How will management change for a patient diagnosed with ischemic stroke?

Management of Ischemic Stroke

The management of patients with ischemic stroke requires a comprehensive approach including acute interventions, prevention of complications, rehabilitation, and secondary prevention measures to reduce mortality and improve quality of life.

Acute Management

• For patients with acute ischemic stroke who are eligible, intravenous recombinant tissue plasminogen activator (rtPA) at 0.9 mg/kg (maximum 90 mg) should be administered within 3 hours of symptom onset 1
• 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 2
• For patients not receiving thrombolysis, blood pressure should generally not be lowered unless diastolic BP >120 mmHg or systolic BP >220 mmHg 3
• Endovascular thrombectomy should be considered for patients with large vessel occlusions, particularly within 6 hours of symptom onset 1, 2

Management of Physiological Parameters

• Monitor blood glucose regularly and treat hypoglycemia promptly, while maintaining blood glucose levels between 140-180 mg/dL 1
• Identify and treat sources of fever, using antipyretics for temperatures >37.5°C 1
• Maintain oxygen saturation >94% with supplemental oxygen as needed 2
• Correct hypovolemia with intravenous normal saline 2

Prevention and Management of Complications

Cerebral Edema and Increased Intracranial Pressure

• Corticosteroids are not recommended for management of cerebral edema following ischemic stroke 3
• Osmotherapy and hyperventilation are recommended for patients deteriorating due to increased intracranial pressure 3
• Surgical decompression and evacuation of large cerebellar infarctions causing brain stem compression and hydrocephalus is recommended 3

Seizures

• Treat recurrent seizures with appropriate antiepileptic medications 3
• Prophylactic administration of anticonvulsants to patients without seizures is not recommended 3

Deep Vein Thrombosis Prevention

• Early mobilization is strongly recommended to prevent complications 3
• Subcutaneous anticoagulants (unfractionated heparin or low-molecular-weight heparins) should be administered to immobilized patients 3
• For patients who cannot receive anticoagulants, intermittent external compression devices are recommended 3
• Aspirin may be used for DVT prevention but is less effective than anticoagulants 3

Nutrition and Hydration

• Swallowing assessment should be performed before the patient is allowed to eat or drink 3
• Patients who cannot take food and fluids orally should receive nasogastric, nasoduodenal, or PEG feedings to maintain hydration and nutrition 3
• The timing of PEG placement should be individualized based on the patient's recovery potential 3

Early Rehabilitation

• Comprehensive specialized stroke care units incorporating rehabilitation are recommended 3
• Rehabilitation therapy should begin as early as possible once the patient is medically stable 1
• Initial assessment by rehabilitation professionals should be conducted within 48 hours of admission 1
• Frequent, brief, out-of-bed activity should begin within 24 hours if no contraindications exist 1

Secondary Prevention

• All patients should receive appropriate antithrombotic therapy before discharge 3, 2
• For non-cardioembolic stroke, antiplatelet therapy is recommended 4, 5
  • Options include aspirin (50-325 mg daily), clopidogrel (75 mg daily), or the combination of aspirin and extended-release dipyridamole 4
  • For minor non-cardioembolic strokes, dual antiplatelet therapy with aspirin and clopidogrel for 21-90 days followed by single antiplatelet therapy is recommended 5, 6
• For cardioembolic stroke (e.g., atrial fibrillation), long-term oral anticoagulation is recommended 4, 5
• Aggressive management of modifiable risk factors including hypertension, diabetes, hyperlipidemia, and smoking cessation 1, 5

Common Pitfalls and Caveats

• Delays in recognition and treatment significantly worsen outcomes - every 30-minute delay in recanalization decreases the chance of good functional outcome by 8-14% 1
• Inadequate blood pressure control before thrombolysis increases hemorrhagic risk 1
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) can worsen outcomes 1
• Overlooking the need for early rehabilitation can delay recovery 1
• Long-term use of the combination of aspirin and clopidogrel should be avoided except in specific situations 4

By implementing this comprehensive approach to ischemic stroke management, clinicians can significantly improve patient outcomes, reduce mortality, and enhance quality of life for stroke survivors.