What is the recommended treatment for acute stroke?

Acute Stroke Treatment Management

For acute ischemic stroke, the recommended treatment includes intravenous alteplase within 4.5 hours of symptom onset followed by endovascular thrombectomy within 24 hours for eligible patients with large vessel occlusion. 1

Initial Management

Immediate Assessment and Stabilization

• Ensure airway, breathing, and circulation are stable
• Maintain oxygen saturation >94% 1
• Correct hypotension and hypovolemia to maintain systemic perfusion 1
• Obtain blood glucose measurement (must precede alteplase initiation) 1
• Perform rapid neuroimaging with non-contrast CT to rule out hemorrhage 2

Blood Pressure Management

• Target BP <185/110 mmHg before initiating IV thrombolysis
• Maintain BP <180/105 mmHg for at least 24 hours after alteplase administration 2

Primary Treatment Options

Intravenous Thrombolysis with Alteplase

• Dosing: 0.9 mg/kg (maximum 90 mg) with 10% as bolus over 1 minute and 90% as infusion over 60 minutes 2
• Time windows:
  • 0-3 hours: strongest evidence for benefit (Class I, Level A) 2
  • 3-4.5 hours: additional exclusion criteria apply (Class I, Level B-R) 2
  • Beyond 4.5 hours: only for selected patients with MRI DWI-FLAIR mismatch 3

Endovascular Thrombectomy (EVT)

• Indications:
  • Proximal large vessel occlusion (carotid artery, M1 segment of MCA, or proximal M2 divisions) 1
  • Treatment within 6 hours of symptom onset (standard window) 1
  • Selected patients up to 24 hours from symptom onset with appropriate imaging criteria 1
• Patient selection criteria for extended window (6-24 hours):
  • DAWN trial criteria: NIHSS ≥10 with small core infarct (0-21 ml if ≥80 years or 0-31 ml if <80 years) 1
  • DEFUSE-3 criteria: Core volume <70 ml, mismatch ratio ≥1.8, and mismatch volume ≥15 ml 1

Important Considerations

Imaging Selection

• Non-contrast CT required to rule out hemorrhage before thrombolysis 2
• CTA recommended for patients with suspected large vessel occlusion 2
• Advanced imaging (CTP or DW-MRI) required for extended time windows (6-24h) 2

Contraindications to Alteplase

• BP >185/110 mmHg despite treatment 2
• Extensive regions of clear hypoattenuation on CT 2
• Blood glucose <50 mg/dL 2
• INR >1.7 or PT >15 seconds for patients on warfarin 2
• Direct oral anticoagulant (DOAC) use (routine administration not recommended) 1

Management of Complications

• For angioedema: staged response with antihistamines, glucocorticoids, and airway management 1
• For bleeding: individual case-based management; insufficient evidence for routine use of blood products 1

Treatment Algorithm

1. Within 4.5 hours of symptom onset:

   • Administer IV alteplase to eligible patients
   • Do not delay alteplase while waiting for laboratory results if no suspicion of coagulopathy 1
   • Do not wait to evaluate response to IV alteplase before proceeding with EVT evaluation 2

2. For patients with large vessel occlusion:

   • Proceed with EVT if eligible (can be performed after IV alteplase) 1
   • EVT indicated for both alteplase-eligible and alteplase-ineligible patients 1

3. Beyond 4.5 hours from symptom onset:

   • Consider EVT for selected patients with appropriate imaging criteria up to 24 hours 1
   • Consider IV thrombolysis for wake-up stroke patients with MRI DWI-FLAIR mismatch 3

4. Post-treatment management:

   • Monitor BP and perform neurological assessments every 15 minutes during alteplase infusion and for 2 hours after, every 30 minutes for the next 6 hours, and hourly until 24 hours 2
   • Obtain follow-up CT or MRI at 24 hours before starting anticoagulants or antiplatelet agents 2
   • Administer oral aspirin (325 mg) within 24-48 hours after stroke onset if not treated with alteplase 1

Common Pitfalls to Avoid

• Delaying treatment while waiting for non-essential laboratory tests 1
• Withholding treatment from eligible elderly patients (no upper age limit) 2
• Administering antiplatelet agents within 24 hours of alteplase (safety uncertain) 2
• Missing the extended treatment window for EVT in eligible patients 1
• Failing to maintain appropriate BP control before and after thrombolysis 2

Remember that "time is brain" - every effort should be made to minimize door-to-needle time for thrombolysis and door-to-groin puncture time for endovascular treatment 2.