What are the guidelines for managing acute ischemic and hemorrhagic stroke?

Guidelines for Managing Acute Ischemic and Hemorrhagic Stroke

The management of acute stroke requires immediate evaluation and treatment, with specific protocols for both ischemic and hemorrhagic stroke to reduce mortality and improve functional outcomes. 1

Acute Ischemic Stroke Management

Initial Assessment and Imaging

• Patients with suspected stroke should be evaluated immediately, with stroke approached as a life-threatening emergency 1
• Urgent neuroimaging is essential to differentiate between ischemic and hemorrhagic stroke 1
• Non-contrast CT (NCCT) is the primary imaging modality to rule out hemorrhage, with CT angiography (CTA) recommended to identify large vessel occlusions (LVOs) 1
• Multiphase CTA provides additional information about collateral circulation and can help guide treatment decisions 1

Thrombolytic Therapy

• Intravenous recombinant tissue plasminogen activator (rtPA/alteplase) is strongly recommended for eligible patients within 3 hours of stroke onset 1
• Treatment with rtPA beyond 3 hours but within 4.5 hours may be considered in selected patients, though with potentially increased risk of symptomatic intracranial hemorrhage 2, 3
• Streptokinase is not recommended for acute ischemic stroke treatment 4
• Tenecteplase may be considered as an alternative to alteplase with comparable safety and efficacy 5

Blood Pressure Management

• Very high blood pressure (>185/110 mmHg) should be treated in patients eligible for thrombolytic therapy 1
• Blood pressure should be lowered and maintained below 185/110 mmHg before rtPA administration and below 180/105 mmHg for 24 hours after treatment 1
• For patients not eligible for thrombolytic therapy, hypertension should not be routinely treated unless extremely elevated (SBP >220 mmHg or DBP >120 mmHg) 1
• When treatment is necessary, blood pressure should be reduced by approximately 15%, and not more than 25%, over the first 24 hours 1

Antiplatelet Therapy

• Oral aspirin (325 mg initial dose) is recommended within 24-48 hours after stroke onset for patients not receiving thrombolysis 1
• Aspirin should not be administered within 24 hours of rtPA treatment 1
• Aspirin is not a substitute for thrombolytic therapy 1
• The use of clopidogrel for acute ischemic stroke treatment is not well established 1
• Intravenous glycoprotein IIb/IIIa inhibitors (tirofiban, eptifibatide) are not recommended outside clinical trials 1

Anticoagulation

• Urgent anticoagulation is not recommended for preventing early recurrent stroke, halting neurological worsening, or improving outcomes 1
• Anticoagulation within 24 hours of rtPA treatment is not recommended 1
• Urgent anticoagulation for non-cerebrovascular conditions is not recommended for patients with moderate-to-severe strokes due to increased risk of intracranial hemorrhage 1

Endovascular Treatment

• Endovascular thrombectomy (EVT) is recommended for eligible patients with large vessel occlusions 1
• CTA should be performed to identify patients who may benefit from EVT 1
• Alberta Stroke Program Early CT Score (ASPECTS) can be used to rapidly identify patients eligible for EVT 1

Hemorrhagic Stroke Management

Initial Management

• Surgical decompression and evacuation of large cerebellar infarctions causing brain stem compression and hydrocephalus is recommended 1
• Surgical interventions, including cerebrospinal fluid drainage, can be used to treat increased intracranial pressure secondary to hydrocephalus 1
• Osmotherapy and hyperventilation are recommended for patients deteriorating due to increased intracranial pressure 1

Prevention of Complications

• Prophylactic measures against deep vein thrombosis should be implemented in patients with restricted mobility 4
• Intermittent pneumatic compression is recommended for patients with acute intracerebral hematoma 4
• Corticosteroids are not recommended for managing cerebral edema and increased intracranial pressure following ischemic stroke 1

Post-Stroke Care and Secondary Prevention

Rehabilitation

• Comprehensive stroke unit care with specialized rehabilitation should be initiated as early as medically possible 6
• Early mobilization is strongly recommended to prevent complications 6
• Standardized assessment of somatosensory function should guide rehabilitation efforts 6

Secondary Prevention

• Appropriate antithrombotic therapy should be prescribed based on stroke etiology 6
• For patients with non-cardioembolic stroke, antiplatelet therapy is recommended 4
• For patients with atrial fibrillation and recent stroke or TIA, long-term oral anticoagulation is recommended 4
• Management of modifiable risk factors including blood pressure and cholesterol is essential 6

Special Considerations

Central Post-Stroke Pain

• Pharmacotherapy combined with therapeutic exercise and psychosocial support is recommended for managing central post-stroke pain 6
• Medication options include amitriptyline, lamotrigine, gabapentin, carbamazepine, and phenytoin 6
• Response to treatment should be assessed with standardized serial measurements 6

Hemorrhagic Transformation After tPA

• Risk factors for hemorrhagic transformation include delayed treatment initiation, ischemia/reperfusion injury, tPA toxicity, and inflammation 7
• Matrix metalloproteinases and free radicals are potential therapeutic targets to reduce hemorrhagic transformation risk 7

By following these evidence-based guidelines, healthcare providers can optimize outcomes for patients with acute ischemic and hemorrhagic stroke, reducing mortality and improving functional recovery.