What is the treatment for stroke?

Stroke Treatment

Intravenous alteplase (r-tPA) should be administered as soon as possible after hospital arrival in eligible patients with acute ischemic stroke, with a target door-to-needle time of less than 60 minutes in 90% of treated patients and a median door-to-needle time of 30 minutes. 1

Acute Ischemic Stroke Treatment

Intravenous Thrombolysis

• Intravenous r-tPA is the cornerstone of acute ischemic stroke treatment and should be administered within 3 hours of symptom onset (Grade 1A evidence) 1
• Treatment window may be extended to 4.5 hours in carefully selected patients (Grade 2C evidence) 1, 2
• Alteplase should be administered at a dose of 0.9 mg/kg (maximum 90 mg), with 10% given as an intravenous bolus over one minute and the remaining 90% as an intravenous infusion over 60 minutes 1
• Earlier treatment is associated with better outcomes - each 60-minute delay in door-to-needle time reduces the odds of functional independence by 45% 3

Endovascular Treatment (EVT)

• Endovascular thrombectomy should be offered within a coordinated system of care for eligible patients 1
• Intraarterial r-tPA may be considered for patients with proximal cerebral artery occlusions who are ineligible for IV r-tPA if treatment can be initiated within 6 hours of symptom onset (Grade 2C) 1
• IV r-tPA is preferred over combination IV/IA r-tPA in eligible patients (Grade 2C) 1

Antiplatelet Therapy

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

DVT Prophylaxis

• For patients with restricted mobility, prophylactic-dose subcutaneous heparin (UFH or LMWH) or intermittent pneumatic compression devices are recommended (Grade 2B) 1
• LMWH is preferred over UFH for DVT prophylaxis (Grade 2B) 1
• Elastic compression stockings are not recommended (Grade 2B) 1

Secondary Prevention

Antiplatelet Therapy

• For patients with noncardioembolic ischemic stroke, 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 are preferred over aspirin alone (Grade 2B) 1

Anticoagulation for Atrial Fibrillation

• In patients with ischemic stroke and atrial fibrillation, oral anticoagulation is recommended over no antithrombotic therapy, aspirin, or combination therapy with aspirin and clopidogrel (Grade 1B) 1
• Oral anticoagulation should generally be initiated within 1-2 weeks after stroke onset 1

Common Pitfalls and Caveats

• Time is brain - Delays in treatment significantly impact outcomes. Every effort should be made to minimize door-to-needle times 1, 3
• Dosing errors - The dosing of alteplase for stroke (0.9 mg/kg) is different from the dosing protocol for myocardial infarction 1
• Hemorrhagic transformation - Symptomatic intracranial hemorrhage is a serious complication of thrombolysis, occurring in approximately 2.4-7.8% of treated patients 2, 4
• Treatment window confusion - While the 3-hour window has the strongest evidence (Grade 1A), the 3-4.5 hour window has moderate evidence (Grade 2C) but requires careful patient selection 1, 2
• Contraindications - Patients on direct oral anticoagulants (DOACs) should not routinely receive alteplase unless specialized tests of DOAC levels and reversal agents are available 1
• Comprehensive care - Treatment should not end with acute intervention but should include measures to prevent complications and comprehensive rehabilitation 1