What is the management of acute ischemic stroke?

Management of Acute Ischemic Stroke

The management of acute ischemic stroke requires immediate evaluation and treatment, with intravenous recombinant tissue plasminogen activator (rtPA) at 0.9 mg/kg (maximum 90 mg) strongly recommended for carefully selected patients who can receive the medication within 4.5 hours of stroke onset, followed by admission to a specialized stroke unit. 1

Initial Assessment and Emergency Management

Immediate Evaluation

• Perform urgent clinical assessment using standardized stroke scales such as NIHSS to determine stroke severity and prognosis 1
• Obtain non-contrast CT (NECT) brain imaging immediately to:
  • Exclude intracranial hemorrhage
  • Assess for early signs of infarction
  • Rule out stroke mimics 1
• Complete essential laboratory tests:
  • Blood glucose
  • Oxygen saturation
  • Serum electrolytes/renal function
  • Complete blood count with platelets
  • Cardiac markers
  • Coagulation studies (PT/INR, aPTT) 1
• Obtain 12-lead ECG to identify atrial fibrillation or evidence of structural heart disease 2

Time-Critical Reperfusion Therapies

Intravenous Thrombolysis

• Administer IV rtPA (0.9 mg/kg, maximum 90 mg) to eligible patients within 4.5 hours of symptom onset 1, 3
• Eligibility criteria include:
  • Confirmed ischemic stroke causing measurable neurological deficit
  • Time of symptom onset clearly determined
  • No intracranial hemorrhage on CT
  • No evidence of extensive early infarct signs (>1/3 MCA territory) 1
• Blood pressure must be ≤185/110 mmHg before rtPA administration 1
• Do not administer aspirin within 24 hours of rtPA administration 2

Mechanical Thrombectomy

• Consider for patients with large vessel occlusion within 6 hours of symptom onset (extended window up to 24 hours for selected patients with favorable imaging) 2
• Perform CT angiography or MR angiography from aortic arch to vertex to identify candidates 1, 2

Blood Pressure Management

For Patients Not Receiving Thrombolysis

• Generally, do not lower blood pressure unless:
  • Diastolic BP >120 mmHg
  • Systolic BP >220 mmHg
  • Evidence of other end-organ damage requiring BP reduction (aortic dissection, acute MI, pulmonary edema) 1

For Patients Receiving Thrombolysis

• Maintain BP ≤185/110 mmHg before rtPA administration and ≤180/105 mmHg for 24 hours after treatment 1
• For BP management:
  • Labetalol 10 mg IV over 1-2 min, may repeat or double every 10 min to maximum 300 mg
  • Nicardipine 5 mg/hr IV infusion as initial dose, titrate up by 2.5 mg/hr every 5 min to maximum 15 mg/hr
  • For severe hypertension: sodium nitroprusside 0.5 μg/kg/min IV infusion and titrate as needed 1

General Supportive Care

Airway and Oxygenation

• Monitor oxygen saturation and maintain >92%
• Provide supplemental oxygen at 2-4 L/min if saturation <92%
• Consider intubation for patients with decreased consciousness or inability to protect airway 2

Temperature Management

• Treat fever aggressively (temperature >99.6°F/37.5°C) with acetaminophen
• Consider cooling systems for refractory hyperthermia 2

Glucose Management

• Monitor blood glucose regularly
• Treat hyperglycemia to maintain glucose levels between 140-180 mg/dL 1
• Avoid hypoglycemia (<60 mg/dL) 1

Swallowing and Nutrition

• Screen swallowing function before oral intake
• Refer to speech-language pathologist for formal assessment if screening abnormal
• Consider early enteral nutrition if oral intake is unsafe 2

Management of Complications

Cerebral Edema and Increased Intracranial Pressure

• Corticosteroids are not recommended 1
• For patients with deterioration due to increased intracranial pressure:
  • Use osmotherapy (mannitol or hypertonic saline)
  • Consider hyperventilation as a temporary measure 1
• Surgical interventions:
  • CSF drainage for hydrocephalus
  • Surgical decompression for large cerebellar infarctions causing brainstem compression
  • Consider decompressive hemicraniectomy for malignant MCA infarctions in selected patients 1

Seizures

• Treat recurrent seizures with appropriate anticonvulsants
• Prophylactic anticonvulsants are not recommended 1

Hemorrhagic Transformation

• Small asymptomatic petechiae are less concerning than hematomas causing neurological decline
• Management depends on the amount of bleeding and symptoms 1

Early Secondary Prevention

• Initiate aspirin (325 mg) within 24-48 hours after stroke onset for patients not receiving thrombolysis 2
• Begin risk factor modification:
  • Antihypertensives
  • Statins
  • Diabetes management
  • Smoking cessation 2
• Initiate appropriate antithrombotic therapy based on stroke etiology 2

Early Rehabilitation

• Begin rehabilitation as early as possible, ideally within 24-48 hours for stable patients 2
• Include:
  • Physical therapy
  • Occupational therapy
  • Speech therapy
  • Cognitive assessment and rehabilitation 2
• Implement measures to prevent complications:
  • Frequent turning
  • Pressure-relieving mattresses
  • Fall prevention
  • Early mobilization when patient is stable 2

Common Pitfalls and Caveats

1. Time delays: "Time is brain" - every minute delay in treatment results in loss of approximately 1.9 million neurons 4

   • Establish stroke protocols to minimize door-to-needle time
   • Target door-to-needle time of ≤60 minutes 1

2. Blood pressure management: Overly aggressive BP reduction can worsen cerebral ischemia 1

   • Follow specific BP parameters for patients receiving thrombolysis
   • For non-thrombolysis patients, avoid BP reduction unless extremely elevated

3. Misinterpretation of imaging: Early infarct signs on CT can be subtle 1

   • Subtle early signs of infarction involving >1/3 of MCA territory increase hemorrhage risk with thrombolysis

4. Neglecting swallowing assessment: Can lead to aspiration pneumonia 2

   • Implement formal swallowing assessment before oral intake

5. Delayed recognition of complications: Monitor for neurological deterioration 1

   • Implement protocols for early detection of hemorrhagic transformation, cerebral edema, and seizures