What are the current guidelines for managing thrombotic stroke?

Current Guidelines for Thrombotic Stroke Management

For acute ischemic stroke management, IV recombinant tissue plasminogen activator (r-tPA) is strongly recommended if treatment can be initiated within 3 hours of symptom onset, with a weaker recommendation for treatment between 3-4.5 hours. 1, 2

Acute Phase Management

Thrombolytic Therapy

• IV r-tPA (0.9 mg/kg, maximum dose 90 mg) is recommended for eligible patients within 3 hours of symptom onset (Grade 1A evidence) 1
• IV r-tPA may be administered between 3-4.5 hours of symptom onset in eligible patients (Grade 2C evidence) 1, 3
• IV r-tPA is not recommended beyond 4.5 hours after symptom onset (Grade 1B) 1, 4
• For patients with proximal cerebral artery occlusions who are ineligible for IV r-tPA, intraarterial (IA) r-tPA may be considered if initiated within 6 hours of symptom onset (Grade 2C) 1
• IV r-tPA alone is preferred over combination IV/IA r-tPA (Grade 2C) 1
• Mechanical thrombectomy is generally not recommended based on older guidelines (Grade 2C), though this recommendation may have evolved in more recent practice 1, 5

Antiplatelet Therapy

• Early aspirin therapy (160-325 mg) is recommended within 48 hours of stroke onset (Grade 1A) 1
• Aspirin is preferred over therapeutic parenteral anticoagulation in the acute setting (Grade 1A) 1

Venous Thromboembolism Prophylaxis

• For patients with restricted mobility, prophylactic-dose subcutaneous heparin (preferably LMWH) or intermittent pneumatic compression devices should be used (Grade 2B) 1
• LMWH is preferred over unfractionated heparin (Grade 2B) 1
• Intermittent pneumatic compression devices should be applied within the first 24 hours after admission 1
• Elastic compression stockings are not recommended (Grade 2B) 1

Early Mobilization

• Initial assessment by rehabilitation professionals should be conducted as soon as possible after admission 1
• Rehabilitation therapy should begin as early as possible once the patient is medically stable 1
• Frequent, brief, out-of-bed activity involving active sitting, standing, and walking, beginning within 24 hours of stroke onset is recommended if there are no contraindications 1

Secondary Prevention

For Non-Cardioembolic Stroke/TIA

• Long-term antiplatelet therapy is recommended with one of the following (Grade 1A) 1:
  • Aspirin (75-100 mg once daily)
  • Clopidogrel (75 mg once daily)
  • Aspirin/extended-release dipyridamole (25 mg/200 mg twice daily)
  • Cilostazol (100 mg twice daily)
• Clopidogrel or aspirin/extended-release dipyridamole is preferred over aspirin alone (Grade 2B) or cilostazol (Grade 2C) 1
• Oral anticoagulants are not recommended for non-cardioembolic stroke (Grade 1B) 1
• Combination of clopidogrel plus aspirin is not recommended for long-term therapy (Grade 1B) 1

For Cardioembolic Stroke/TIA with Atrial Fibrillation

• Oral anticoagulation is recommended over no antithrombotic therapy (Grade 1A), aspirin alone (Grade 1B), or combination therapy with aspirin and clopidogrel (Grade 1B) 1
• Dabigatran 150 mg twice daily may be preferred over adjusted-dose vitamin K antagonist therapy (Grade 2B) 1
• For patients unsuitable for oral anticoagulation, combination therapy with aspirin and clopidogrel is recommended over aspirin alone (Grade 1B) 1

Common Pitfalls and Caveats

• Time is critical in acute stroke management - delays in administering r-tPA significantly reduce its effectiveness 6, 7
• Patient selection is crucial to minimize hemorrhagic complications - careful assessment for contraindications to thrombolysis is essential 2
• Symptomatic intracerebral hemorrhage is a significant risk with r-tPA (occurring in 6.4% of treated patients vs 0.6% with placebo in the NINDS trial) 6
• For patients receiving antiplatelet therapy, the benefit of clopidogrel over aspirin in preventing major vascular events with long-term use (>5 years) may be offset by a reduction in cancer-related mortality with aspirin-containing regimens 1
• When initiating oral anticoagulation in patients with atrial fibrillation, patients should be bridged with aspirin until anticoagulation has reached a therapeutic level 1