What are the guidelines for managing acute ischemic stroke?

Guidelines for Managing Acute Ischemic Stroke

Acute ischemic stroke management requires immediate intervention with intravenous thrombolysis for eligible patients within the appropriate time window, followed by endovascular therapy for those with large vessel occlusions, along with comprehensive supportive care and early rehabilitation to optimize outcomes. 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 including heart rate, rhythm, blood pressure, temperature, and oxygen saturation
• Check blood glucose levels immediately (hypoglycemia can mimic stroke symptoms)
• Determine the 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

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

Acute Treatment

Intravenous Thrombolysis

• Administer IV alteplase (0.9 mg/kg, maximum 90 mg) over 60 minutes with 10% given as a bolus over 1 minute for eligible patients within 3 hours of symptom onset (Class I, Level A evidence) 2, 1
• Consider IV alteplase for selected patients between 3-4.5 hours after symptom onset (lower level of evidence) 1

Eligibility criteria for IV thrombolysis:

• Measurable neurological deficit
• Blood pressure ≤185/110 mmHg before treatment
• No evidence of intracranial hemorrhage on CT
• No recent major surgery or serious trauma within 14 days
• 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
• CT without multilobar infarction (hypodensity <1/3 cerebral hemisphere) 2

Endovascular Therapy

• Perform endovascular thrombectomy within 6 hours for standard cases with large vessel occlusion
• Extended window of 6-24 hours available for selected patients with salvageable tissue
• Combined approach using stent-retrievers and aspiration is preferred for fastest reperfusion 1

Blood Pressure Management

• For patients receiving thrombolysis: maintain BP ≤180/105 mmHg during and for 24 hours after procedure
• For patients not receiving thrombolysis: withhold antihypertensive agents unless diastolic BP >120 mmHg or systolic BP >220 mmHg
• Use easily titrated agents like labetalol when treatment is needed 1

Monitoring Protocol After Thrombolysis

• Admit patient to intensive care or stroke unit
• Perform neurological assessments every 15 minutes during infusion, every 30 minutes for the next 6 hours, then hourly until 24 hours after treatment
• Measure blood pressure every 15 minutes for first 2 hours, every 30 minutes for next 6 hours, then hourly until 24 hours
• If patient develops severe headache, acute hypertension, nausea, or vomiting, discontinue infusion and obtain emergency CT scan
• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters
• Obtain follow-up CT scan at 24 hours before starting anticoagulants or antiplatelet agents 2

Antithrombotic Therapy

• Delay anticoagulants and antiplatelet agents for 24 hours after thrombolysis 2
• Administer aspirin (325 mg initially, then 81-325 mg daily) within 24-48 hours after stroke onset for patients not receiving thrombolysis 1
• For patients who received thrombolysis, delay aspirin administration until >24 hours after treatment 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 body temperature and treat fever (>38°C) if it occurs
• Implement DVT prophylaxis with intermittent pneumatic compression devices or low molecular weight heparin for patients with limited mobility 1

Secondary Prevention

• Begin rehabilitation as early as possible, ideally within 24-48 hours for stable patients
• Manage modifiable risk factors (hypertension, diabetes, hyperlipidemia, smoking)
• Determine stroke etiology to guide appropriate secondary prevention:
  • Non-cardioembolic stroke: antiplatelet therapy
  • Cardioembolic stroke (e.g., atrial fibrillation): anticoagulation
  • Symptomatic carotid stenosis (70-99%): carotid endarterectomy strongly recommended 1

Important Caveats and Pitfalls

• Risk of symptomatic intracranial hemorrhage with thrombolysis: The original NINDS trial reported a 6.4% risk, though recent community studies report lower rates 2, 3
• Time is brain: Every 30-minute delay in recanalization decreases good functional outcome chance by 8-14% 1
• Contraindications must be strictly observed: Careful patient selection is essential to minimize bleeding complications 2
• Extended time windows require advanced imaging: Standard time windows (3-4.5 hours for IV thrombolysis, 6 hours for thrombectomy) can be extended with appropriate imaging selection 1
• Seizures at presentation: Thrombolysis may be used when evidence suggests residual deficits are due to ischemia rather than the postictal state 2