Is IV (intravenous) lidocaine a recommended treatment for acute ischemic stroke?

IV Lidocaine is Not Recommended for Acute Ischemic Stroke

IV lidocaine is not recommended for the treatment of acute ischemic stroke as it is not included in any current stroke management guidelines and is not an approved therapy for this condition. 1, 2

Standard of Care for Acute Ischemic Stroke

The cornerstone treatments for acute ischemic stroke are:

1. IV Thrombolysis with Alteplase (tPA)

   • Standard dosing: 0.9 mg/kg (maximum 90 mg)
   • Time window: within 4.5 hours of symptom onset
   • Class I recommendation with Level of Evidence A for treatment within 3 hours 1, 2
   • Class I recommendation with Level of Evidence B-R for treatment between 3-4.5 hours in eligible patients 1

2. Mechanical Thrombectomy

   • For patients with large vessel occlusion
   • Time window: up to 24 hours in selected patients based on imaging criteria 1

Contraindications and Eligibility for IV Alteplase

Patients must meet specific criteria to receive IV alteplase:

• Blood pressure must be <185/110 mmHg before initiation 1, 2
• No history of intracranial hemorrhage 1
• No recent major surgery (within 14 days) 1, 2
• No recent stroke or serious head trauma (within 3 months) 1, 2
• No GI or GU bleeding within 21 days 1, 2

Why IV Lidocaine is Not Used

1. No evidence of efficacy: There are no randomized controlled trials demonstrating benefit of IV lidocaine in acute ischemic stroke 1, 2

2. Not mentioned in guidelines: The comprehensive 2018 American Heart Association/American Stroke Association guidelines for acute ischemic stroke management make no mention of lidocaine as a treatment option 1

3. Established alternatives exist: IV alteplase has proven efficacy with a number needed to treat (NNT) of 8 for better functional outcomes 2, 3

4. Time-dependent treatment: The focus in acute stroke care is on rapid administration of proven therapies, as "time is brain" 1, 2

Appropriate Management of Acute Ischemic Stroke

The management algorithm for acute ischemic stroke includes:

1. Rapid assessment to confirm ischemic stroke
2. Determine eligibility for IV thrombolysis:
   • Time from symptom onset ≤4.5 hours
   • Absence of contraindications
3. Blood pressure management to ≤185/110 mmHg before thrombolysis
4. Administer IV alteplase at 0.9 mg/kg (10% as bolus, remainder over 60 minutes)
5. Monitor for complications including angioedema and bleeding
6. Initiate antiplatelet therapy (usually aspirin 160-300 mg) after 24 hours in patients who received thrombolysis 1, 2

Research Developments

Research continues to explore extended time windows for thrombolysis:

• The HOPE trial is investigating alteplase in the 4.5-24 hour window using CT perfusion to identify salvageable tissue 4
• The ECASS III trial established the 3-4.5 hour treatment window for alteplase 5

Conclusion

While research continues to refine stroke treatment protocols, IV lidocaine has no established role in acute ischemic stroke management. Clinicians should focus on rapid assessment and administration of evidence-based therapies like IV alteplase and, when indicated, mechanical thrombectomy.