How to manage ischemic stroke?

Management of Acute Ischemic Stroke

Acute ischemic stroke should be treated as a medical emergency with intravenous recombinant tissue plasminogen activator (rtPA/alteplase) administered within 3 hours of symptom onset as the cornerstone of treatment, followed by endovascular therapy for eligible patients with large vessel occlusions. 1, 2

Initial Assessment and Management

Immediate Actions (First 3 Hours)

• Ensure patent airway, adequate oxygenation, and circulatory support
• Perform urgent neuroimaging (CT scan) to rule out hemorrhage
• Determine time of symptom onset (when patient was last known normal)
• Monitor vital signs, especially blood pressure

Blood Pressure Management

• For rtPA candidates: Maintain BP <185/110 mmHg before treatment
• After rtPA: Keep BP ≤180/105 mmHg during and after administration
• For non-rtPA candidates: Cautious lowering only if extremely elevated (>220/120 mmHg)
• Avoid precipitous BP reduction which may worsen cerebral perfusion

Thrombolytic Therapy

IV rtPA (Alteplase) Administration 1, 2

• Dose: 0.9 mg/kg (maximum 90 mg) with 10% given as bolus over 1 minute, remainder over 60 minutes
• Primary therapeutic window: 0-3 hours from symptom onset (strongest evidence, Class I, Level A)
• Extended window: 3-4.5 hours for selected patients without contraindications

Post-rtPA Monitoring 1

• Measure BP and perform neurological assessments:
  • Every 15 minutes during infusion and for 2 hours after
  • Every 30 minutes for 6 hours
  • Hourly until 24 hours after treatment
• Obtain follow-up CT or MRI at 24 hours before starting anticoagulants or antiplatelets
• Delay placement of nasogastric tubes, indwelling catheters, or intra-arterial pressure catheters if possible

Management of Symptomatic Intracranial Hemorrhage 1

• Stop alteplase infusion immediately
• Obtain emergent non-enhanced head CT
• Check CBC, PT (INR), aPTT, fibrinogen level
• Consider cryoprecipitate (10 units) for fibrinogen <200 mg/dL
• Consider tranexamic acid 1000 mg IV or ε-aminocaproic acid 4-5 g
• Obtain hematology and neurosurgery consultations

Endovascular Therapy

Patient Selection 1, 2

• Consider for patients with large vessel occlusion (ICA or proximal MCA)
• Treatment window: within 6 hours of symptom onset
• Do not delay endovascular therapy to observe response to IV rtPA

Technique 1

• Stent retrievers are the preferred mechanical thrombectomy device
• Combined approach using stent-retrievers and aspiration techniques is optimal
• Consider "BADDASS" approach: Balloon guide with large bore Distal access catheter with Dual Aspiration with Stent-retriever as Standard Approach

Antiplatelet and Anticoagulant Therapy

Antiplatelet Therapy 1, 2

• For patients not receiving thrombolysis: Administer aspirin (325 mg) within 24-48 hours after stroke onset
• For patients receiving rtPA: Delay antiplatelet therapy for 24 hours

Anticoagulation 1, 2, 3

• Urgent anticoagulation is not recommended for improving outcomes or preventing early recurrent stroke
• Prophylactic low-dose subcutaneous heparin or LMWH recommended for patients with restricted mobility to prevent DVT

Systems of Care

• Transport patients rapidly to the closest certified primary stroke center or comprehensive stroke center
• Develop regional systems of stroke care to facilitate rapid treatment
• Time is brain: Each 30-minute delay reduces probability of favorable outcome by 10.6%

Common Pitfalls and Caveats

1. Time window misinterpretation: When uncertain, the time of onset should be considered the time when the patient was last known to be normal 1

2. Delaying treatment for additional diagnostic studies: This should be avoided as the benefit of rtPA is highly time-dependent 1, 2

3. Inappropriate blood pressure management: Overly aggressive BP lowering may worsen cerebral perfusion 2

4. Administering antiplatelet agents too soon: Do not give aspirin or other antiplatelets within 24 hours of rtPA administration 2

5. Overlooking wake-up strokes: Patients with unknown symptom onset may benefit from alteplase if they have favorable imaging profiles on MRI showing DWI/FLAIR mismatch 1

6. Protocol deviations: These are associated with higher risk of symptomatic intracranial hemorrhage and death 2

The evidence strongly supports immediate treatment of acute ischemic stroke, with the greatest benefit seen when treatment is initiated within the first 3 hours of symptom onset 1, 2, 4. While some studies have explored treatment beyond this window, the risk-benefit ratio becomes less favorable with time 5, 6.