Immediate Management of Ischemic Stroke
The immediate treatment for ischemic stroke is intravenous recombinant tissue plasminogen activator (rtPA) at a dose of 0.9 mg/kg (maximum 90 mg) administered within 3 hours of symptom onset for eligible patients. 1
Initial Assessment and Intervention
- Rapid recognition using validated stroke screening tools
- Immediate brain imaging with non-contrast CT to exclude hemorrhage
- CT angiography from aortic arch to vertex to assess extracranial and intracranial circulation
- Essential laboratory investigations:
- Complete blood count
- Electrolytes and renal function
- Coagulation studies
- Blood glucose
- ECG
Reperfusion Therapy Algorithm
Intravenous Thrombolysis
- Time window: Within 3 hours of clearly defined symptom onset (strongest evidence) 2
- Extended window: Up to 4.5 hours in selected patients 1
- Dosage: 0.9 mg/kg (maximum 90 mg)
- 10% as initial bolus over 1 minute
- Remainder over 60 minutes
Patient Selection for IV rtPA
Eligibility criteria include:
- Measurable neurological deficit
- No spontaneous clearing of symptoms
- No signs of intracranial hemorrhage on CT
- No major surgery or stroke in previous 3 months
- Blood pressure <185/110 mmHg
- No anticoagulant use or INR <1.5
- Platelet count >100,000/mm³
- Blood glucose >50 mg/dL
Endovascular Thrombectomy
- Consider for large vessel occlusions
- Time window: Up to 6 hours from symptom onset
- Extended window possible with appropriate imaging selection
- Particularly beneficial for basilar artery occlusion 1
Blood Pressure Management
- For patients eligible for reperfusion: Maintain BP <185/110 mmHg
- For patients ineligible for reperfusion: Only treat if systolic >220 mmHg or diastolic >120 mmHg
- Medications: Labetalol or nicardipine preferred
- Maintain normovolemia using crystalloids
Early Antiplatelet Therapy
- For patients not receiving thrombolysis: Early aspirin therapy (160-325 mg) 3
- For patients receiving thrombolysis: Delay antiplatelet therapy for 24 hours
Prevention of Complications
- DVT prophylaxis for patients with restricted mobility
- Early swallowing assessment to prevent aspiration
- Fever management
- Pressure ulcer prevention
- Blood glucose monitoring and management
Multidisciplinary Care
- All stroke patients should be managed in a dedicated stroke unit
- Early mobilization when stable
- Early rehabilitation assessment within 24-48 hours
Common Pitfalls and Caveats
- Time is brain - Delays in treatment dramatically reduce effectiveness of rtPA
- Contraindications must be strictly observed - Administering rtPA to ineligible patients increases hemorrhage risk
- Blood pressure management is critical - Uncontrolled hypertension increases bleeding risk
- Avoid anticoagulants for 24 hours after rtPA - Increases risk of hemorrhagic transformation
- Do not use streptokinase - Associated with excess mortality in stroke patients 2
- Prophylactic anticonvulsants are not recommended - No evidence of benefit in patients without seizures 2
Special Considerations
- Patients with major strokes (NIHSS score >22) have poor prognosis regardless of treatment but may still benefit from rtPA 2
- Posterior circulation strokes may benefit from MRI with diffusion-weighted imaging when available 1
- Surgical decompression may be considered for large cerebellar infarctions causing brainstem compression 2
The evidence strongly supports the use of IV rtPA within 3 hours of symptom onset as the cornerstone of acute ischemic stroke management. While earlier treatment (within 90 minutes) may yield better outcomes, treatment between 90-180 minutes is still beneficial 2. The management approach should focus on rapid assessment, appropriate patient selection for reperfusion therapy, and comprehensive supportive care to minimize complications and optimize outcomes.