What is the immediate treatment for a patient with ischemic stroke?

Immediate Treatment of Ischemic Stroke

The immediate treatment for ischemic stroke is intravenous recombinant tissue plasminogen activator (rtPA/alteplase) at 0.9 mg/kg (maximum 90 mg) administered within 3-4.5 hours of symptom onset for eligible patients. 1, 2

Initial Assessment and Stabilization

1. Assess and stabilize ABCs (Airway, Breathing, Circulation)
2. Perform rapid neurological examination using NIHSS
3. Check vital signs (heart rate, blood pressure, temperature, oxygen saturation)
4. Determine precise time of symptom onset
5. Perform fingerstick glucose test to rule out hypoglycemia

Immediate Imaging and Diagnostics

• Complete non-contrast CT or MRI brain imaging immediately
• Perform vascular imaging (CTA or MRA from aortic arch to vertex) concurrently
• Conduct essential laboratory tests:
  • CBC
  • Electrolytes
  • Coagulation studies (INR, PT)
  • Glucose
  • Renal function
  • Troponin

Intravenous rtPA Administration

Inclusion Criteria:

• Diagnosis of ischemic stroke causing measurable neurological deficit
• Treatment can be initiated within 3-4.5 hours of symptom onset

Administration Protocol:

• Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 minutes
• Give 10% of the dose as a bolus over 1 minute
• Target door-to-needle time of <60 minutes 2

Post-Administration Monitoring:

• Measure blood pressure and perform neurological assessments:
  • Every 15 minutes during and after rtPA infusion for 2 hours
  • Every 30 minutes for 6 hours
  • Hourly until 24 hours after treatment
• Maintain blood pressure <180/105 mmHg after treatment
• Obtain follow-up CT or MRI scan at 24 hours before starting anticoagulants or antiplatelet agents

Endovascular Treatment Considerations

For patients with large vessel occlusion (internal carotid artery or proximal MCA):

• Consider endovascular therapy with stent retrievers if treatment can be initiated within 6 hours of symptom onset 1
• Particularly beneficial for patients with:
  • Contraindications to IV rtPA
  • Persistent large vessel occlusion after IV rtPA

Key Points for Endovascular Therapy:

• Technical goal should be TICI grade 2b/3 angiographic result 1
• Stent retrievers are indicated in preference to other mechanical thrombectomy devices
• Time to reperfusion is critical - each 30-minute delay reduces probability of favorable outcome by approximately 10% 1

Important Caveats and Contraindications

• Time is brain - earlier treatment with rtPA (within 90 minutes) is associated with better outcomes than treatment at 90-180 minutes 1
• Relative contraindications to rtPA that require careful risk-benefit assessment:
  • Minor or rapidly improving symptoms
  • Pregnancy
  • Seizure at onset with postictal residual deficits
  • Major surgery or trauma within 14 days
  • Recent GI/GU hemorrhage (within 21 days)
  • Recent myocardial infarction (within 3 months) 1

Pitfalls to Avoid

1. Delaying treatment - Do not wait for laboratory results in patients without history of coagulopathy or thrombocytopenia; treatment can be initiated before results are available 1
2. Waiting for clinical improvement - Observing patients after IV rtPA to assess for clinical response before pursuing endovascular therapy is not recommended 1
3. Premature anticoagulation - Delay anticoagulants and antiplatelet agents for 24 hours after rtPA treatment 1, 2
4. Invasive procedures - Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if the patient can be safely managed without them 1

For patients who are not eligible for rtPA or endovascular therapy, initiate aspirin (325 mg initially, then 81-325 mg daily) within 24-48 hours if no contraindications exist 2.