What is the initial management for acute stroke infarct?

Initial Management of Acute Ischemic Stroke

The most critical intervention in acute ischemic stroke management is intravenous recombinant tissue plasminogen activator (rtPA) administration within 4.5 hours of symptom onset, with the primary therapeutic window being 0-3 hours. 1

Immediate Assessment and Stabilization

• Airway, Breathing, Circulation (ABC): Ensure patent airway, adequate oxygenation, and circulatory support 2
• Rapid neurological evaluation: Use standardized stroke scales (e.g., NIHSS)
• Urgent neuroimaging: CT scan to rule out hemorrhage and determine eligibility for thrombolysis 2
• Blood pressure management:
  • For rtPA candidates: Maintain BP <185/110 mmHg before treatment
  • For non-rtPA candidates: Cautious lowering of severely elevated BP 2

Thrombolytic Therapy

IV rtPA (Alteplase) Administration

• Dosage: 0.9 mg/kg (maximum 90 mg) 1

  • 10% as initial bolus over 1 minute
  • Remaining 90% as continuous infusion over 60 minutes

• Time windows:

  • 0-3 hours: Strongest evidence for benefit (Class I, Level A) 2
  • 3-4.5 hours: Extended window with additional exclusion criteria (Class I, Level B) 2

• Monitoring during rtPA:

  • BP every 15 minutes for 2 hours
  • Then every 30 minutes for 6 hours
  • Then hourly until 24 hours post-treatment 2

• Contraindications include:

  • Intracranial hemorrhage
  • Recent major surgery or trauma
  • Recent stroke or head trauma
  • Uncontrolled hypertension (>185/110 mmHg)
  • Active bleeding or bleeding diathesis
  • Current anticoagulant use with elevated INR 1

Endovascular Therapy

• Consider for patients with large vessel occlusion (ICA or proximal MCA) within 6 hours of symptom onset 2
• Stent retrievers are preferred over other mechanical thrombectomy devices (Class I, Level A) 2
• Do not delay endovascular therapy to observe for clinical response to IV rtPA 2

Antithrombotic Therapy

• Aspirin (325 mg) should be administered within 24-48 hours after stroke onset for patients not receiving thrombolysis (Class I, Level A) 2
• Do not administer aspirin or other antiplatelets within 24 hours of rtPA administration (Class III, Level C) 2
• Urgent anticoagulation is not recommended for improving outcomes or preventing early recurrent stroke (Grade A) 2

Blood Pressure Management

For rtPA Candidates:

• Pre-treatment: BP must be ≤185/110 mmHg
• During/after rtPA: Maintain BP ≤180/105 mmHg 2
• Medications for BP control:
  • Labetalol 10-20 mg IV over 1-2 minutes (may repeat)
  • Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h) 2

For Non-rtPA Candidates:

• Permissive hypertension is generally allowed unless BP is extremely elevated
• Avoid aggressive BP lowering which may worsen cerebral perfusion 2

Common Pitfalls to Avoid

1. Delayed treatment: Time is brain - each 30-minute delay reduces favorable outcome probability by 10.6% 1
2. Protocol deviations: Increase risk of symptomatic intracranial hemorrhage and death 1
3. Premature anticoagulation: Increases hemorrhagic risk without clear benefit 2
4. Overlooking large vessel occlusion: Patients who might benefit from endovascular therapy
5. Inadequate BP monitoring: Especially during and after rtPA administration

Systems of Stroke Care

• Transport patients rapidly to the closest certified primary stroke center or comprehensive stroke center 2
• Regional systems of stroke care should be developed to facilitate rapid treatment 2
• Centers providing initial emergency care should develop capability for emergency vascular imaging 2

By following this evidence-based approach to acute ischemic stroke management, focusing on rapid assessment, appropriate selection for reperfusion therapies, and careful monitoring, patient outcomes can be significantly improved with reduced morbidity and mortality.