What is the management plan for a patient with ischemic stroke?

Management Plan for Ischemic Stroke Patients

The management of ischemic stroke requires immediate intervention with intravenous rtPA (0.9 mg/kg, maximum 90 mg) for eligible patients within 3 hours of symptom onset, followed by comprehensive stroke unit care including early rehabilitation and secondary prevention measures. 1, 2

Initial Assessment and Acute Management

• All suspected stroke patients should undergo urgent brain CT or MRI within 24 hours of symptom onset, ideally as soon as possible, to rule out intracranial hemorrhage and identify vessel occlusion 2
• For patients eligible for thrombolysis, intravenous rtPA (0.9 mg/kg, maximum 90 mg) is strongly recommended if treatment can be initiated within 3 hours of clearly defined symptom onset 1, 3
• Blood pressure must be <185/110 mmHg before administering rtPA 1, 2
• For patients with large vessel occlusions, endovascular thrombectomy should be considered, particularly within 6 hours of symptom onset 1, 2
• Patients eligible for intravenous rtPA should receive it even if intra-arterial treatments are being considered 1
• For patients with acute ischemic stroke who are not receiving thrombolysis, early aspirin therapy (initial dose 325 mg) within 24-48 hours after stroke onset is recommended 1, 3

Management of Physiological Parameters

• Adopt a cautious approach to hypertension, avoiding treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg 2
• Monitor blood glucose regularly and treat hyperglycemia to maintain levels <300 mg/dL 2
• Treat sources of fever and use antipyretics for elevated temperatures >37.5°C 2
• Increase monitoring frequency and investigate possible infections in febrile patients 2

Management of Complications

• Corticosteroids are not recommended for cerebral edema and increased intracranial pressure following ischemic stroke 1
• Osmotherapy and hyperventilation are recommended for patients whose condition is deteriorating due to increased intracranial pressure, including those with herniation syndromes 1
• Surgical interventions, including drainage of cerebrospinal fluid, can be used to treat increased intracranial pressure secondary to hydrocephalus 1
• Surgical decompression and evacuation of large cerebellar infarctions causing brain stem compression and hydrocephalus is recommended 1
• Recurrent seizures should be treated as with any other acute neurological condition 1
• Prophylactic administration of anticonvulsants to patients who have had stroke but not seizures is not recommended 1

Early Rehabilitation and Supportive Care

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

Secondary Prevention

• For non-cardioembolic stroke, antiplatelet therapy should be initiated 1, 3, 4
• For minor non-cardioembolic strokes and high-risk TIAs, dual antiplatelet therapy with aspirin and clopidogrel for 21-90 days followed by single antiplatelet therapy is recommended 5, 6
• For patients with atrial fibrillation and recent stroke or TIA, long-term oral anticoagulation is recommended (target INR 2.5, range 2.0-3.0) 3, 4
• Address modifiable risk factors including hypertension, diabetes, hyperlipidemia, and smoking 2, 6
• Consider carotid imaging for patients with carotid territory symptoms who might be candidates for revascularization 2

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% 2, 7
• Overly selective treatment criteria may exclude patients who could benefit from therapy 2
• Inadequate blood pressure control before thrombolysis increases hemorrhagic risk 1, 2
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) can worsen outcomes 2
• The administration of aspirin (or other antiplatelet agents) as an adjunctive therapy within 24 hours of intravenous fibrinolysis is not recommended 1