What is the best management strategy for acute ischemic stroke patients not eligible for thrombolysis (clot dissolution)?

Management of Acute Ischemic Stroke Patients Not Eligible for Thrombolysis

For patients with acute ischemic stroke who are not eligible for thrombolytic therapy, management should focus on stroke unit care with careful monitoring of vital signs, blood pressure management, prevention of complications, and early initiation of secondary prevention measures.

Initial Assessment and Stabilization

• Perform rapid assessment of airway, breathing, and circulation as the first priority 1
• Conduct standardized neurological examination using a validated stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) to determine focal deficits and stroke severity 1
• Obtain immediate point-of-care glucose measurement to rule out hypoglycemia as a stroke mimic 2
• Monitor oxygen saturation and provide supplemental oxygen only if oxygen saturation is below 94% 1

Urgent Investigations

• Perform urgent non-contrast CT scan of the brain to exclude hemorrhage and assess for other structural causes 1, 2
• Consider CT angiography (CTA) to identify large vessel occlusions that may be eligible for endovascular thrombectomy even when intravenous thrombolysis is contraindicated 1
• Obtain baseline ECG to assess cardiac rhythm and identify atrial fibrillation or evidence of structural heart disease 1
• Conduct acute blood work including complete blood count, coagulation studies, and metabolic panel 1

Blood Pressure Management

• For patients not eligible for thrombolytic therapy, avoid routine treatment of hypertension in the acute setting 1
• Only treat extreme blood pressure elevations (systolic >220 mmHg or diastolic >120 mmHg) by reducing blood pressure by approximately 15%, and not more than 25%, over the first 24 hours 1
• Avoid rapid or excessive lowering of blood pressure as this may exacerbate existing ischemia, particularly in the setting of intracranial or extracranial arterial occlusion 1
• Correct hypotension and hypovolemia to maintain systemic perfusion levels necessary to support organ function 1

Stroke Unit Care

• All patients with acute ischemic stroke should be admitted to a stroke unit as soon as possible, ideally within 3 hours of hospital arrival 1
• Stroke unit care has been shown to reduce mortality and improve functional outcomes with benefits comparable to those achieved with IV thrombolysis 1
• In the absence of a specialized stroke unit, patients should still receive stroke nursing care consistent with best practice regardless of the hospital unit to which they are admitted 1

Prevention and Management of Complications

• Monitor temperature routinely and treat if above 37.5°C as hyperthermia is associated with increased morbidity and mortality 1
• Avoid the use of indwelling urethral catheters due to the risk of urinary tract infections; if used, assess daily and remove as soon as possible 1
• For patients with restricted mobility, provide prophylactic low-dose subcutaneous heparin or low-molecular-weight heparins to prevent deep vein thrombosis 1, 3
• Perform bedside dysphagia screening before oral intake to prevent aspiration pneumonia 1

Consideration for Endovascular Therapy

• Even when intravenous thrombolysis is contraindicated, patients with large vessel occlusion may still be candidates for endovascular thrombectomy (EVT) 1
• Eligible patients with large vessel occlusion who can be treated with EVT within 6 hours of symptom onset should receive EVT 1
• Highly selected patients with large vessel occlusion may be candidates for EVT up to 24 hours from symptom onset based on advanced imaging criteria 1

Secondary Prevention

• Initiate early aspirin therapy (160-325 mg daily) for patients with acute ischemic stroke who are not receiving thrombolysis 1, 4
• For long-term stroke prevention in patients with non-cardioembolic stroke, antiplatelet therapy should be initiated 4, 3
• In patients with atrial fibrillation and ischemic stroke, long-term oral anticoagulation should be considered 4, 3

Common Pitfalls and Caveats

• Avoid hypotonic fluids in patients with suspected metabolic encephalopathy as they may exacerbate cerebral edema 2
• Remember that many patients are ineligible for thrombolysis due to delayed presentation (>4.5 hours from symptom onset), which emphasizes the importance of public education about stroke symptoms and the need to seek immediate medical attention 5
• Be aware that stroke mimics (such as hypoglycemia, seizures, migraine, or metabolic disorders) may present with stroke-like symptoms and require different management approaches 2
• Recognize that patient preferences regarding stroke treatment may vary; studies show that most patients would prefer treatments that reduce disability even if they carry some risk of mortality 6