What are the latest guidelines for stroke management?

Latest Evidence in Stroke Management

The most current guidelines for stroke management emphasize rapid assessment, early intervention with appropriate reperfusion therapies, and comprehensive post-stroke care to reduce morbidity and mortality. 1

Acute Ischemic Stroke Management

Initial Assessment and Imaging

• Urgent neuroimaging with non-contrast CT is essential to differentiate between ischemic and hemorrhagic stroke, with CT angiography recommended to identify large vessel occlusions 1
• Cardiac monitoring should be performed for at least the first 24 hours to detect potentially serious cardiac arrhythmias 2
• Supplemental oxygen should be provided to maintain oxygen saturation >94% 2

Reperfusion Therapy

• Intravenous recombinant tissue plasminogen activator (rtPA/alteplase) remains the cornerstone treatment for eligible patients within 3 hours of stroke onset, with treatment extension to 4.5 hours in selected patients 1, 3
• Blood pressure must be carefully managed before rtPA administration (<185/110 mmHg) and maintained below 180/105 mmHg for at least 24 hours after treatment 2, 1
• Endovascular thrombectomy is recommended for eligible patients with large vessel occlusions, identified through CT angiography 1

Antiplatelet Therapy

• Oral aspirin (initial dose 325 mg) should be administered within 24-48 hours after stroke onset for patients not receiving thrombolysis 2, 1
• Aspirin should not be given within 24 hours of rtPA treatment 2, 1
• Clopidogrel alone or in combination with aspirin is not recommended for acute ischemic stroke treatment 2
• The efficacy of intravenous glycoprotein IIb/IIIa inhibitors (tirofiban, eptifibatide) is not well established and should only be used in clinical trials 2

Blood Pressure Management

• In patients not receiving fibrinolysis with markedly elevated blood pressure, a reasonable goal is to lower blood pressure by 15% during the first 24 hours, withholding medications unless systolic BP >220 mmHg or diastolic BP >120 mmHg 2
• Restarting antihypertensive medications after the first 24 hours is reasonable for patients with preexisting hypertension who are neurologically stable 2

Management of Complications

Cerebral Edema and Increased Intracranial Pressure

• Surgical decompression and evacuation of large cerebellar infarctions causing brain stem compression and hydrocephalus is recommended 1
• Osmotherapy and hyperventilation are recommended for patients deteriorating due to increased intracranial pressure 1
• Corticosteroids are not recommended for managing cerebral edema and increased intracranial pressure following ischemic stroke 1

Metabolic Management

• Hypoglycemia (blood glucose <60 mg/dL) should be treated promptly 2
• Hyperglycemia should be treated to achieve blood glucose levels between 140-180 mg/dL 2
• Hypovolemia should be corrected with intravenous normal saline 2

Post-Stroke Care

• Comprehensive stroke unit care with specialized rehabilitation should be initiated as early as medically possible 1
• Early mobilization is strongly recommended to prevent complications 1
• Management of modifiable risk factors including blood pressure and cholesterol is essential for secondary prevention 1

Special Considerations

Rural Settings

• Evidence suggests that tPA can be safely administered in rural hospitals with appropriate protocols in place, increasing access to treatment and improving outcomes 4

Patients on Novel Oral Anticoagulants (NOACs)

• For patients on NOACs who develop acute ischemic stroke, reversal of anticoagulant effects (e.g., idarucizumab for dabigatran) before tPA administration may be considered, though data is limited 5

Common Pitfalls to Avoid

• Delaying neuroimaging and reperfusion therapy assessment
• Administering aspirin within 24 hours of rtPA treatment 2
• Using corticosteroids for cerebral edema management 1
• Neglecting blood pressure management before and after rtPA administration 2
• Overlooking the importance of early rehabilitation and secondary prevention measures 1

Despite significant advances in stroke management, additional research remains urgently needed as many recommendations are based on limited data 2. The implementation of comprehensive stroke systems of care has contributed to stroke dropping from the third to the fourth leading cause of death in the United States 2.