What are the guidelines for managing acute ischemic stroke?

Guidelines for Managing Acute Ischemic Stroke

The cornerstone of acute ischemic stroke management includes immediate brain imaging, early administration of intravenous tissue plasminogen activator (tPA) for eligible patients within 3 hours of symptom onset, and aspirin administration within 24-48 hours for those not receiving thrombolysis. 1, 2

Initial Assessment and Imaging

• Immediate brain imaging is essential before initiating any specific therapy to treat acute ischemic stroke 1

  • Non-contrast CT (NECT) or MRI must be performed to exclude intracranial hemorrhage
  • Brain imaging should be interpreted within 45 minutes of patient arrival by a physician with expertise in reading CT and MRI studies 1
  • CT perfusion and MRI perfusion/diffusion imaging may be considered for selecting patients for reperfusion therapy beyond standard time windows 1

• Vascular imaging:

  • Noninvasive intracranial vascular imaging (CTA or MRA) is strongly recommended during initial evaluation if intra-arterial fibrinolysis or mechanical thrombectomy is contemplated 1, 2
  • Should not delay intravenous tPA administration if indicated 1

Reperfusion Therapy

Intravenous Thrombolysis (tPA/Alteplase)

• Administer intravenous tPA (0.9 mg/kg, maximum 90 mg) to eligible patients within 3 hours of symptom onset 1, 3

  • The NINDS trial demonstrated improved outcomes at 3 months despite increased risk of symptomatic intracranial hemorrhage (6.4% vs 0.6%) 3
  • Mortality at 3 months was not significantly different (17% with tPA vs 21% with placebo) 3

• Administration protocol 1:

  • Infuse 0.9 mg/kg (maximum 90 mg) over 60 minutes with 10% given as bolus over 1 minute
  • Perform neurological assessments every 15 minutes during infusion, every 30 minutes for 6 hours, then hourly until 24 hours
  • Monitor blood pressure every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours

• Contraindications include:

  • Time of symptom onset unknown or >3 hours
  • Minor or rapidly improving symptoms
  • Prior intracranial hemorrhage
  • Recent major surgery or serious trauma
  • Recent gastrointestinal or urinary tract hemorrhage
  • Recent arterial puncture at noncompressible site
  • Seizure at stroke onset with postictal residual neurological impairments
  • Blood pressure >185/110 mmHg despite treatment
  • Blood glucose <50 mg/dL
  • Platelet count <100,000/mm³
  • INR >1.7 if on warfarin
  • Abnormal aPTT if receiving heparin in previous 48 hours
  • CT showing multilobar infarction (hypodensity >1/3 cerebral hemisphere) 1

Blood Pressure Management

• For patients receiving tPA: Maintain BP <180/105 mmHg for at least 24 hours after treatment 1, 2

  • Before tPA administration, BP should be <185/110 mmHg 1

• For patients not receiving tPA:

  • Withhold medications unless systolic BP >220 mmHg or diastolic BP >120 mmHg 1
  • If treatment needed, lower BP by approximately 15% during first 24 hours 1

Antiplatelet Therapy

• Administer aspirin (325 mg initially) within 24-48 hours after stroke onset for most patients not receiving thrombolysis 1, 2

  • Aspirin reduces early recurrent stroke and mortality when given within 48 hours 1
  • Do not administer aspirin within 24 hours of tPA administration 1, 2
  • Continue aspirin at lower maintenance dose (81 mg daily) for long-term secondary prevention 2

• Aspirin is not a substitute for other acute interventions such as intravenous tPA 1

Anticoagulation

• Urgent anticoagulation is NOT recommended for preventing early recurrent stroke or improving outcomes after acute ischemic stroke 1, 2

  • Parenteral anticoagulants (heparin, LMW heparins) increase risk of serious bleeding complications 1
  • Do not initiate anticoagulant therapy within 24 hours of tPA administration 1, 2

• The usefulness of argatroban or other thrombin inhibitors is not well established and should be used only in clinical trials 1

Glycoprotein IIb/IIIa Inhibitors

• The efficacy of intravenous tirofiban and eptifibatide is not well established and should only be used in clinical trials 1
• Administration of other intravenous antiplatelet agents that inhibit glycoprotein IIb/IIIa receptor is not recommended 1

Supportive Care

• Airway management:

  • Provide airway support and ventilatory assistance for patients with decreased consciousness or bulbar dysfunction 1
  • Supplement oxygen to maintain saturation >94% 1, 2

• Temperature management:

  • Identify and treat sources of hyperthermia (temperature >38°C) 1, 2
  • Administer antipyretic medications to lower temperature in hyperthermic patients 1

• Glucose management:

  • Treat hypoglycemia (blood glucose <60 mg/dL) 1
  • Target blood glucose levels in range of 140-180 mg/dL 1
  • Monitor closely to prevent hypoglycemia 1

• Volume management:

  • Correct hypovolemia with intravenous normal saline 1
  • Maintain euvolemia with isotonic solutions 2
  • Avoid hypotonic solutions that may worsen cerebral edema 2

Monitoring

• Cardiac monitoring should be performed for at least the first 24 hours to detect atrial fibrillation and other serious cardiac arrhythmias 1, 2
• Neurological monitoring with serial examinations to detect early deterioration 2
• Dysphagia screening before initiating oral intake to reduce pneumonia risk 2

Early Rehabilitation

• Initiate rehabilitation within 24-48 hours for stable patients 2
• Use multidisciplinary approach including physical, occupational, and speech therapy 2

Common Pitfalls to Avoid

1. Delaying neuroimaging - This leads to delayed diagnosis and treatment
2. Inappropriate blood pressure management - Too aggressive lowering may worsen outcomes
3. Missing dysphagia - Increases risk of aspiration pneumonia
4. Overlooking cardiac sources - May miss paroxysmal atrial fibrillation or other cardiac sources of embolism
5. Delayed mobilization - Increases risk of complications including DVT and pressure ulcers
6. Administering anticoagulants or antiplatelets within 24 hours of tPA - Increases bleeding risk

By following these evidence-based guidelines, clinicians can optimize outcomes for patients with acute ischemic stroke, reducing morbidity and mortality while improving quality of life.