What are the guidelines for managing embolic stroke?

Guidelines for Managing Embolic Stroke

The management of embolic stroke requires immediate implementation of evidence-based interventions focused on diagnosis, acute treatment, and secondary prevention to reduce morbidity and mortality.

Initial Assessment and Management

Immediate Evaluation

• Perform immediate brain imaging (CT or MRI) before any specific treatment 1
• Use a validated stroke severity scale (e.g., NIHSS) 1
• Consider non-invasive angiography (CTA) for suspected large vessel occlusion 1
• Maintain oxygen saturation ≥94% and correct hypotension to ensure adequate perfusion 1
• Control blood pressure (maintaining <180/105 mmHg) 1

Acute Thrombolytic Therapy

• Administer IV recombinant tissue plasminogen activator (r-tPA) if treatment can be initiated within 3 hours of symptom onset (Grade 1A) and consider up to 4.5 hours (Grade 2C) 1
• Dosing: 0.9 mg/kg (maximum 90 mg) over 60 minutes with initial 10% as bolus over 1 minute 1
• Blood pressure must be below 185/110 mmHg before initiating thrombolysis 1
• For patients treated with IV alteplase (tPA), delay aspirin administration until 24 hours after thrombolysis 1

Diagnostic Workup for Embolic Source

Cardiovascular Investigations

• Perform 12-lead ECG to assess cardiac rhythm and identify atrial fibrillation or flutter 2
• For patients with suspected embolic stroke of undetermined source whose initial short-term ECG monitoring does not reveal atrial fibrillation, prolonged ECG monitoring for at least two weeks is recommended 2
• Consider echocardiography (2D or transesophageal) for patients with suspected embolic stroke and normal neurovascular imaging 2, particularly relevant for younger adults with stroke or TIA of unknown etiology

Antithrombotic Management

Antiplatelet Therapy

• For non-cardioembolic embolic stroke, administer aspirin 160-325 mg within 24-48 hours after stroke onset, after intracranial hemorrhage has been ruled out 1
• For minor ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4), initiate dual antiplatelet therapy (DAPT) with aspirin 81 mg daily and clopidogrel 75 mg daily within 12-24 hours of symptom onset 1
  • Use loading doses: aspirin (160-325 mg) and clopidogrel (300-600 mg) 1
  • Continue DAPT for 21 days, then switch to single antiplatelet therapy 1
• For mild-moderate stroke (NIHSS ≤5), consider aspirin 75-100 mg daily and ticagrelor 90 mg twice daily for 30 days, followed by single antiplatelet therapy 2

Anticoagulation Therapy

• Urgent anticoagulation with heparin or low-molecular-weight heparin is NOT recommended for non-cardioembolic embolic stroke as it increases bleeding risk without improving outcomes 2, 1
• For embolic stroke due to atrial fibrillation, oral anticoagulation is strongly recommended (Grade 1B) 1
  • Do not start anticoagulation within 24 hours of tPA administration 1
  • Dabigatran 150 mg twice daily is suggested over adjusted-dose vitamin K antagonists (Grade 2B) 1

Embolic Stroke of Undetermined Source (ESUS)

• Recent trials have shown that anticoagulation (rivaroxaban, dabigatran) is not superior to aspirin for secondary prevention in ESUS patients 3, 4
• Single antiplatelet therapy remains the standard treatment for ESUS 2

Venous Thromboembolism Prophylaxis

• Assess all stroke patients for risk of developing venous thromboembolism 2
• High-risk patients (unable to move one/both lower limbs, unable to mobilize independently, previous VTE history, dehydration, cancer) should receive prophylaxis 2
• Use thigh-high intermittent pneumatic compression devices (IPC) or pharmacological VTE prophylaxis immediately if no contraindication exists 2
• If using IPC, apply within first 24 hours after admission and discontinue when patient becomes independently mobile, at discharge, or by 30 days 2
• Monitor skin integrity daily when using IPC devices 2
• Consider low-molecular-weight heparin for patients at high risk of VTE; use unfractionated heparin for patients with renal failure 2

Monitoring and Follow-up

• Perform frequent neurological evaluations: every 15 minutes during first 2 hours, every 30 minutes for next 6 hours, and hourly thereafter 1
• Complete formal swallowing assessment before oral intake; keep patient NPO until assessment is completed 1
• Begin mobilization after 24 hours if patient is stable 1
• Monitor for symptomatic intracranial hemorrhage, which typically occurs within first 12 hours after treatment 1

Long-term Secondary Prevention

• For non-cardioembolic stroke, continue long-term antiplatelet therapy with one of the following:

  • Aspirin (75-100 mg daily)
  • Clopidogrel (75 mg daily)
  • Aspirin/extended-release dipyridamole (25 mg/200 mg twice daily)
  • Cilostazol (100 mg twice daily) 1

• For embolic stroke with identified cardioembolic source (e.g., atrial fibrillation), continue long-term anticoagulation 1

By following these evidence-based guidelines, clinicians can optimize outcomes for patients with embolic stroke, reducing morbidity, mortality, and improving quality of life.