What is the immediate treatment for acute ischemic stroke?

Immediate Treatment for Acute Ischemic Stroke

Eligible patients with acute ischemic stroke should receive intravenous alteplase (0.9 mg/kg, maximum 90 mg) as soon as possible after hospital arrival, with a target door-to-needle time of less than 60 minutes in 90% of treated patients, and a median door-to-needle time of 30 minutes. 1

Initial Assessment and Management

• Time window for IV alteplase:

  • Standard window: Within 4.5 hours of symptom onset 1
  • Extended window: 4.5-24 hours with perfusion imaging showing salvageable brain tissue 2

• Blood pressure management:

  • Target BP ≤185/110 mmHg before initiating IV thrombolysis 1, 3
  • Maintain BP ≤180/105 mmHg during and for 24 hours after treatment 1, 3
  • Options for BP control:
    • Labetalol 10-20 mg IV over 1-2 min (may repeat once)
    • Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 min (maximum 15 mg/h)
    • Clevidipine 1-2 mg/h IV, titrate by doubling dose every 2-5 min (maximum 21 mg/h)

IV Alteplase Administration Protocol

1. Dosing: 0.9 mg/kg (maximum 90 mg) with 10% given as IV bolus over 1 minute and remaining 90% as IV infusion over 60 minutes 1

   • CAUTION: This dosing differs from alteplase protocols for myocardial infarction 1

2. Monitoring during and after administration:

   • Neurological assessments every 15 minutes during infusion and for 2 hours
   • Every 30 minutes for next 6 hours
   • Hourly until 24 hours after treatment 3
   • Obtain follow-up CT or MRI at 24 hours post-treatment 3

3. Management of complications:

   • For angioedema: staged response using antihistamines, glucocorticoids, and standard airway management 1
   • For bleeding: individualized approach; insufficient evidence for routine use of cryoprecipitate, fresh frozen plasma, prothrombin complex concentrates, tranexamic acid, factor VIIa, or platelet transfusions 1

Endovascular Thrombectomy (EVT)

• Indicated for patients with:

  • Large vessel occlusion
  • Within 6 hours of symptom onset (standard window)
  • Extended window (up to 24 hours) with appropriate imaging selection 1

• System requirements:

  • Coordinated system of care including agreements with EMS
  • Rapid neurovascular imaging
  • Coordination between EMS, ED, stroke team, and radiology
  • Local expertise in neurointervention
  • Access to stroke unit for ongoing management 1

Antiplatelet Therapy

• Aspirin administration:

  • Recommended within 24-48 hours after stroke onset 1, 3
  • Dose: 160-300 mg 1, 3
  • For patients treated with IV alteplase, delay aspirin for 24 hours 1

• Dual antiplatelet therapy:

  • For minor stroke: aspirin plus clopidogrel for 21 days may be beneficial when started within 24 hours 1

Important Contraindications for IV Alteplase

• Symptom onset >4.5 hours (unless using extended window protocol with appropriate imaging)
• Unknown time of symptom onset (unless using advanced imaging selection)
• Another stroke or serious head injury within preceding 3 months
• Major surgery within prior 14 days
• History of intracranial hemorrhage
• Gastrointestinal or genitourinary hemorrhage within previous 21 days 3

Common Pitfalls to Avoid

1. Delaying treatment: Every minute counts - "Time is Brain." Treatment should be initiated immediately after CT scan 1

2. Incorrect dosing: Using the myocardial infarction protocol instead of the stroke protocol for alteplase 1

3. Inadequate BP control: Failure to control blood pressure before, during, and after thrombolysis increases hemorrhage risk 1, 3

4. Using anticoagulation routinely: Urgent anticoagulation with heparin is not recommended for routine management as it does not improve outcomes and may increase bleeding 1, 3

5. Substituting aspirin for acute reperfusion therapy: Aspirin is not a substitute for IV alteplase or mechanical thrombectomy in eligible patients 1

6. Treating beyond the time window without appropriate imaging: Standard treatment window is 4.5 hours, with extended window treatment requiring perfusion imaging to identify salvageable tissue 2

The evidence strongly supports immediate treatment with IV alteplase for eligible patients with acute ischemic stroke, followed by appropriate monitoring and management of complications. For patients with large vessel occlusions, endovascular thrombectomy should be considered. The benefit of treatment is highly time-dependent, emphasizing the importance of rapid assessment and intervention.