What are the current guidelines for managing acute ischemic and hemorrhagic strokes, including medication and blood pressure management?

Current Guidelines for Managing Acute Ischemic and Hemorrhagic Strokes

For acute stroke management, blood pressure control is critical with specific targets: maintain BP <185/110 mmHg before thrombolysis and <180/105 mmHg for 24 hours after treatment in ischemic stroke, while more aggressive BP lowering to 140-160 mmHg systolic is recommended for hemorrhagic stroke. 1, 2, 3

Initial Assessment and Management

• All patients with suspected stroke should undergo urgent neuroimaging (non-contrast CT) to differentiate between ischemic and hemorrhagic stroke 2
• CT angiography (CTA) should be performed to identify large vessel occlusions, though this must not delay thrombolysis 1, 2
• ECG should be performed to assess baseline cardiac rhythm, but should not delay assessment for thrombolysis 1, 2
• For patients with suspected cardioembolic stroke without initial evidence of atrial fibrillation, prolonged ECG monitoring up to 30 days is recommended 1

Acute Ischemic Stroke Management

Thrombolytic Therapy

• Intravenous alteplase (rtPA) is recommended for eligible patients within 3 hours of stroke onset, with consideration for selected patients up to 4.5 hours 2
• Standard dosing is 0.9 mg/kg (maximum 90 mg), with 10% as bolus and 90% as infusion over 60 minutes 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 1, 2, 3
• Door-to-needle time target is less than 60 minutes in 90% of treated patients 2

Endovascular Therapy

• Endovascular thrombectomy (EVT) is indicated for patients with large vessel occlusions, including those who have received IV alteplase and those not eligible for IV alteplase 2
• EVT should be offered within a coordinated system of care with rapid access to neurovascular imaging and specialized expertise 2

Blood Pressure Management

• For patients receiving thrombolysis: BP must be <185/110 mmHg before treatment and maintained <180/105 mmHg for 24 hours after 1, 2, 3
• For patients not eligible for thrombolysis: Treatment of hypertension should not be routinely undertaken 1
• For patients with extreme BP elevation (systolic >220 mmHg or diastolic >120 mmHg): Reduce BP by approximately 15%, and not more than 25%, over the first 24 hours 1, 2
• Starting or restarting antihypertensive therapy during hospitalization is reasonable for neurologically stable patients with BP >140/90 mmHg 1

First-Line BP Medications

• Labetalol: Initial dose 10-20 mg IV over 1-2 minutes, may be repeated or doubled every 10-20 minutes to maximum 300 mg 3
• Nicardipine: Initial dose 5 mg/hr IV infusion, titrate by increasing 2.5 mg/hr every 5-15 minutes to maximum 15 mg/hr 3

Acute Hemorrhagic Stroke Management

• More aggressive blood pressure lowering to 140-160 mmHg systolic is recommended 3
• Avoid rapid or excessive lowering of blood pressure as this may exacerbate existing ischemia 1
• Pharmacological agents should be chosen to avoid precipitous falls in blood pressure 1

Supportive Care

• Temperature should be routinely monitored and treated if above 37.5°C 1, 2
• Supplemental oxygen is not required for patients with normal oxygen saturation levels, but should be provided to maintain oxygen saturation >94% 1, 2
• Hypoglycemia (blood glucose <60 mg/dL) should be treated, with a goal to achieve normoglycemia 2
• Hyperglycemia should be treated to achieve blood glucose levels in a range of 140 to 180 mg/dL 2
• The use of indwelling urethral catheters should be avoided due to risk of urinary tract infections 1

Post-Stroke Care

• 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
• Comprehensive stroke unit care with specialized rehabilitation should be initiated as early as medically possible 2
• Management of modifiable risk factors including blood pressure and cholesterol is essential 2

Common Pitfalls to Avoid

• Delaying thrombolysis for additional imaging beyond non-contrast CT 1, 2
• Lowering blood pressure too rapidly or excessively in acute ischemic stroke, which can worsen ischemia 1, 3
• Using indwelling urethral catheters unnecessarily, increasing risk of urinary tract infections 1
• Administering aspirin within 24 hours of rtPA treatment 2
• Missing the opportunity for endovascular treatment in eligible patients with large vessel occlusions 2