What is the treatment for stroke?

Stroke Treatment

For acute ischemic stroke, intravenous recombinant tissue plasminogen activator (IV r-tPA) is strongly recommended if treatment can be initiated within 3 hours of symptom onset (Grade 1A), with a more cautious recommendation for the 3-4.5 hour window (Grade 2C), while thrombolysis is not recommended beyond 4.5 hours. 1

Acute Ischemic Stroke Management

Immediate Assessment and Treatment

1. Brain Imaging: Immediate CT or MRI before initiating any specific treatment
2. Time-Based Treatment Algorithm:
   • Within 3 hours of symptom onset: IV r-tPA at 0.9 mg/kg (maximum 90 mg) over 60 minutes with initial 10% as bolus 2, 1
   • 3-4.5 hours after symptom onset: IV r-tPA may still be beneficial but with more caution 1
   • Beyond 4.5 hours: IV r-tPA is not recommended 2
   • For proximal cerebral artery occlusions ineligible for IV r-tPA: Consider intraarterial (IA) r-tPA if within 6 hours of symptom onset 2, 1

Exclusion Criteria for tPA

• Symptom onset >4.5 hours or unknown onset time
• Another stroke or serious head injury within preceding 3 months
• Major surgery within prior 14 days
• History of intracranial hemorrhage
• Gastrointestinal or genitourinary hemorrhage within previous 21 days 1

Monitoring After tPA Administration

• Neurological evaluations every 15 minutes for first 2 hours, every 30 minutes for next 6 hours, and hourly thereafter
• Monitor for symptomatic intracranial hemorrhage, especially within first 12 hours 1
• Maintain blood pressure <180/105 mmHg 1

Antiplatelet Therapy

• Early aspirin therapy: 160-325 mg within 48 hours of acute ischemic stroke (Grade 1A) 2, 1
• For secondary prevention in non-cardioembolic stroke:
  • Options include: aspirin (75-100 mg daily), clopidogrel (75 mg daily), or aspirin/extended-release dipyridamole (25 mg/200 mg twice daily) 2, 1
  • Clopidogrel or aspirin/extended-release dipyridamole are suggested over aspirin alone (Grade 2B) 2
  • For minor ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4): Consider dual antiplatelet therapy with aspirin 81 mg and clopidogrel 75 mg daily for 21 days, followed by single antiplatelet therapy 1

Anticoagulation Therapy

• For stroke with atrial fibrillation or other cardioembolic sources:
  • Long-term oral anticoagulation is recommended over antiplatelet therapy (Grade 1B) 2, 1
  • Target INR of 2.0-3.0 for warfarin 1
  • Direct oral anticoagulants like dabigatran 150 mg twice daily may be preferred over vitamin K antagonists 1

Venous Thromboembolism (VTE) Prevention

• For patients with restricted mobility:
  • Prophylactic-dose subcutaneous heparin (LMWH preferred over UFH) (Grade 2B) 2, 1
  • Intermittent pneumatic compression devices as an alternative to heparin 1
  • Avoid elastic compression stockings (Grade 2B) 2, 1

Supportive Care

• Maintain oxygen saturation ≥94% 1
• Correct hypotension and hypovolemia to ensure adequate perfusion 1
• Intubate only if compromised airway or insufficient ventilation 1
• Early mobilization and adequate hydration to help prevent VTE 1

Clinical Efficacy Considerations

• Standard-dose IV tPA (0.9 mg/kg) has shown better functional outcomes compared to lower doses without increasing the risk of symptomatic intracranial hemorrhage 3
• The effectiveness of tPA treatment decreases with time, making rapid assessment and treatment critical for optimal outcomes 4

Common Pitfalls and Caveats

• Delayed presentation is the most common reason patients miss the window for tPA treatment 5
• Strict adherence to exclusion criteria is essential to minimize bleeding complications
• Blood pressure must be controlled (<185/110 mmHg) before initiating thrombolysis 1
• tPA itself may activate matrix metalloproteases, potentially aggravating blood-brain barrier disruption 6
• Rural hospitals can safely administer tPA when protocols are followed, making this treatment accessible beyond specialized stroke centers 5

By following this evidence-based approach to stroke treatment, clinicians can maximize the chances of favorable outcomes while minimizing risks of complications.