What is the stepwise evidence-based management of acute ischemic stroke?

Stepwise Evidence-Based Management of Acute Ischemic Stroke

The management of acute ischemic stroke requires immediate intervention with intravenous alteplase and/or endovascular thrombectomy within a time-critical window, followed by admission to a specialized stroke unit for ongoing care to reduce mortality and improve functional outcomes. 1, 2

Prehospital Phase

• Immediate recognition of stroke symptoms using validated tools (FAST: Face, Arms, Speech, Time)
• Rapid activation of emergency medical services with pre-notification to receiving hospital
• Priority transport to nearest stroke-capable center with "code stroke" pre-notification 1
• Direct transport to comprehensive stroke centers for suspected large vessel occlusion if transport time difference is <30-45 minutes 1

Emergency Department Phase

1. Immediate Assessment (Door to Treatment Decision) 1, 2

   • Rapid triage with stroke team activation upon arrival
   • Immediate neurological assessment using NIH Stroke Scale
   • Establish time of symptom onset (critical for treatment decisions)
   • Obtain vital signs, blood glucose, and focused medical history
   • Establish two IV lines and draw blood for laboratory tests
   • Perform 12-lead ECG

2. Urgent Neuroimaging 1

   • Non-contrast CT brain within 20 minutes of arrival to exclude hemorrhage
   • CT angiography of head and neck to identify large vessel occlusion
   • Perfusion imaging may be considered for extended time windows
   • MRI can be used instead of CT if immediately available and won't delay treatment

3. Reperfusion Therapy Decision 1

   • Intravenous thrombolysis (alteplase):

     • Administer within 4.5 hours of symptom onset (3-4.5 hours has more exclusions)
     • Dose: 0.9 mg/kg (maximum 90 mg), with 10% as bolus and remainder over 60 minutes
     • BP must be <185/110 mmHg before treatment and maintained <180/105 mmHg for 24 hours

   • Endovascular thrombectomy (EVT):

     • For large vessel occlusion in anterior circulation
     • Standard window: within 6 hours of symptom onset
     • Extended window: up to 24 hours with appropriate perfusion imaging showing salvageable tissue
     • Combined stent-retriever and aspiration approach recommended for faster reperfusion 1

Acute Hospital Management

1. Admission to Stroke Unit 1, 2

   • All stroke patients should be admitted to a specialized stroke unit
   • If no stroke unit available, implement stroke protocols in general ward

2. Vital Signs Monitoring and Management 1, 2

   • Monitor vital signs every 1-4 hours for first 48 hours (more frequently if unstable)
   • Temperature: Treat fever >37.5°C with antipyretics
   • Blood Pressure:
     • Post-thrombolysis: Maintain <180/105 mmHg for 24 hours
     • Without thrombolysis: Cautious reduction if >220/120 mmHg (by no more than 20% in first 24 hours)
     • Avoid intensive BP lowering (systolic <140 mmHg) in acute phase
   • Oxygen: Provide supplemental oxygen only if saturation <94%
   • Blood Glucose: Maintain 140-180 mg/dL (7.8-10 mmol/L)

3. Prevent Early Complications 1, 2

   • VTE Prophylaxis:
     • Start intermittent pneumatic compression devices immediately
     • Consider pharmacological prophylaxis after 24-48 hours if hemorrhage excluded
   • Dysphagia Management:
     • Perform swallowing assessment before any oral intake
     • Implement appropriate feeding strategy based on assessment
   • Bladder and Bowel Management:
     • Avoid indwelling catheters when possible
     • Implement bladder training and bowel management programs
   • Early Mobilization:
     • Avoid frequent out-of-bed activity within first 24 hours
     • Begin mobilization between 24-48 hours if no contraindications

4. Early Rehabilitation Assessment 2

   • Assessment by rehabilitation professionals within 48 hours
   • Formal, individualized rehabilitation plan within 72 hours
   • Begin rehabilitation as early as patient stability allows

5. Secondary Prevention 1

   • Antiplatelet therapy:
     • Start aspirin 160-325 mg within 24-48 hours of onset if no thrombolysis
     • After thrombolysis, start aspirin after 24 hours if follow-up imaging excludes hemorrhage
     • Consider dual antiplatelet therapy (aspirin plus clopidogrel) for 21 days in minor stroke/TIA
   • Statin therapy: High-intensity statin regardless of baseline LDL
   • Antihypertensive therapy: Resume or initiate after first 24 hours if stable
   • Atrial fibrillation: Start anticoagulation after 3-14 days based on stroke severity and hemorrhagic risk

Discharge Planning and Transition of Care

• Begin discharge planning during initial assessment
• Provide formal education to patient and family
• Ensure appropriate follow-up appointments
• Implement secondary prevention strategies
• Arrange ongoing rehabilitation as needed 2

Common Pitfalls to Avoid

• Delaying neuroimaging or thrombolysis decision due to minor contraindications
• Withholding thrombolysis based on mild or improving symptoms (these can worsen later)
• Excessive focus on BP control at the expense of timely reperfusion
• Failing to screen for large vessel occlusion in all acute stroke patients
• Delaying EVT while waiting for response to IV thrombolysis
• Overlooking dysphagia screening before oral intake
• Starting mobilization too early (<24 hours) or too late (>48 hours)
• Neglecting to establish stroke unit care principles even in facilities without dedicated units 1, 2

The evidence strongly supports that rapid assessment, early reperfusion therapy, and specialized stroke unit care are the cornerstones of effective acute ischemic stroke management, with each minute saved in time to treatment improving outcomes and reducing disability 1.