Treatment of Acute Ischemic Stroke
Intravenous alteplase and endovascular therapy are the mainstay treatments for acute ischemic stroke, with treatment decisions being highly time-dependent to maximize outcomes and minimize complications. 1, 2
Initial Management
Diagnosis and Imaging
- Rapid neuroimaging is crucial to:
- Rule out intracranial hemorrhage
- Identify vessel occlusion location
- Assess risk/benefit ratio for treatment 1
- Non-contrast CT (NCCT) is preferred due to:
- Time efficiency
- Wide availability
- Ability to exclude hemorrhage 1
- CT angiography (CTA) should be performed to identify vessel occlusions, particularly large vessel occlusions (LVOs) 1
Intravenous Thrombolysis
- IV alteplase (r-tPA) is first-line treatment for eligible patients within 4.5 hours of symptom onset 2
- Dosing:
Time Windows
- Most effective when given within 3 hours of symptom onset 2
- Can be administered up to 4.5 hours after symptom onset 2
- Recent evidence suggests benefit in selected patients with salvageable brain tissue on perfusion imaging between 4.5-24 hours, despite increased risk of symptomatic hemorrhage 4
Pre-Treatment Requirements
- Blood pressure must be <185/110 mmHg before initiation 2
- Maintain BP <180/105 mmHg during and for 24 hours after treatment 2
Contraindications
- Symptom onset >4.5 hours (unless qualifying for extended window with perfusion imaging)
- Unknown time of symptom onset
- Stroke or serious head injury within preceding 3 months
- Major surgery within prior 14 days
- History of intracranial hemorrhage
- GI or GU hemorrhage within previous 21 days 2
Endovascular Therapy
- Indicated for patients with proximal large vessel occlusions 2
- Time windows:
- Standard window: within 6 hours of symptom onset
- Extended window: up to 24 hours in selected patients based on imaging criteria 2
- Combined approach using stent-retrievers and aspiration is most effective for achieving fast first-pass complete reperfusion 1
- Patients eligible for IV alteplase should receive it before or concurrent with endovascular treatment 2
Post-Acute Management
Antithrombotic Therapy
- Aspirin 160-325 mg should be given within 24-48 hours after stroke onset
- Delay aspirin for 24 hours in patients treated with IV alteplase 2
- Long-term antiplatelet options:
- Aspirin 75-100 mg daily
- Clopidogrel 75 mg daily
- Aspirin/extended-release dipyridamole 25/200 mg twice daily 2
VTE Prophylaxis
- Prophylactic-dose subcutaneous heparin (preferably LMWH) should start between days 2-4 for patients with restricted mobility
- Intermittent pneumatic compression devices can be used as an alternative
- Avoid elastic compression stockings 2
Monitoring and Complication Management
- 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 and manage:
Transport and Systems of Care
- Rapid patient transfer is crucial for time-sensitive treatments
- Pre-notification, parallel processing, teamwork, and standardized workflows minimize delays
- Transport models depend on local geography and hospital efficiency:
- Mothership: direct transport to comprehensive stroke centers
- Drip-and-ship: thrombolysis at primary stroke center, then transfer for endovascular therapy if needed 1
Caution
- Strategies to improve blood flow by changing rheological characteristics or increasing perfusion pressure are not recommended outside clinical trials 1
- Surgical interventions like emergency carotid endarterectomy are generally not performed in acute ischemic stroke due to high risks 1
The treatment of acute ischemic stroke requires rapid assessment, diagnosis, and implementation of appropriate therapies to maximize neurological recovery and minimize complications.