What is the immediate medical management for acute ischemic stroke?

Immediate Medical Management for Acute Ischemic Stroke

Intravenous alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% as bolus over 1 minute) is the cornerstone of acute ischemic stroke management and should be administered as quickly as possible to eligible patients within 3-4.5 hours of symptom onset. 1, 2, 3

Initial Assessment and Stabilization

• Rapid clinical assessment using standardized tools such as the National Institutes of Health Stroke Scale (NIHSS) should be performed immediately 2, 3
• Urgent neuroimaging (non-contrast CT or MRI) must be completed within 45 minutes of patient arrival to exclude hemorrhage and assess for early ischemic changes 1
• Blood pressure should be monitored closely and maintained below 185/110 mmHg before administering IV alteplase 1, 3
• Initial laboratory tests should include complete blood count, electrolytes, renal function, glucose, and coagulation studies 2

Thrombolytic Therapy

• For patients presenting within 3 hours of symptom onset:

  • IV alteplase is strongly recommended for all eligible patients regardless of age, stroke severity, or early ischemic changes (except frank hypodensity) on CT 1
  • Treatment should be initiated as quickly as possible with a target door-to-needle time of less than 60 minutes 3

• For patients presenting between 3-4.5 hours:

  • IV alteplase is recommended for patients ≤80 years of age without a history of both diabetes mellitus and prior stroke, NIHSS score ≤25, not taking oral anticoagulants, and without imaging evidence of ischemic injury involving more than one-third of the MCA territory 1, 4
  • Note that the benefit in this extended time window may be less robust than earlier treatment 5

• Contraindications to IV alteplase include:

  • Acute intracranial hemorrhage on neuroimaging 1
  • Unclear time of symptom onset with last known well time >4.5 hours 1
  • Frank hypodensity involving more than one-third of the MCA territory 1

Endovascular Therapy

• For patients with large vessel occlusions, endovascular thrombectomy should be considered, particularly within 6 hours of symptom onset 2, 3
• A noninvasive intracranial vascular study (CTA or MRA) is strongly recommended during initial imaging if endovascular therapy is contemplated, but should not delay IV alteplase if indicated 1

Post-Thrombolysis Management

• Monitor vital signs and perform neurological assessments every 15 minutes during and after alteplase infusion for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours 3
• Monitor for complications of thrombolysis, particularly symptomatic intracranial hemorrhage 1
• For symptomatic intracranial hemorrhage after alteplase, stop the infusion immediately, obtain emergent head CT, and check coagulation studies 3

Antithrombotic Therapy

• Oral aspirin (325 mg initial dose) should be administered within 24-48 hours after stroke onset for patients not receiving thrombolysis 1
• For patients who received IV alteplase, delay antiplatelet therapy for at least 24 hours and obtain repeat brain imaging before starting 1
• Antiplatelet agents should not be administered as an adjunctive therapy within 24 hours of IV alteplase 1

Management of Physiological Parameters

• Blood pressure management:
  • For patients not receiving thrombolysis, avoid treating hypertension unless systolic BP >220 mmHg or diastolic BP >120 mmHg 2
  • For patients receiving thrombolysis, maintain BP <180/105 mmHg during and after treatment 3
• Monitor blood glucose regularly and treat hyperglycemia to maintain levels <300 mg/dL 2
• Monitor temperature at least every 4 hours and treat fever (>37.5°C) with antipyretics 2, 3

Common Pitfalls and Caveats

• Delays in recognition and treatment significantly worsen outcomes - every minute counts in acute stroke management 2
• Overly selective treatment criteria may exclude patients who could benefit from therapy 2
• Inadequate blood pressure control before thrombolysis increases hemorrhagic risk 3
• Failure to recognize the extended time window (3-4.5 hours) eligibility criteria may result in missed treatment opportunities 1, 4
• The benefit of IV alteplase diminishes with time, emphasizing the importance of rapid assessment and treatment 4