What is the management of hyperacute stroke infarction?

Hyperacute Stroke Infarction Management

The management of hyperacute stroke infarction requires immediate assessment, stabilization, and rapid implementation of reperfusion therapies within a narrow time window to minimize brain tissue damage and improve patient outcomes.

Initial Assessment and Stabilization

• Immediate contact with Emergency Medical Services (EMS) is strongly recommended for suspected stroke patients 1
• EMS personnel should use standardized acute stroke screening tools during on-scene assessment 1
• Upon hospital arrival, rapid assessment of airway, breathing, and circulation (ABCs) should be performed immediately 1
• Cardiac monitoring should be initiated during the initial evaluation to detect atrial fibrillation and potentially life-threatening arrhythmias 1
• All patients with suspected stroke should undergo urgent brain imaging (CT or MRI) within 24 hours, but ideally as soon as possible 1

Neuroimaging and Diagnosis

• Brain CT or MRI is essential to differentiate between ischemic and hemorrhagic stroke 1
• Vascular imaging (CT angiography, MR angiography) should be performed to identify large vessel occlusions that may be amenable to endovascular therapy 1
• For patients with carotid territory symptoms who might be candidates for carotid revascularization, urgent carotid duplex ultrasound should be performed 1

Reperfusion Therapies

Intravenous Thrombolysis

• Intravenous tissue plasminogen activator (tPA/alteplase) is highly effective for selected patients when administered within 3 hours of symptom onset 1, 2
• The treatment window may be extended to 4.5 hours for eligible candidates 3
• Blood pressure must be <185/110 mmHg before administering tPA 1
• Patients receiving tPA require close monitoring for 24 hours with strict blood pressure management 1

Endovascular Therapy

• Endovascular treatment (mechanical thrombectomy) should be considered for patients with large vessel occlusion 1
• A combined approach using stent-retrievers and aspiration is most effective for achieving complete reperfusion 1
• Time to reperfusion is critical - every 30-minute delay decreases the chance of good functional outcome by 8-14% 1

Blood Pressure Management

• For patients not receiving thrombolytic therapy:

  • Antihypertensive agents should generally be withheld unless systolic BP >220 mmHg or diastolic BP >120 mmHg 1
  • When treatment is indicated, blood pressure should be lowered cautiously by 15-25% within the first day 1
  • Preferred agents include labetalol or nicardipine which can be easily titrated 1

• For patients receiving thrombolytic therapy:

  • Blood pressure must be maintained below 185/110 mmHg before treatment and below 180/105 mmHg for the first 24 hours after treatment 1

• For hypotensive patients:

  • Identify and treat the cause (aortic dissection, volume depletion, cardiac arrhythmias) 1
  • Volume replacement with normal saline and correction of arrhythmias are priorities 1
  • Vasopressors may be used if these measures are ineffective 1

Management of Other Physiological Parameters

• Glucose Management:

  • Promptly measure serum glucose and correct hypoglycemia immediately 1
  • Hyperglycemia is associated with poor outcomes and should be managed, though optimal targets remain uncertain 1

• Temperature Management:

  • Treat sources of fever and use antipyretics to control elevated temperatures 1

• Oxygen Therapy:

  • Provide supplemental oxygen to hypoxic patients 1
  • Non-hypoxic patients do not require supplemental oxygen 1

Post-Acute Care

• Patients should be monitored in a stroke unit or intensive care unit with specialized neuroscience expertise 4
• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours 4
• Implement intermittent pneumatic compression for prevention of venous thromboembolism 4
• Conduct formal screening for dysphagia before initiating oral intake 4
• Aspirin (160-300 mg/day) should be started within 48 hours of onset for ischemic stroke patients not receiving thrombolysis 1

Common Pitfalls and Considerations

• Delaying imaging or treatment decisions while waiting for diagnostic test results 4
• Aggressively lowering blood pressure in acute ischemic stroke, which may reduce cerebral perfusion and expand infarction 1
• Using sublingual nifedipine or other agents that cause precipitous blood pressure reduction 1
• Failing to recognize early neurological deterioration, which is common in the first few hours 4
• Overlooking the importance of time - "time is brain" - delays in treatment significantly impact outcomes 1, 5