What are the guidelines for managing acute ischemic stroke?

Guidelines for Managing Acute Ischemic Stroke

The management of acute ischemic stroke requires immediate assessment, rapid imaging, and prompt initiation of reperfusion therapy with intravenous thrombolysis within 3 hours (or up to 4.5 hours in selected patients) and/or endovascular thrombectomy within 6-24 hours for eligible patients with large vessel occlusions. 1

Initial Assessment and Stabilization

• Assess and stabilize airway, breathing, and circulation immediately
• Use a standardized stroke scale (NIHSS) to assess stroke severity
• Monitor vital signs (heart rate, rhythm, blood pressure, temperature, oxygen saturation)
• Check blood glucose levels immediately (hypoglycemia can mimic stroke symptoms)
• Determine exact time of symptom onset (crucial for thrombolysis eligibility)
• Triage acute stroke with the same priority as acute myocardial infarction or serious trauma 1

Imaging and Diagnostic Evaluation

• Perform non-contrast CT scan immediately to rule out hemorrhage
• Consider advanced imaging (CT perfusion or MRI with diffusion-weighted imaging) for patients presenting beyond 6 hours to identify salvageable tissue
• Use CT angiography to identify large vessel occlusions
• Complete all imaging within 24 hours of symptom onset 1

Intravenous Thrombolysis

Eligibility Criteria for IV rtPA (alteplase):

• Treatment within 3 hours of symptom onset (strongest evidence)
• Selected patients may be treated between 3-4.5 hours (weaker evidence)
• Blood pressure ≤185/110 mmHg before treatment
• No evidence of intracranial hemorrhage on CT
• No multilobar infarction (hypodensity >1/3 cerebral hemisphere)
• INR ≤1.7 if on anticoagulants
• Normal aPTT if receiving heparin in previous 48 hours
• Platelet count ≥100,000/mm³
• Blood glucose ≥50 mg/dL
• No seizure with postictal residual neurological impairments 2, 1

Administration Protocol:

• Dose: 0.9 mg/kg (maximum 90 mg) over 60 minutes with 10% as bolus over 1 minute
• Admit patient to intensive care or stroke unit for monitoring
• Perform neurological assessments every 15 minutes during infusion, every 30 minutes for 6 hours, then hourly until 24 hours
• Monitor blood pressure every 15 minutes for 2 hours, every 30 minutes for 6 hours, then hourly until 24 hours
• Maintain blood pressure ≤180/105 mmHg during and after treatment
• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters
• Withhold anticoagulants and antiplatelet agents for 24 hours after treatment
• Obtain follow-up CT scan at 24 hours before starting antithrombotics 2, 1

Endovascular Therapy

Eligibility Criteria:

• Large vessel occlusion
• Disabling stroke symptoms
• ASPECTS score ≥6
• Treatment within 6 hours of symptom onset (standard window)
• Selected patients may be treated between 6-24 hours if salvageable tissue is present on advanced imaging 1

Procedure:

• Combined approach using stent-retrievers and aspiration is preferred
• Blood pressure target ≤180/105 mmHg during and for 24 hours after procedure
• Consider lower blood pressure targets (BP <140/90 mmHg) after successful reperfusion 1

Blood Pressure Management

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

Hospital Care and Monitoring

• Admit patients to a dedicated stroke unit or ICU
• Perform cardiac monitoring for at least 24 hours to detect atrial fibrillation
• Monitor and treat fever (>38°C)
• Implement DVT prophylaxis with intermittent pneumatic compression devices or low molecular weight heparin for patients with limited mobility 1

Secondary Prevention

• Begin antithrombotic therapy after 24 hours in patients who received thrombolysis
• For non-cardioembolic stroke: Aspirin (325 mg initially, then 81-325 mg daily) within 24-48 hours
• For cardioembolic stroke (e.g., atrial fibrillation): Anticoagulation
• Manage modifiable risk factors (hypertension, diabetes, hyperlipidemia, smoking)
• Consider carotid endarterectomy for symptomatic carotid stenosis (strongly recommended for 70-99% stenosis) 1

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
• Encourage regular moderate to vigorous physical activity and avoid prolonged sedentary behavior 1

Important Considerations and Pitfalls

• Time is brain: Every 30-minute delay in recanalization decreases good functional outcome chance by 8-14%
• Hemorrhage risk: Symptomatic intracranial hemorrhage occurs in approximately 6.4% of patients treated with rtPA 3
• Contraindications: Carefully review all contraindications before administering thrombolysis
• Extended time windows: While the 3-hour window has the strongest evidence, selected patients may benefit from treatment up to 4.5 hours after onset
• Imaging interpretation: Teleradiology systems can help facilities without in-house expertise for timely review of brain imaging 1

Despite earlier concerns about the efficacy of endovascular treatment 4, more recent guidelines strongly support its use for eligible patients with large vessel occlusions, with evidence showing increased functional independence from 26.5% to 46% when performed within 6 hours 1.