What are the guidelines for early management of ischemic stroke?

Early Management of Ischemic Stroke

Emergency imaging of the brain is recommended before initiating any specific therapy to treat acute ischemic stroke, with non-contrast CT (NCCT) being sufficient in most instances to make decisions about emergency management. 1

Initial Assessment and Management

• Emergency brain imaging should be interpreted within 45 minutes of patient arrival by a physician with expertise in reading CT and MRI studies 1
• All patients with suspected stroke should undergo ECG to assess baseline cardiac rhythm, though this should not delay assessment for thrombolysis 2
• 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 with markedly elevated blood pressure, medications should be withheld unless systolic blood pressure is >220 mmHg or diastolic blood pressure is >120 mmHg 2

Reperfusion Therapies

Intravenous Thrombolysis

• Intravenous rtPA (0.9 mg/kg, maximum 90 mg) is strongly recommended for eligible patients who can receive the medication within 3 hours of stroke onset 1
• Standard dosing for alteplase is 0.9 mg/kg to a maximum of 90 mg total dose, with 10% given as an intravenous bolus over one minute and the remaining 90% given as an intravenous infusion over 60 minutes 2
• Eligible patients should receive intravenous alteplase as soon as possible after hospital arrival, with a target door-to-needle time of less than 60 minutes 2, 3
• Intravenous fibrinolytic therapy is recommended even in the setting of early ischemic changes on CT (other than frank hypodensity), regardless of their extent 1
• If frank hypodensity involves more than one third of the MCA territory, intravenous rtPA treatment should be withheld 1

Endovascular Thrombectomy (EVT)

• EVT is indicated for patients with large vessel occlusions, including those who have received intravenous alteplase and those who are not eligible for intravenous alteplase 2
• A noninvasive intracranial vascular study is strongly recommended during initial imaging evaluation if either intra-arterial fibrinolysis or mechanical thrombectomy is contemplated, but should not delay intravenous rtPA if indicated 1
• Intra-arterial thrombolysis is an option for selected patients who have major stroke of <6 hours' duration due to occlusions of the MCA and who are not otherwise candidates for intravenous rtPA 1
• Treatment requires the patient to be at an experienced stroke center with immediate access to cerebral angiography and qualified interventionalists 1

Antithrombotic Therapy

• Oral aspirin (325 mg initial dose) is recommended within 24-48 hours after stroke onset for patients not receiving thrombolysis 2
• Aspirin should not be administered within 24 hours of rtPA treatment 2
• Urgent routine anticoagulation with the goal of improving neurological outcomes or preventing early recurrent stroke is not recommended for the treatment of patients with acute ischemic stroke 1
• Urgent anticoagulation is not recommended for treatment of patients with moderate-to-severe stroke because of a high risk of serious intracranial bleeding complications 1
• Initiation of anticoagulant therapy within 24 hours of treatment with intravenously administered rtPA is not recommended 1

Management of Complications

• Corticosteroids are not recommended for the management of cerebral edema and increased intracranial pressure following ischemic stroke 1, 4
• Osmotherapy and hyperventilation are recommended for patients whose condition is deteriorating secondary to increased intracranial pressure 1
• Surgical decompression and evacuation of large cerebellar infarctions that are leading to brain stem compression and hydrocephalus is recommended 1, 2
• Surgical interventions, including drainage of cerebrospinal fluid, can be used to treat increased intracranial pressure secondary to hydrocephalus 1
• Recurrent seizures should be treated as with any other acute neurological condition, but prophylactic administration of anticonvulsants to patients who have had stroke but not seizures is not recommended 1

Supportive Care

• Airway support and ventilatory assistance are recommended for patients with decreased consciousness or bulbar dysfunction, and supplemental oxygen should be provided to maintain oxygen saturation >94% 2
• Sources of hyperthermia (temperature >38°C) should be identified and treated 2, 4
• Hypovolemia should be corrected with intravenous normal saline 2
• Hypoglycemia (blood glucose <60 mg/dL) should be treated, with a goal to achieve normoglycemia, and hyperglycemia should be treated to achieve blood glucose levels in a range of 140 to 180 mg/dL 2
• Early mobilization is strongly recommended to prevent complications 2

Common Pitfalls and Caveats

• Delaying treatment with rtPA beyond the recommended time window significantly reduces its effectiveness; earlier treatment (within 90 minutes) may be more likely to result in a favorable outcome 1
• The availability of intra-arterial thrombolysis should generally not preclude the intravenous administration of rtPA in otherwise eligible patients 1
• CT perfusion and MRI perfusion/diffusion imaging may be considered for selecting patients for acute reperfusion therapy beyond the time windows for intravenous fibrinolysis, but should not delay standard treatment for eligible patients 1
• Streptokinase should not be used for stroke treatment due to unacceptably high rates of hemorrhage 1
• Gadolinium-based MR contrast media generally should be avoided in patients with advanced renal failure with estimated glomerular filtration rate <30 mL/min/1.73 m² 1