What is the treatment for acute ischemic stroke?

Treatment for Acute Ischemic 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

Initial Management

Intravenous Thrombolysis

• IV r-tPA (alteplase) remains the mainstay of early treatment for acute ischemic stroke 2
• Dosing: 0.9 mg/kg with maximum dose of 90 mg 2, 1
  • 10% given as bolus over 1 minute
  • Remaining 90% administered as continuous infusion over 60 minutes 2
• Time window:
  • Most effective when given within 3 hours of symptom onset
  • Can be administered up to 4.5 hours after symptom onset 1
  • Earlier treatment associated with better outcomes 2

Blood Pressure Management

• Before thrombolysis: BP must be <185/110 mmHg 1
• During and after thrombolysis: Maintain BP <180/105 mmHg for 24 hours 1
• BP management protocol 2:
  • For systolic >185 mmHg or diastolic >110 mmHg pre-treatment:
    • Labetalol 10-20 mg IV over 1-2 min (may repeat once) or
    • Nicardipine drip, 5 mg/h, titrate up by 2.5 mg/h at 5-15 min intervals (maximum 15 mg/h)
  • During and after treatment:
    • Monitor BP every 15 min for 2 hours, then every 30 min for 6 hours, then hourly for 16 hours

Contraindications for IV r-tPA

• Symptom onset >4.5 hours or unknown onset time
• Recent stroke or serious head injury (within 3 months)
• Major surgery within 14 days
• History of intracranial hemorrhage
• GI or GU hemorrhage within 21 days 1

Endovascular Treatment

• Indicated for patients with proximal large vessel occlusions 1
• Can be performed within 6 hours of symptom onset for all eligible patients 1
• Extended window up to 24 hours for selected patients based on imaging criteria 1
• Mechanical thrombectomy is the preferred endovascular approach 1
• Patients eligible for IV r-tPA should receive it before endovascular treatment 2

Antiplatelet Therapy

• Aspirin 160-325 mg should be administered within 24-48 hours after stroke onset 1
• Delay aspirin for 24 hours in patients who received IV r-tPA 1
• Long-term antiplatelet options include:
  • Aspirin 75-100 mg daily
  • Clopidogrel 75 mg daily
  • Aspirin/extended-release dipyridamole 25/200 mg twice daily 1

Prevention of Complications

• Neurological assessments: every 15 minutes during infusion and for 2 hours, then every 30 minutes for 6 hours, and hourly until 24 hours 1
• VTE prophylaxis:
  • Start prophylactic-dose subcutaneous heparin (preferably LMWH) between days 2-4 for patients with restricted mobility 1
  • Intermittent pneumatic compression devices as an alternative 1
  • Avoid elastic compression stockings 1
• Early mobilization and adequate hydration 1

Management of Complications

• Symptomatic intracerebral hemorrhage is a serious complication of thrombolytic therapy 3, 4
• Angioedema should be managed with antihistamines, glucocorticoids, and standard airway management 1
• Bleeding complications require individualized management 1

Important Considerations

• Time is critical - every effort should be made to minimize delays in treatment initiation 2
• If patients are eligible for IV r-tPA, they should begin receiving it before being transported for additional imaging or endovascular treatment 2
• The risk of symptomatic intracerebral hemorrhage increases with delayed administration of r-tPA beyond 3 hours 3
• Recent evidence supports the efficacy of mechanical thrombectomy with stent retrievers, which were not widely used in earlier trials 5

While some studies have explored lower doses of r-tPA (0.6 mg/kg) 6, the standard dose of 0.9 mg/kg remains the recommended protocol in current guidelines 2, 1.