What are the guidelines for managing ischemic (lack of blood flow) stroke?

Guidelines for Managing Ischemic Stroke

The management of ischemic stroke requires immediate recognition, rapid assessment, and prompt treatment in specialized stroke units with a multidisciplinary approach to reduce mortality and improve functional outcomes. 1

Immediate Recognition and Response

• Rapid recognition of stroke symptoms is the first critical step in the stroke chain of survival, with immediate activation of emergency medical services (EMS) by calling 911 1
• EMS should use validated stroke screening tools for rapid and accurate assessment, with early notification to receiving hospitals 1
• High-priority transportation, rapid triage, and expedited access to imaging are essential components of pre-hospital care 1

Emergency Department Management

• All patients with suspected stroke should undergo urgent brain CT or MRI within 24 hours of symptom onset, ideally as soon as possible 1
• A standardized stroke severity evaluation should be performed to assess prognosis and rehabilitation potential 1
• Written hospital protocols defining processes and responsibilities should be established to streamline care 1

Acute Treatment for Ischemic Stroke

• Intravenous recombinant tissue plasminogen activator (rtPA) is strongly recommended for carefully selected patients who can receive the medication within 3 hours of stroke onset 1
• Aspirin (325 mg) should be administered within the first 48 hours due to its reasonable safety profile and modest benefit 1
• Anticoagulation with intravenous unfractionated heparin is not recommended as standard treatment due to increased bleeding risk 1
• Blood pressure management is crucial - antihypertensive agents should be avoided unless systolic blood pressure is >220 mm Hg or diastolic blood pressure is >120 mm Hg 2
• If thrombolytic therapy is being used, blood pressure must be reduced to systolic <180 mmHg and diastolic <105 mmHg 3

Stroke Unit Care

• All stroke patients should be admitted to a geographically defined stroke unit with specialized staff 1
• The multidisciplinary team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 1
• Comprehensive specialized stroke care units incorporating comprehensive rehabilitation are recommended 2

Prevention and Management of Complications

• Early screening and management of swallowing difficulties is essential to prevent aspiration pneumonia 1, 2
• Pneumonia is an important cause of death following stroke and requires prompt antibiotic therapy when identified 2
• Deep vein thrombosis prevention through subcutaneous anticoagulants or intermittent external compression stockings is strongly recommended for immobilized patients 2
• For patients with significant brain edema and increased intracranial pressure, osmotherapy and hyperventilation are recommended 1
• Hemicraniectomy within 48 hours has been shown to substantially reduce death and disability in selected patients (18-60 years old) with extensive hemispheric infarcts 1

Nutrition and Hydration

• Sustaining nutrition is important as malnutrition can interfere with recovery 2
• Swallowing assessment is crucial before allowing oral intake 2
• When necessary, nasogastric or nasoduodenal tubes can be inserted to provide feedings and medication administration 2
• Percutaneous endoscopic gastric tube placement is superior to nasogastric tube feeding if prolonged feeding support is anticipated 2

Early Rehabilitation

• Early mobilization is strongly recommended to prevent complications 1
• Assessment and management of mobility, activities of daily living, incontinence, and mood should be undertaken early after stroke 1
• Speech and language pathologists should evaluate and treat all stroke patients for residual communication difficulties 1

Secondary Prevention

• Continuation of statin therapy during the acute period is reasonable for patients already taking statins at the time of stroke onset 2
• Dual antiplatelet therapy with aspirin and clopidogrel is indicated for minor noncardioembolic ischemic strokes and high-risk TIAs, converting to single antiplatelet therapy after 21-90 days 4
• Secondary prevention of cardioembolic stroke requires long-term anticoagulation, with direct oral anticoagulants preferred over warfarin for patients with nonvalvular atrial fibrillation 4

Common Pitfalls and Caveats

• Delayed recognition and treatment beyond the 3-hour window significantly reduces the effectiveness of thrombolytic therapy 5
• Sublingual nifedipine and other antihypertensive agents causing precipitous reductions in blood pressure should be avoided 2
• Hypoglycemia can mimic stroke symptoms and requires prompt measurement and correction of serum glucose 2
• Indwelling bladder catheters should be avoided when possible due to infection risk 2
• Neuroprotective agents have not demonstrated efficacy in improving outcomes after ischemic stroke and are not recommended 2

Quality Improvement

• In-hospital stroke performance and quality data should be examined and used to drive focused quality improvement efforts 1
• Metrics such as response times, imaging acquisition times, treatment rates, and outcomes should be monitored 1
• Reporting all stroke cases to a registry helps monitor the true incidence of stroke and provides data for future research 1