What is the treatment for a thrombotic stroke?

Treatment for Thrombotic Stroke

The treatment for thrombotic stroke includes early intravenous recombinant tissue plasminogen activator (IV r-tPA) within 4.5 hours of symptom onset, followed by early aspirin therapy (160-325 mg within 48 hours) for those who do not receive thrombolysis or after the thrombolysis window. 1

Acute Phase Treatment

Thrombolytic Therapy

1. IV r-tPA (Alteplase)

   • First-line treatment if within time window
   • Dosing: 0.9 mg/kg (maximum 90 mg) over 60 minutes with initial 10% as bolus over 1 minute 1
   • Time windows:
     • 0-3 hours: Strongly recommended (Grade 1A) 2, 1
     • 3-4.5 hours: Recommended with caution (Grade 2C) 2, 1, 3
     • Beyond 4.5 hours: Not recommended in standard practice (Grade 1B) 2, 1

2. Intraarterial (IA) r-tPA

   • Consider for patients ineligible for IV r-tPA with proximal cerebral artery occlusions
   • Must be initiated within 6 hours of symptom onset (Grade 2C) 2, 1

3. Key exclusion criteria for thrombolysis 1:

   • Symptom onset >4.5 hours or unknown onset time
   • Prior stroke or serious head injury within 3 months
   • Major surgery within 14 days
   • History of intracranial hemorrhage
   • GI or GU hemorrhage within 21 days

Antiplatelet Therapy

1. Early aspirin therapy
   • 160-325 mg within 48 hours of symptom onset (Grade 1A) 2, 1
   • Recommended over parenteral anticoagulation in acute phase (Grade 1A) 2

Venous Thromboembolism Prophylaxis

1. For patients with restricted mobility:
   • Prophylactic-dose LMWH preferred over UFH (Grade 2B) 2, 1
   • Alternative: Intermittent pneumatic compression devices (Grade 2B) 2
   • Avoid elastic compression stockings (Grade 2B) 2, 1

Secondary Prevention

For Non-Cardioembolic Stroke

1. Antiplatelet therapy options (Grade 1A) 2, 1:

   • Clopidogrel (75 mg once daily)
   • Aspirin/extended-release dipyridamole (25 mg/200 mg twice daily)
   • Aspirin (75-100 mg once daily)
   • Cilostazol (100 mg twice daily)

2. Preferred antiplatelet regimens:

   • Clopidogrel or aspirin/extended-release dipyridamole suggested over aspirin alone (Grade 2B) 2
   • Consider dual antiplatelet therapy (aspirin + clopidogrel) for 21 days in minor stroke (NIHSS ≤3) or high-risk TIA, followed by single agent 1

For Cardioembolic Stroke (with Atrial Fibrillation)

1. Oral anticoagulation (Grade 1A/1B) 2, 1:
   • Recommended over antiplatelet therapy
   • Dabigatran 150 mg twice daily suggested over vitamin K antagonists (Grade 2B) 2, 1
   • Timing: Generally initiated within 1-2 weeks after stroke onset 2
   • Bridge with aspirin until therapeutic anticoagulation is achieved 2

Monitoring and Management

1. Neurological monitoring:

   • Every 15 minutes for first 2 hours
   • Every 30 minutes for next 6 hours
   • Every hour thereafter 1

2. Blood pressure management:

   • Maintain BP <180/105 mmHg 1
   • Correct hypotension to ensure adequate perfusion 1

3. Oxygenation:

   • Maintain oxygen saturation ≥94% 1

Important Considerations and Pitfalls

1. Time is critical: The effectiveness of thrombolytic therapy decreases significantly with time. Door-to-needle time should be minimized.

2. Hemorrhagic transformation risk: Monitor closely for symptomatic intracranial hemorrhage, especially within the first 12 hours after thrombolysis. The risk of hemorrhage is significantly higher with thrombolysis (2.4% vs. 0.2% with placebo) 3.

3. Stroke mimics: Ensure accurate diagnosis before administering thrombolytics, as misdiagnosis can lead to unnecessary risks.

4. Blood pressure control: Uncontrolled hypertension (>185/110 mmHg) is a contraindication for thrombolysis and must be addressed before treatment.

5. Anticoagulation timing: Starting anticoagulation too early in cardioembolic stroke may increase hemorrhagic transformation risk; delaying too long increases recurrent stroke risk.