Initial Management of Acute Ischemic Stroke
The most critical first steps in managing acute ischemic stroke include rapid assessment, neuroimaging, blood glucose measurement, and administration of intravenous thrombolytic therapy within 60 minutes of arrival for eligible patients. 1, 2, 3
Immediate Assessment (First 10 Minutes)
- Assess and stabilize airway, breathing, and circulation, with tracheal intubation indicated for patients with compromised airway or inadequate ventilation 3
- Provide supplemental oxygen to maintain oxygen saturation ≥94% 3
- Check blood glucose immediately (hypoglycemia is a common stroke mimic) 1
- Perform rapid neurological assessment using a validated stroke scale such as NIHSS 3
- Obtain vital signs with particular attention to blood pressure 1
- Establish IV access 1
Rapid Diagnostic Evaluation (First 25 Minutes)
Obtain emergent non-contrast CT scan of the brain to rule out hemorrhage and other stroke mimics 1, 2
Order essential laboratory tests (do not delay thrombolysis while waiting for results unless specific concerns exist) 1:
- Complete blood count with platelets
- Coagulation studies (PT/INR, aPTT)
- Serum electrolytes and renal function
- Blood glucose (if not already obtained)
- Cardiac biomarkers
Consider CT angiography to identify large vessel occlusions if endovascular therapy is available 2, 3
Time-Critical Decision Making (First 45 Minutes)
- Have CT scan read by qualified physician within 45 minutes of patient arrival 1
- Determine eligibility for intravenous thrombolysis (rtPA) 1, 2
- Control blood pressure if >185/110 mmHg in potential thrombolysis candidates 1, 2:
- Labetalol 10-20 mg IV over 1-2 minutes (may repeat once)
- Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h)
Treatment Initiation (Within 60 Minutes of Arrival)
- Administer intravenous rtPA (0.9 mg/kg, maximum 90 mg) to eligible patients within 60 minutes of arrival and within 4.5 hours of symptom onset 1, 2, 4
- 10% as bolus over 1 minute
- Remaining 90% as infusion over 60 minutes
- Monitor vital signs every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours after rtPA administration 1
- Maintain blood pressure <180/105 mmHg for at least 24 hours after thrombolysis 1, 2
For Patients Not Eligible for Thrombolysis
- Administer aspirin 325 mg within 24-48 hours of stroke onset 2, 4
- Control blood pressure only if severely elevated (>220/120 mmHg) or if there are other specific indications (acute MI, aortic dissection, heart failure) 3
- Consider endovascular thrombectomy for patients with large vessel occlusions 2, 5
Common Pitfalls to Avoid
- Delaying neuroimaging - CT scan should be completed within 25 minutes of arrival 1
- Missing the treatment window - "time is brain" with approximately 1.9 million neurons lost per minute during stroke 3
- Inadequate blood pressure control before thrombolysis - must be <185/110 mmHg before rtPA administration 1, 2
- Failing to check blood glucose - hypoglycemia can mimic stroke symptoms 1
- Administering aspirin before or within 24 hours of rtPA - increases bleeding risk 2
- Delaying treatment while waiting for laboratory results - unless specific concerns about coagulopathy exist 1
Early Management of Complications
- Monitor for and treat cerebral edema - surgical decompression may be necessary for large cerebellar infarcts causing brainstem compression 1, 3
- Treat hyperthermia (temperature >38°C) as it worsens outcomes 1, 3
- Correct hypovolemia with intravenous normal saline 2
- Manage hyperglycemia to achieve blood glucose levels between 140-180 mg/dL 2, 3
The American Heart Association/American Stroke Association emphasizes that rapid assessment and treatment are essential, with a goal of administering thrombolytic therapy within 60 minutes of hospital arrival for eligible patients 1. This "door-to-needle" time is a critical performance metric that directly impacts patient outcomes 2, 3.