What is the management of acute ischemic and hemorrhagic stroke?

Management of Acute Ischemic and Hemorrhagic Stroke

Immediate neuroimaging with non-contrast CT and CT angiography is essential for all patients with suspected acute stroke to determine eligibility for thrombolysis and endovascular thrombectomy, with treatment decisions prioritizing rapid reperfusion therapies within appropriate time windows. 1

Initial Assessment and Management

Immediate Evaluation

• Rapid assessment of airway, breathing, and circulation 1, 2
• Neurological examination using standardized stroke scale (e.g., NIHSS) 1
• Assessment of vital signs: heart rate, blood pressure, temperature, oxygen saturation 1
• Immediate blood work: electrolytes, glucose, complete blood count, coagulation status, creatinine 1
• 12-lead ECG to assess cardiac rhythm and identify atrial fibrillation 1

Urgent Neuroimaging

• Non-contrast CT (NCCT) without delay for all suspected stroke patients 1
• CT angiography (CTA) from arch-to-vertex for patients potentially eligible for endovascular thrombectomy (EVT) 1
• Consider advanced imaging (CT perfusion or multiphase CTA) to aid patient selection, but this should not delay treatment 1

Management of Acute Ischemic Stroke

Thrombolytic Therapy

• Administer intravenous alteplase (0.9 mg/kg, maximum 90 mg) within 4.5 hours of symptom onset for eligible patients 2, 3
• Greatest benefit occurs when administered within 90 minutes of symptom onset 4
• Blood pressure must be <185/110 mmHg before alteplase administration and maintained <180/105 mmHg for 24 hours after administration 1, 2
• Recent evidence suggests potential benefit of alteplase in selected patients with salvageable brain tissue 4.5-24 hours after onset, though with increased risk of symptomatic intracerebral hemorrhage 5

Endovascular Thrombectomy (EVT)

• First-line treatment for large vessel occlusions with significant neurological deficits 2
• Greatest benefit when performed within 6 hours of symptom onset 2
• Can be considered up to 24 hours with appropriate imaging selection 2
• Primary stroke centers without CTA capability should complete NCCT, offer intravenous alteplase if appropriate, and rapidly transfer eligible patients to comprehensive stroke centers 1

Blood Pressure Management in Ischemic Stroke

• For patients eligible for thrombolysis: Maintain BP <185/110 mmHg before treatment and <180/105 mmHg for 24 hours after treatment 1, 2
• For patients not eligible for thrombolysis: Do not routinely treat hypertension 1
• For extreme BP elevation (SBP >220 mmHg or DBP >120 mmHg): Reduce BP by approximately 15%, not more than 25%, over the first 24 hours 1
• Avoid rapid or excessive BP lowering as this may exacerbate ischemia 1, 2

Management of Hemorrhagic Stroke

Immediate Management

• Reverse anticoagulation immediately with appropriate reversal agents 2
• Avoid platelet transfusions for patients on antiplatelet therapy 2
• Control blood pressure targeting systolic BP of 130-150 mmHg 2
• Consider surgical interventions for specific cases:
  • Surgical decompression for large cerebellar hemorrhages causing brainstem compression 2
  • Stereotactic surgery for deep intracerebral hemorrhage may be an option 2

Supportive Care for All Stroke Patients

Hospital Care

• Admit to a dedicated stroke unit with multidisciplinary team approach 2
• Perform regular neurological assessments to detect clinical deterioration 2
• Begin rehabilitation therapy as early as possible once medically stable 2
• Implement early mobilization and adequate hydration to prevent venous thromboembolism 2
• Monitor temperature every 4 hours for the first 48 hours and treat temperature >37.5°C 2

VTE Prophylaxis

• Use intermittent pneumatic compression devices starting at admission 2
• Consider low-molecular-weight heparin for high-risk patients 2
• Avoid anti-embolism stockings alone for VTE prophylaxis 2

Seizure Management

• Treat new-onset seizures with appropriate short-acting medications (e.g., lorazepam IV) if not self-limited 1
• Single, self-limiting seizures occurring at onset or within 24 hours after stroke should not be treated with long-term anticonvulsants 1

Common Pitfalls and Considerations

• Inappropriate blood pressure management can worsen outcomes; avoid overly aggressive BP lowering 2
• Failure to perform swallowing assessment before initiating oral medications increases aspiration risk 2
• Delayed treatment significantly reduces effectiveness of reperfusion therapies; implement standardized protocols to minimize door-to-needle time 1
• Monitor for orthostatic hypotension during mobilization to prevent falls 2
• Failure to coordinate multidisciplinary care can compromise outcomes 2

By following these evidence-based recommendations, clinicians can optimize outcomes for patients with acute stroke, reducing mortality and improving functional recovery.