What is the management of an ischemic infarct?

Management of Ischemic Infarct

The cornerstone of ischemic stroke management is rapid restoration of blood flow to the ischemic area through intravenous recombinant tissue plasminogen activator (rtPA) within 3 hours of symptom onset, followed by comprehensive supportive care and secondary prevention measures. 1

Initial Assessment and Stabilization

• Airway, breathing, circulation: Ensure adequate oxygenation and ventilation
• Neurological assessment: Use standardized stroke scale (e.g., NIHSS)
• Vital signs monitoring: Check blood pressure, heart rate, temperature, oxygen saturation
• Laboratory tests: Complete blood count, coagulation studies, electrolytes, glucose
• Imaging: Non-contrast CT to distinguish between ischemic and hemorrhagic stroke 2

Acute Reperfusion Therapy

Intravenous Thrombolysis

• rtPA (Alteplase): 0.9 mg/kg IV (maximum 90 mg), with 10% given as bolus and remainder over 60 minutes 1
• Time window: Within 3 hours of symptom onset (strongest evidence) 2
• Blood pressure requirements:
  • Before rtPA: BP must be <185/110 mmHg
  • After rtPA: Maintain BP <180/105 mmHg for 24 hours 1, 2

Endovascular Thrombectomy

• First-line treatment for large-vessel occlusions with NIHSS ≥6
• Can be considered up to 24 hours with appropriate imaging selection 2
• Requires accurate clot localization, typically using CT angiography 1

Blood Pressure Management

• For patients not receiving thrombolysis:

  • Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg
  • If treatment needed, reduce BP by 10-15% 1

• For patients receiving thrombolysis:

  • Before treatment: Reduce BP to <185/110 mmHg
  • During/after treatment: Maintain BP <180/105 mmHg
  • Preferred agents: Labetalol 10-20 mg IV over 1-2 min (may repeat) or nicardipine 1

• Avoid precipitous BP reductions as they may worsen cerebral ischemia

• Avoid sublingual nifedipine due to risk of rapid, uncontrolled BP reduction 1

Supportive Care and Management of Complications

Temperature Management

• Treat fever (temperature >38°C) with antipyretics 1
• Target normothermia as fever can worsen neurological outcomes

Glucose Management

• Monitor blood glucose regularly
• Treat hyperglycemia: Maintain glucose <300 mg/dL (<16.63 mmol/L) 1
• Avoid glucose-containing IV solutions unless treating hypoglycemia
• Treat hypoglycemia promptly to prevent secondary brain injury

Cardiac Monitoring

• Continuous cardiac monitoring for at least 24 hours to detect arrhythmias, especially atrial fibrillation 1
• Treat clinically significant arrhythmias that may compromise cerebral perfusion

Management of Cerebral Edema

• Close monitoring for neurological deterioration, especially in large infarcts
• Peak edema typically occurs 3-4 days after stroke but can occur earlier with large infarcts
• Malignant edema may require neurosurgical intervention (e.g., decompressive craniectomy) 1

Prevention of Complications

• Early mobilization for stable patients to prevent venous thromboembolism 2
• DVT prophylaxis: Low molecular weight heparin preferred over unfractionated heparin 1
• Adequate hydration to maintain euvolemia
• Swallowing assessment before oral intake to prevent aspiration

Secondary Prevention

Antithrombotic Therapy

• Aspirin: Initial dose 325 mg, then 81-325 mg daily 2
• Short-term dual antiplatelet therapy (aspirin plus clopidogrel) for 21-30 days may be beneficial for minor stroke or high-risk TIA 2
• Anticoagulation for cardioembolic stroke (e.g., atrial fibrillation) 2

Risk Factor Management

• Hypertension control: Target based on individual factors
• Lipid management: Target LDL <100 mg/dL
• Diabetes management: Target fasting glucose <126 mg/dL
• Smoking cessation
• Lifestyle modifications: Mediterranean diet, regular exercise 2

Rehabilitation

• Begin as early as possible (within 24-48 hours for stable patients)
• Multidisciplinary approach: Physical therapy, occupational therapy, speech therapy
• Cognitive assessment and rehabilitation as needed 2

Common Pitfalls to Avoid

1. Delayed recognition and treatment of acute stroke
2. Overly aggressive blood pressure reduction causing hypoperfusion of the ischemic penumbra
3. Inadequate monitoring for complications like cerebral edema
4. Failure to identify and treat the underlying cause of stroke
5. Neglecting secondary prevention measures

Remember that "time is brain" - every minute delay in treatment results in loss of approximately 1.9 million neurons. Rapid assessment, diagnosis, and implementation of appropriate therapies are critical to improving outcomes in ischemic stroke.