What is the management of ischemic stroke?

Management of Ischemic Stroke

Intravenous alteplase (0.9 mg/kg, maximum 90 mg) administered within 4.5 hours of symptom onset followed by endovascular thrombectomy for large vessel occlusions is the cornerstone of acute ischemic stroke management. 1, 2

Initial Management (First 24 Hours)

Immediate Assessment and Stabilization

• Ensure airway, breathing, and circulation
• Rapid neurological assessment using NIHSS (National Institutes of Health Stroke Scale)
• Emergent non-contrast CT scan to rule out hemorrhage
• CT angiography to identify large vessel occlusions
• Monitor vital signs and neurological status every 15 minutes during and after IV alteplase for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours 1

Reperfusion Therapy

1. IV Thrombolysis:

   • Administer alteplase 0.9 mg/kg (maximum 90 mg) over 60 minutes with 10% given as bolus over 1 minute 1
   • Time window: Within 4.5 hours of symptom onset 3
   • Blood pressure must be ≤185/110 mmHg before treatment 1

2. Endovascular Thrombectomy:

   • Indicated for large vessel occlusions
   • Time window: Within 6 hours of symptom onset (Class I, Level A evidence) 2
   • Stent retrievers preferred over coil retrievers 2
   • Consider combined approach with stent-retrievers and aspiration for optimal results 1

Management of Complications

• Symptomatic Intracranial Hemorrhage:

  • Stop alteplase infusion
  • Obtain CBC, PT/INR, aPTT, fibrinogen level
  • Administer cryoprecipitate 10 units
  • Consider tranexamic acid 1000 mg IV or ε-aminocaproic acid 4-5 g 1

• Blood Pressure Management:

  • For patients not receiving thrombolysis: Withhold antihypertensive agents unless diastolic BP >120 mmHg or systolic BP >220 mmHg 1
  • For patients receiving thrombolysis: Maintain BP ≤180/105 mmHg 1
  • Use easily titrated agents like labetalol when treatment is needed 1

• Cerebral Edema:

  • Elevate head of bed to 30° 2
  • Consider osmotic therapy with mannitol 0.25-0.5 g/kg IV every 6 hours 2
  • Surgical decompression for large cerebellar infarctions or extensive hemispheric infarcts in selected patients 2

Post-Acute Management (24-72 Hours)

• Admit to dedicated stroke unit or ICU 2
• Cardiac monitoring for at least 24 hours to detect atrial fibrillation 2
• DVT prophylaxis with intermittent pneumatic compression devices or low molecular weight heparin 2
• Obtain follow-up CT or MRI at 24 hours after IV alteplase before starting anticoagulants or antiplatelet agents 1
• Begin antithrombotic therapy:
  • For non-cardioembolic stroke: Aspirin 325 mg initially, then 81-325 mg daily 2
  • For cardioembolic stroke (e.g., atrial fibrillation): Oral anticoagulation 2
• Monitor and treat fever (>38°C) 2
• Maintain euglycemia 1

Rehabilitation and Secondary Prevention

Early Rehabilitation

• Begin rehabilitation within 24-48 hours for stable patients 2
• Include physical therapy, occupational therapy, speech therapy, and cognitive assessment 2

Secondary Prevention

• Antiplatelet Therapy:

  • For non-cardioembolic stroke: Aspirin 81-325 mg daily or clopidogrel 75 mg daily 2
  • For minor non-cardioembolic strokes: Consider dual antiplatelet therapy (aspirin + clopidogrel) for 21-90 days, then convert to single agent 4

• Anticoagulation:

  • For cardioembolic stroke: Warfarin (target INR 2.0-3.0) or direct oral anticoagulants 2
  • Direct oral anticoagulants preferred for non-valvular atrial fibrillation 4

• Risk Factor Management:

  • Blood pressure: Target <140/90 mmHg for most patients 2
  • Lipids: Target LDL <100 mg/dL 2
  • Diabetes: Target fasting glucose <126 mg/dL 2
  • Smoking cessation counseling and support 2
  • Regular physical activity and Mediterranean diet 2
  • Carotid endarterectomy for symptomatic carotid stenosis (70-99%) 2

Common Pitfalls and Caveats

1. Delayed Treatment: Time is brain—every minute counts. Establish systems to minimize door-to-needle time for thrombolysis.

2. Blood Pressure Management: Overly aggressive BP lowering can worsen ischemia; too permissive BP management can increase hemorrhage risk.

3. Misdiagnosis: Stroke mimics (hypoglycemia, seizures, migraines) can lead to inappropriate thrombolysis.

4. Incomplete Workup: Failure to identify stroke etiology can lead to inadequate secondary prevention.

5. Hemorrhagic Transformation: Risk increases with delayed thrombolysis; symptomatic ICH occurs in approximately 2.4% of patients treated with alteplase between 3-4.5 hours 3.

6. Inadequate Rehabilitation: Early, intensive rehabilitation improves functional outcomes.

By following this structured approach to ischemic stroke management, clinicians can optimize patient outcomes by minimizing brain damage, improving functional recovery, and preventing recurrent strokes.