Latest Guidelines for Stroke Treatment
The current standard of care for acute ischemic stroke includes intravenous alteplase within 4.5 hours of symptom onset and endovascular thrombectomy for eligible patients with large vessel occlusions, while hemorrhagic stroke management focuses on blood pressure control and specialized neurocritical care. 1, 2
Acute Ischemic Stroke Management
Initial Assessment and Imaging
- Urgent neuroimaging with non-contrast CT is essential to differentiate between ischemic and hemorrhagic stroke 2
- CT angiography should be performed to identify large vessel occlusions that may benefit from endovascular therapy 2
- All patients with suspected stroke should undergo ECG to assess baseline cardiac rhythm, though this should not delay assessment for thrombolysis 1
Intravenous Thrombolysis
- Eligible patients should receive intravenous alteplase (rtPA) as soon as possible after hospital arrival 1
- Target door-to-needle time should be less than 60 minutes in 90% of treated patients, with a median time of 30 minutes 1
- Standard dosing for alteplase is 0.9 mg/kg to a maximum of 90 mg total dose:
- 10% (0.09 mg/kg) given as an intravenous bolus over one minute
- Remaining 90% (0.81 mg/kg) given as an intravenous infusion over 60 minutes 1
- Treatment window:
- Strong recommendation for treatment within 3 hours of symptom onset
- Selected patients may be treated between 3-4.5 hours after symptom onset 2
- Blood pressure must be controlled below 185/110 mmHg before rtPA administration and maintained below 180/105 mmHg for at least 24 hours after treatment 1
Endovascular Thrombectomy (EVT)
- EVT is indicated for patients with large vessel occlusions, including those who have received intravenous alteplase and those who are not eligible for intravenous alteplase 1
- EVT should be offered within a coordinated system of care including rapid access to neurovascular imaging and specialized neurointerventional expertise 1
- Treatment should be initiated as quickly as possible, with systems in place for rapid transfer to comprehensive stroke centers when necessary 1
Management of Complications from Alteplase
- For patients with angioedema, a staged response using antihistamines, glucocorticoids, and standard airway management should be used 1
- There is insufficient evidence to support routine use of cryoprecipitate, fresh frozen plasma, prothrombin complex concentrates, tranexamic acid, factor VIIa, or platelet transfusions for alteplase-associated bleeding 1
Hemorrhagic Stroke Management
Subarachnoid Hemorrhage
- Nimodipine is indicated for improving neurological outcomes by reducing the incidence and severity of ischemic deficits in patients with subarachnoid hemorrhage from ruptured intracranial berry aneurysms 3
- Standard dosing of nimodipine is required every 4 hours due to its short half-life 3
General Management
- Surgical decompression and evacuation may be necessary for large cerebellar infarctions causing brain stem compression and hydrocephalus 2
- Osmotherapy and hyperventilation are recommended for patients deteriorating due to increased intracranial pressure 2
- Corticosteroids are not recommended for managing cerebral edema and increased intracranial pressure following ischemic stroke 2
Supportive Care in Acute Stroke
Blood Pressure Management
- For patients not receiving thrombolysis with markedly elevated blood pressure, a reasonable goal is to lower blood pressure by 15% during the first 24 hours 1
- Medications should be withheld unless systolic blood pressure is >220 mmHg or diastolic blood pressure is >120 mmHg 1
- Restarting antihypertensive medications is reasonable after the first 24 hours for patients with preexisting hypertension who are neurologically stable 1
Other Supportive Measures
- Airway support and ventilatory assistance are recommended for patients with decreased consciousness or bulbar dysfunction 1
- Supplemental oxygen should be provided to maintain oxygen saturation >94% 1
- Sources of hyperthermia (temperature >38°C) should be identified and treated 1
- Hypovolemia should be corrected with intravenous normal saline 1
- Hypoglycemia (blood glucose <60 mg/dL) should be treated, with a goal to achieve normoglycemia 1
- Hyperglycemia should be treated to achieve blood glucose levels in a range of 140 to 180 mg/dL 1
Post-Stroke Care and Secondary Prevention
- Comprehensive stroke unit care with specialized rehabilitation should be initiated as early as medically possible 2
- Oral aspirin (325 mg initial dose) is recommended within 24-48 hours after stroke onset for patients not receiving thrombolysis 2
- Aspirin should not be administered within 24 hours of rtPA treatment 2
- Management of modifiable risk factors including blood pressure and cholesterol is essential for secondary prevention 2