What is the treatment for stroke in a critical care setting?

Treatment for Stroke in a Critical Care Setting

The most effective treatment for acute ischemic stroke is rapid reperfusion through intravenous thrombolysis with alteplase (tPA) for eligible patients within 4.5 hours of symptom onset, and/or mechanical thrombectomy for those with large vessel occlusions, supported by comprehensive stroke unit care. 1, 2

Initial Assessment and Stabilization

• Patients with suspected stroke should undergo rapid assessment within 10 minutes of arrival to the emergency department 1
• Oxygen should be administered to hypoxemic stroke patients (oxygen saturation <94%) 1
• Establish IV access and obtain baseline blood studies (complete blood count, coagulation studies, blood glucose) 1
• Perform neurological screening assessment and order emergent CT scan of the brain 1
• Cardiac monitoring is recommended during the first 24 hours to detect atrial fibrillation and potentially life-threatening arrhythmias 1
• Only assessment of blood glucose must precede the initiation of IV alteplase in all patients 2

Acute Reperfusion Therapies

Intravenous Thrombolysis

• IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% as bolus) should be administered to eligible patients within 4.5 hours of symptom onset 2
• Treatment should be initiated as quickly as possible with a target door-to-needle time of less than 60 minutes 2, 3
• Blood pressure must be controlled below 185/110 mmHg before tPA administration and maintained below 180/105 mmHg for at least 24 hours after treatment 2, 3
• For patients with unclear time of onset >4.5 hours from last known well, IV alteplase may be beneficial if MRI shows DWI-FLAIR mismatch 2

Mechanical Thrombectomy

• Mechanical thrombectomy is recommended for eligible patients with large vessel occlusions (internal carotid artery or MCA-M1) 2, 3
• Treatment can be initiated within 6 hours of symptom onset for all eligible patients 2
• Extended window thrombectomy (6-24 hours) is recommended for selected patients with favorable imaging profiles showing salvageable tissue 2
• Patients should receive IV thrombolysis even if mechanical thrombectomy is being considered 2
• Non-invasive angiography (CTA) should be performed in patients with clinically suspected large vessel occlusion 2

Blood Pressure Management

• For patients receiving thrombolysis: maintain BP <180/105 mmHg for at least 24 hours after treatment 3
• For patients not receiving thrombolysis with markedly elevated blood pressure: lower BP by 15% during the first 24 hours 3
• Medications should be withheld unless systolic BP >220 mmHg or diastolic BP >120 mmHg in patients not receiving thrombolysis 3

Critical Care Management

• Admission to a specialized stroke unit or neurocritical care unit is essential for optimal outcomes 1
• Airway support and ventilatory assistance are recommended for patients with decreased consciousness or bulbar dysfunction 3
• Identify and treat sources of hyperthermia (temperature >38°C) 3
• Correct hypovolemia with intravenous normal saline 3
• Treat hypoglycemia (blood glucose <60 mg/dL) to achieve normoglycemia 3
• Manage hyperglycemia to achieve blood glucose levels between 140-180 mg/dL 3
• For patients with hemorrhagic stroke, manage increased intracranial pressure with osmotherapy and hyperventilation when indicated 3
• Consider surgical decompression for large cerebellar infarctions causing brain stem compression and hydrocephalus 3

Antiplatelet Therapy

• Oral aspirin (325 mg initial dose) is recommended within 24-48 hours after stroke onset for patients not receiving thrombolysis 3
• Aspirin should not be administered within 24 hours of tPA treatment 3

Systems of Care

• Hospitals should function as primary stroke centers or have pre-established transfer protocols to appropriate stroke centers 1
• Telemedicine can extend stroke expertise to underserved areas 1
• Standardized stroke orders or integrated stroke pathways improve adherence to best practices 1
• A stroke system should ensure that hospitals identified as "acute stroke capable" possess appropriate resources and deliver primary stroke care according to national recommendations 1

Common Pitfalls and Caveats

• Delays in evaluation and initiation of therapy should be avoided as earlier treatment leads to better outcomes 2
• Observation after IV alteplase to assess for clinical response before mechanical thrombectomy should not be performed as delays worsen outcomes 2
• Patients on direct oral anticoagulants (DOACs) should not routinely receive alteplase, though endovascular thrombectomy may be considered 2
• Approximately 25% of patients may have neurological worsening during the first 24-48 hours after stroke, requiring close monitoring 1
• Symptomatic intracerebral hemorrhage is a serious complication of thrombolysis, occurring in approximately 6.4% of treated patients 4