What medicine should I give to a patient suspected of having an ischemic stroke?

Management of Suspected Ischemic Stroke

For patients with suspected ischemic stroke, intravenous recombinant tissue plasminogen activator (r-tPA) should be administered if treatment can be initiated within 3 hours of symptom onset, followed by early aspirin therapy. 1

Initial Acute Management

Thrombolytic Therapy

• IV r-tPA is strongly recommended if treatment can be initiated within 3 hours of symptom onset (Grade 1A) 1, 2
• IV r-tPA may be considered if treatment can be initiated within 4.5 hours but not within 3 hours of symptom onset (Grade 2C) 1, 2
• For patients who don't meet eligibility criteria for IV r-tPA but have proximal cerebral artery occlusions, intraarterial r-tPA may be considered if initiated within 6 hours of symptom onset 1
• The standard dose for IV alteplase is 0.9 mg/kg (maximum 90 mg) over 60 minutes, with 10% given as a bolus over 1 minute 1

Antiplatelet Therapy

• Early aspirin therapy at a dose of 160-325 mg should be administered within 24-48 hours after stroke onset (delayed until >24 hours after IV thrombolysis) 1, 2
• For patients with acute ischemic stroke who were not previously on an antiplatelet agent, a single loading dose of 160 mg aspirin should be given after intracranial hemorrhage is ruled out 1
• For patients with swallowing difficulties, rectal aspirin 325 mg daily or aspirin 81 mg/clopidogrel 75 mg daily via enteral tube are reasonable alternatives 1

Secondary Prevention Based on Stroke Subtype

Non-cardioembolic Stroke

• For long-term secondary prevention in non-cardioembolic ischemic stroke, antiplatelet therapy is indicated 1
• Options include:
  • Aspirin 81-325 mg daily
  • Clopidogrel 75 mg daily
  • Aspirin 25 mg plus extended-release dipyridamole 200 mg twice daily 1
• Of these options, clopidogrel or aspirin/extended-release dipyridamole are preferred over aspirin alone 1, 2

Minor Ischemic Stroke or High-Risk TIA

• For minor ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4), dual antiplatelet therapy (DAPT) with aspirin and clopidogrel should be initiated early (ideally within 12-24 hours of symptom onset) 1
• Initial loading doses: aspirin 160-325 mg and clopidogrel 300-600 mg 1
• Continue DAPT for 21 days, then switch to single antiplatelet therapy 1
• Continuous use of DAPT beyond 90 days increases bleeding risk and is not recommended 1

Cardioembolic Stroke

• For patients with ischemic stroke due to atrial fibrillation, oral anticoagulation is recommended over antiplatelet therapy 1, 2
• Direct oral anticoagulants are preferred over warfarin for patients with non-valvular atrial fibrillation 3

Special Considerations

Monitoring and Management

• Admit patients to a specialized stroke unit or intensive care unit if critically ill 4
• 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 after treatment 1
• Maintain blood pressure below 180/105 mmHg for at least 24 hours after acute reperfusion treatment 4
• Obtain follow-up CT or MRI at 24 hours after IV alteplase before starting anticoagulants or antiplatelet agents 1

Management of Complications

• If symptomatic intracranial bleeding occurs within 24 hours of alteplase administration:
  • Stop alteplase infusion immediately
  • Obtain emergent non-enhanced head CT
  • Consider cryoprecipitate, tranexamic acid, or ε-aminocaproic acid 1

Common Pitfalls to Avoid

• Delaying thrombolytic therapy while waiting for laboratory results (only blood glucose assessment must precede IV alteplase initiation) 4
• Using dual antiplatelet therapy beyond 90 days in non-cardioembolic stroke (increases bleeding risk) 1
• Waiting to evaluate response to IV thrombolysis before proceeding with catheter angiography for mechanical thrombectomy in eligible patients 4
• Failing to lower blood pressure below 185/110 mmHg before initiating IV thrombolysis 4