From the Guidelines
Stroke treatment requires immediate medical attention, with the goal of restoring blood flow to the brain as quickly as possible, and the most effective approach is to administer intravenous tissue plasminogen activator (tPA) within 4.5 hours of symptom onset, followed by mechanical thrombectomy for eligible patients with large vessel occlusions, as recommended by the most recent and highest quality study 1.
Treatment Options for Ischemic Stroke
For ischemic strokes, the primary treatment options include:
- Intravenous tPA, administered within 4.5 hours of symptom onset at a dose of 0.9 mg/kg (maximum 90 mg), with 10% given as an initial bolus and the remainder infused over 60 minutes 1
- Mechanical thrombectomy, which may be performed up to 24 hours after symptom onset for eligible patients with large vessel occlusions 1
- Antiplatelet therapy, typically following tPA administration, with aspirin 325 mg initially, then 81 mg daily indefinitely 1
Treatment Options for Hemorrhagic Stroke
For hemorrhagic strokes, treatment focuses on:
- Controlling blood pressure and reversing anticoagulation if applicable 1
- Secondary prevention, including blood pressure control (target <130/80 mmHg), cholesterol management (often with high-intensity statins like atorvastatin 40-80 mg daily), and antiplatelet or anticoagulant therapy depending on stroke etiology 1
Lifestyle Modifications and Rehabilitation
Lifestyle modifications are essential, including:
- Smoking cessation
- Limited alcohol intake
- Regular exercise
- A Mediterranean or DASH diet Rehabilitation should begin as soon as the patient is medically stable, with therapy tailored to specific deficits, as recommended by the most recent and highest quality study 1.
Key Considerations
The effectiveness of these interventions stems from their ability to restore blood flow, prevent further clot formation, reduce inflammation, and promote neuroplasticity during recovery, and it is crucial to prioritize the single most recent and highest quality study, which in this case is 1, to ensure the best possible outcomes for patients with stroke.
From the Research
Treatment Options for Cerebrovascular Accident (CVA) or Stroke
- Intravenous thrombolysis with alteplase is a primary treatment option for acute ischemic stroke, as it has been shown to improve functional outcomes when administered within 4.5 hours of symptom onset 2, 3, 4, 5
- The efficacy and safety of alteplase have been established in several studies, with a significant improvement in clinical outcomes compared to placebo 2, 4
- However, the use of alteplase also carries a risk of bleeding, including symptomatic intracranial hemorrhage, which has been reported in around 3% of cases 4
- Intra-arterial thrombolysis is another treatment option, although it has a less extensive evidence base and is mostly unapproved for acute stroke 4
- Endovascular thrombectomy has emerged as a promising adjuvant therapy for acute ischemic stroke, particularly in patients with large vessel occlusion 6, 5
- Imaging selection strategies, such as MRI DWI-FLAIR mismatch, can help identify patients who may benefit from intravenous thrombolysis beyond the traditional 4.5-hour time window 5
- Tenecteplase is another thrombolytic agent being investigated as a potential treatment option for acute ischemic stroke, although further randomized controlled trials are needed to inform clinical decision-making 5
Patient Selection and Timing of Treatment
- Appropriate patient selection and timely treatment are crucial for optimal outcomes in acute stroke management 5
- Patients with acute ischemic stroke should be treated with intravenous thrombolysis as soon as possible, ideally within 4.5 hours of symptom onset 2, 3, 4, 5
- Patients who wake up with stroke symptoms and have an unknown time of onset may still be eligible for intravenous thrombolysis if they have an MRI DWI-FLAIR mismatch 5
- Relative and absolute contraindications to alteplase should be carefully considered when selecting patients for treatment 5