What are the acute interventions for ischemic stroke?

Acute Interventions for Ischemic Stroke

IV thrombolysis with alteplase within 4.5 hours of symptom onset and endovascular thrombectomy within 6-24 hours for eligible patients are the cornerstone treatments for acute ischemic stroke management. 1

Initial Assessment and Management

• Ensure airway, breathing, and circulation
• Rapid neurological assessment using NIHSS
• 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
  • Every 30 minutes for 6 hours
  • Hourly until 24 hours 1

IV Thrombolysis

Time Windows and Recommendations

• Within 3 hours of symptom onset: Strongly recommended (Grade 1A) 2
• 3-4.5 hours after symptom onset: Recommended but with lower evidence (Grade 2C) 2
• Beyond 4.5 hours: Not recommended (Grade 1B) 2

Administration Protocol

• Dose: 0.9 mg/kg (maximum 90 mg) over 60 minutes with 10% given as bolus over 1 minute
• Blood pressure must be ≤185/110 mmHg before treatment 1

Eligibility Considerations

While the ECASS III trial initially supported the 3-4.5 hour window 3, reanalysis of this data has raised questions about efficacy when adjusting for baseline imbalances 4. Despite this controversy, current guidelines still support treatment in this extended window.

Endovascular Interventions

Recommendations

• Intraarterial r-tPA: Consider within 6 hours of symptom onset for patients with proximal cerebral artery occlusions who don't meet criteria for IV r-tPA (Grade 2C) 2
• Mechanical thrombectomy:
  • The 2012 guidelines suggested against routine use (Grade 2C) 2
  • However, newer guidelines strongly recommend endovascular thrombectomy for eligible patients with large vessel occlusions, particularly within 6 hours of symptom onset 1
  • Extended window of 6-24 hours for selected patients with salvageable tissue 1

Efficacy

• Increases functional independence from 26.5% to 46% when performed within 6 hours 1
• Every 30-minute delay in recanalization decreases good functional outcome chance by 8-14% 1

Antithrombotic Therapy

• Early aspirin therapy: Recommended within 48 hours at a dose of 160-325 mg (Grade 1A) 2
• Timing after thrombolysis: Delay aspirin until >24 hours after IV thrombolysis 1
• Aspirin vs. anticoagulation: Early aspirin therapy is preferred over therapeutic parenteral anticoagulation (Grade 1A) 2

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
• Long-term targets: <140/90 mmHg for most patients, <130/80 mmHg for patients with target-organ damage 1

DVT Prophylaxis

• For patients with restricted mobility:
  • Prophylactic-dose subcutaneous heparin (UFH or LMWH) or intermittent pneumatic compression devices (Grade 2B) 2
  • LMWH is preferred over UFH (Grade 2B) 2
  • Avoid elastic compression stockings (Grade 2B) 2

Management of Complications

Symptomatic Intracranial Hemorrhage

• Stop alteplase infusion immediately
• 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

Hospital Care

• Admit to dedicated stroke unit or ICU
• Cardiac monitoring for at least 24 hours to detect atrial fibrillation
• Obtain follow-up CT or MRI at 24 hours after IV alteplase before starting anticoagulants or antiplatelet agents
• Maintain euglycemia 1

Telemedicine Considerations

• Teleradiology systems are recommended for timely review of brain imaging in facilities without in-house expertise 2
• Telestroke evaluations can effectively guide IV alteplase eligibility decisions 2

Early Rehabilitation

• Begin rehabilitation as early as possible, ideally within 24-48 hours for stable patients
• Include physical therapy, occupational therapy, speech therapy, and cognitive assessment 1

Common Pitfalls to Avoid

1. Delayed treatment: "Time is brain" - every minute counts in acute stroke management
2. Inappropriate BP management: Too aggressive BP lowering can worsen ischemia
3. Missing large vessel occlusions: Failure to obtain vascular imaging can miss candidates for endovascular therapy
4. Overlooking contraindications: Careful screening for contraindications to thrombolysis is essential
5. Inadequate monitoring: Close monitoring after thrombolysis is crucial to detect complications early

The evidence clearly supports a time-sensitive approach to ischemic stroke management, with rapid assessment, imaging, and appropriate reperfusion therapy as the cornerstones of effective treatment.