What is the management of acute ischemic stroke?

Management of Acute Ischemic Stroke

The cornerstone of acute ischemic stroke management is rapid recognition, immediate emergency medical services activation, and prompt administration of intravenous recombinant tissue plasminogen activator (rtPA) for eligible patients within the therapeutic window, followed by admission to a specialized stroke unit for comprehensive care. 1, 2

Initial Recognition and Pre-hospital Management

• Emergency Medical Services (EMS) should be contacted immediately when stroke symptoms are recognized, using validated tools such as FAST (Face, Arms, Speech, Time) 1
• EMS dispatchers should be trained to recognize stroke symptoms and prioritize rapid response 3
• Pre-notification of the receiving hospital by EMS is essential to activate stroke protocols and prepare the stroke team, imaging, and other necessary resources 1
• Paramedics should minimize on-scene time with a "recognize and mobilize" approach 1, 3

Emergency Department Assessment and Imaging

• All suspected stroke patients should undergo urgent brain CT or MRI within 24 hours of symptom onset, but ideally as soon as possible 1, 2
• Imaging is crucial to rule out intracranial hemorrhage, identify vessel occlusion and its location, and assess the risk/benefit ratio of potential treatments 1
• Initial laboratory tests should include complete blood count, electrolytes, renal function, glucose, lipids, and coagulation studies 1, 2
• A standardized stroke severity evaluation should be performed to assess prognosis and rehabilitation potential 2

Acute Treatment of Ischemic Stroke

• Intravenous rtPA (0.9 mg/kg, maximum 90 mg) is strongly recommended for carefully selected patients within 3 hours of stroke onset 1, 2, 4
• Blood pressure must be <185/110 mmHg before administering rtPA 3
• For patients with large vessel occlusions, endovascular thrombectomy should be considered, particularly within 6 hours of symptom onset 1
• Oral administration of aspirin (initial dose 325 mg) within 24 to 48 hours after stroke onset is recommended for most patients not receiving thrombolysis 3, 2
• Aspirin is not recommended as a substitute for other acute interventions for treatment of stroke, including intravenous rtPA 3

Blood Pressure Management

• For patients eligible for acute reperfusion therapy with BP >185/110 mmHg, consider:
  • Labetalol 10–20 mg IV over 1–2 minutes, may repeat once; or
  • Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h 3
• After rtPA administration, maintain BP ≤180/105 mmHg with frequent monitoring 3
• For patients not receiving thrombolysis, a cautious approach to hypertension is recommended, with treatment generally avoided unless systolic BP >220 mmHg or diastolic BP >120 mmHg 1, 3

Management of Physiological Parameters

• Monitor blood glucose regularly and treat hyperglycemia to maintain levels <300 mg/dL 1
• Treat sources of fever and use antipyretics for elevated temperatures 1
• For temperatures >37.5°C, increase monitoring frequency and investigate possible infections 1
• Monitor oxygen saturation and provide supplemental oxygen if needed to maintain saturation >94% 1

Management of Complications

• For cerebral edema and increased intracranial pressure, osmotherapy and hyperventilation are recommended for deteriorating patients 1, 2
• Surgical decompression may be life-saving for large cerebellar infarctions causing brainstem compression 1, 2
• Hemicraniectomy within 48 hours has been shown to substantially reduce death and disability in selected patients (18-60 years old) with extensive hemispheric infarcts 2
• New-onset seizures should be treated with appropriate short-acting medications if not self-limiting 1
• Prophylactic anticonvulsants are not recommended 1

Stroke Unit Care

• All stroke patients should be admitted to a geographically defined stroke unit with specialized staff 2
• Stroke unit care should be provided by an interdisciplinary team with expertise in stroke management 2
• The multidisciplinary team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 2

Early Rehabilitation and Supportive Care

• Initial assessment by rehabilitation professionals should be conducted within 48 hours of admission 1
• Rehabilitation therapy should begin as early as possible once the patient is medically stable 1, 2
• Frequent, brief, out-of-bed activity involving active sitting, standing, and walking should begin within 24 hours if no contraindications exist 1
• Swallowing, nutritional, and hydration status should be screened as early as possible, ideally on the day of admission 1, 2
• Patients who cannot take food and fluids orally should receive appropriate feeding to maintain hydration and nutrition 1

Secondary Prevention

• Identify stroke etiology to guide secondary prevention strategies 1, 5
• Initiate appropriate antithrombotic therapy before discharge 1, 4
• For patients with noncardioembolic stroke, antiplatelet therapy options include:
  • Aspirin (50-100 mg/day)
  • Combination of aspirin and extended-release dipyridamole
  • Clopidogrel (75 mg daily) 4
• For patients with atrial fibrillation and stroke, long-term oral anticoagulation is recommended 4
• Address modifiable risk factors including hypertension, diabetes, hyperlipidemia, and smoking 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
• Overly selective treatment criteria may exclude patients who could benefit from therapy 1
• Inadequate blood pressure control before thrombolysis increases hemorrhagic risk 3, 1
• Administration of aspirin (or other antiplatelet agents) within 24 hours of intravenous fibrinolysis is not recommended due to bleeding risk 3
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) can worsen outcomes 1
• The administration of intravenous antiplatelet agents that inhibit the glycoprotein IIb/IIIa receptor is not recommended outside clinical trials 3