What are the initial treatments for acute ischemic stroke and hemorrhagic stroke?

Acute Interventions for Stroke

For acute ischemic stroke, intravenous recombinant tissue plasminogen activator (IV r-tPA) at 0.9 mg/kg (maximum 90 mg) should be administered within 4.5 hours of symptom onset, with treatment within 3 hours having the strongest evidence. 1, 2

Acute Ischemic Stroke Management

Initial Assessment and Stabilization

• Rapid neuroimaging with non-contrast CT to exclude hemorrhage
• Target door-to-imaging time < 45 minutes
• Blood pressure control to <185/110 mmHg before thrombolysis

Thrombolytic Therapy

1. IV r-tPA (Alteplase)

   • Timing:
     • 0-3 hours: Class I, Level A evidence 1, 2
     • 3-4.5 hours: Class I, Level B evidence for eligible patients 2
   • Dosing: 0.9 mg/kg (maximum 90 mg), with 10% as bolus and remainder over 60 minutes 2
   • Target door-to-needle time: <60 minutes 2
   • Contraindications:
     • Intracranial hemorrhage
     • Stroke or serious head injury within 3 months
     • Major surgery within 14 days
     • GI or GU hemorrhage within 21 days 2

2. Endovascular Therapy

   • Indicated for patients with proximal large vessel occlusions 1, 2
   • Can be performed up to 6 hours from symptom onset in standard cases 2
   • Selected patients may benefit up to 24 hours based on imaging criteria 2
   • Options include:
     • Mechanical thrombectomy (preferred with newer devices)
     • Intra-arterial thrombolysis (for patients within 6 hours of symptom onset) 1

Antiplatelet Therapy

• Aspirin: 160-325 mg within 24-48 hours after stroke onset 1, 2
• Delay aspirin for 24 hours in patients who received IV thrombolysis 2
• Not a substitute for thrombolytic therapy 1
• Other antiplatelet agents (clopidogrel, tirofiban, eptifibatide) not well established for acute treatment 1

Acute Hemorrhagic Stroke Management

Initial Assessment and Stabilization

• Non-contrast CT to confirm hemorrhage
• CTA may be considered to evaluate for underlying vascular malformations 1
• Blood pressure management (target depends on specific clinical scenario)

Specific Interventions

• Reversal of anticoagulation if applicable
• Consider neurosurgical consultation for large hematomas or cerebellar hemorrhages
• For patients with restricted mobility:
  • Prophylactic-dose subcutaneous heparin (preferably LMWH) started between days 2-4 1
  • Intermittent pneumatic compression devices as an alternative 1
  • Avoid elastic compression stockings (Grade 2B) 1

Post-Acute Monitoring and Care

For Patients Receiving Thrombolysis

• Neurological assessments:
  • Every 15 minutes during infusion and for 2 hours
  • Every 30 minutes for the next 6 hours
  • Hourly until 24 hours after treatment 2
• Monitor for complications:
  • Angioedema: Manage with antihistamines, glucocorticoids, and airway management if needed
  • Hemorrhagic transformation: Individualized approach to management 2

DVT Prophylaxis

• Early mobilization for all stroke patients 2
• For immobile patients:
  • Prophylactic-dose LMWH preferred over UFH (Grade 2B) 1
  • Intermittent pneumatic compression devices as an alternative 1, 2

Clinical Pearls and Pitfalls

• Time is brain: Every effort should be made to minimize delays in treatment initiation
• Do not withhold IV r-tPA while waiting for additional imaging if the patient meets criteria based on non-contrast CT
• Aspirin is not a substitute for thrombolytic therapy in eligible patients
• The benefit of IV r-tPA outweighs the risk of symptomatic intracerebral hemorrhage (which occurs in approximately 6.4% of treated patients) 3
• Early ischemic changes on CT increase the risk of hemorrhagic transformation but are not an absolute contraindication to thrombolysis 4
• For patients with large vessel occlusions, consider both IV thrombolysis and endovascular therapy when appropriate