recommend that patients with acute ischemic stroke should be evaluated and treated immediately, with a focus on rapid patient transfer, diagnosis, and treatment 1.
• Time is critical in stroke treatment—"time is brain"—as approximately 1.9 million neurons die each minute during a stroke, making immediate medical attention essential for the best outcomes.
• The use of intravenous alteplase and endovascular therapy are the only two available treatment options for acute ischemic stroke due to large-vessel occlusion, and treatment delays and patient overselection for treatment should be avoided 1.
• Current challenges are standardization and simplification of imaging protocols, management of patients who do not meet current guideline recommendations for treatment, and optimization of patient transfer 1.

From the Research

Treatment Options for Acute Cerebral Stroke (CVA)

• Intravenous thrombolysis with alteplase (0.9 mg/kg body weight, maximum 90 mg) is recommended within 4.5 hours of onset of ischemic stroke 2, 3, 4, 5
• Intravenous alteplase can be used in patients with seizures at stroke onset, if the neurological deficit is related to acute cerebral ischemia 2
• Intra-arterial thrombolysis can be contemplated on a case-by-case basis after multidisciplinary discussion within a 6-hour time window for patients with acute middle cerebral artery or carotid occlusions, and within a larger time window for patients with basilar artery occlusion 2
• Mechanical thrombectomy can also be contemplated in the same situations as intra-arterial thrombolysis 2
• Antiplatelet agents, such as aspirin (160 mg-325 mg), are recommended within 48 hours of ischemic stroke onset, but should be delayed for 24 hours if thrombolysis is performed or contemplated 2, 4
• Urgent anticoagulation is not recommended for the treatment of ischemic stroke, but may be used for secondary prevention in patients with a high risk for cardioembolism 2, 4
• Neuroprotective agents are not recommended for the treatment of ischemic stroke 2
• Patients with cerebral venous thrombosis should be treated with therapeutic doses of heparin, even in case of concomitant intracranial hemorrhage related to cerebral venous thrombosis 2
• Urgent blood transfusions are recommended to reduce hemoglobin S to <30% in patients with sickle cell disease and acute ischemic stroke 2

Ongoing Research and Future Directions

• Current research efforts involve trying to treat a larger proportion of patients by overcoming some of the contraindications to intravenous thrombolysis and assessing combined or alternative treatments to achieve a higher early recanalization rate 3
• The HOPE trial is investigating the benefits of intravenous thrombolysis with alteplase in patients who had an acute ischemic stroke between 4.5 and 24 hours after symptom onset 6