Immediate Treatment for Ischemic Stroke
Intravenous alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is the first-line treatment for patients with acute ischemic stroke who can be treated within 3 hours of symptom onset. 1
Initial Assessment and Management
- Acute ischemic stroke should be treated as a life-threatening emergency requiring immediate evaluation and treatment 1
- Urgent evaluation should determine if ischemic stroke is the likely cause of symptoms and whether the patient is eligible for IV alteplase 1
- Initial management should include measures to protect airway, breathing, and circulation, especially in seriously ill or comatose patients 1
- All patients with suspected acute stroke must undergo immediate noncontrast brain CT imaging and vascular imaging with CTA to guide hyperacute care 1
Thrombolytic Therapy with Alteplase
Treatment Window and Dosing
For patients presenting within 3 hours of symptom onset:
For patients presenting between 3-4.5 hours after symptom onset:
Post-Thrombolysis Care
- Monitor BP and perform neurological assessments every 15 minutes during and after IV alteplase infusion for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours 1
- Increase frequency of BP measurements if SBP >180 mm Hg or DBP >105 mm Hg; administer antihypertensive medications to maintain BP below these levels 1
- Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if the patient can be safely managed without them 1
- Obtain follow-up CT or MRI at 24 hours after IV alteplase before starting anticoagulants or antiplatelet agents 1
Management of Complications
Symptomatic Intracranial Hemorrhage
If symptomatic intracranial bleeding occurs within 24 hours after alteplase administration:
- Stop alteplase infusion immediately 1
- Obtain CBC, PT (INR), aPTT, fibrinogen level, and type and cross-match 1
- Perform emergent nonenhanced head CT 1
- Consider cryoprecipitate (10 units infused over 10-30 minutes) for fibrinogen level <200 mg/dL 1
- Consider tranexamic acid 1000 mg IV or ε-aminocaproic acid 4-5 g over 1 hour 1
- Obtain hematology and neurosurgery consultations 1
Additional Treatments
Antiplatelet Therapy
- Aspirin (160-300 mg) should be administered within 24-48 hours after stroke onset 1
- For patients treated with IV alteplase, aspirin administration should generally be delayed until 24 hours later 1
- In patients presenting with minor stroke, treatment for 21 days with dual antiplatelet therapy (aspirin and clopidogrel) begun within 24 hours can be beneficial for early secondary stroke prevention for up to 90 days 1
Mechanical Thrombectomy
- For patients with large vessel occlusions who meet criteria, mechanical thrombectomy with stent retrievers is recommended over intra-arterial thrombolysis as first-line therapy 1
- This treatment can be considered up to 16-24 hours after symptom onset in selected patients 4
Special Considerations
- Patients with a small number (1-10) of cerebral microbleeds can reasonably receive IV alteplase 1
- Patients with high burden of cerebral microbleeds (>10) may have increased risk of symptomatic intracerebral hemorrhage 1
- For patients with concurrent acute ischemic stroke and acute myocardial infarction, treatment with IV alteplase at the dose appropriate for cerebral ischemia, followed by percutaneous coronary angioplasty if indicated, is reasonable 1
Pitfalls and Caveats
- Aspirin should not be used as a substitute for acute stroke treatment in patients eligible for IV alteplase or mechanical thrombectomy 1
- Prophylactic use of anticonvulsant medications in patients with acute stroke but no seizures is not recommended 1
- Streptokinase or other thrombolytic agents cannot be safely substituted for alteplase 1
- Time is critical - every effort should be made to minimize door-to-needle time, as outcomes are highly time-dependent 1