What is the immediate treatment for a patient presenting with ischemic stroke?

Immediate Treatment for Ischemic Stroke

The immediate treatment for a patient presenting with ischemic stroke is intravenous alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) administered within 3 hours of symptom onset or last known well time. 1

Initial Assessment and Management

• Protect airway, breathing, and circulation (ABCs) as the first priority in all stroke patients, especially those who are seriously ill or comatose 1, 2
• Perform rapid evaluation to confirm ischemic stroke is the likely cause of symptoms and determine eligibility for IV alteplase 1
• Approach stroke as a life-threatening emergency requiring immediate evaluation and treatment 1
• Monitor neurological status closely using standardized stroke severity assessment tools 2

IV Thrombolysis with Alteplase

Time Windows for Treatment

• 0-3 hours: Strongly recommended for carefully selected patients (Class I; Level A) 1
• 3-4.5 hours: Recommended for selected patients who meet European Cooperative Acute Stroke Study (ECASS) III inclusion/exclusion criteria (Class I; Level B) 1
• Treatment should be administered as rapidly as possible once the decision is made 1

Dosing and Administration

• Dose: 0.9 mg/kg (maximum 90 mg) 1
• Administration: 10% as bolus over 1 minute, remaining 90% infused over 60 minutes 1
• For patients with mild stroke presenting in the 3-4.5 hour window, treatment may be reasonable after weighing risks and benefits (Class IIb; Level B-NR) 1

Post-Thrombolysis Monitoring

• Measure blood pressure 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 1
• Increase frequency of BP measurements if systolic BP >180 mmHg or diastolic BP >105 mmHg 1
• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if the patient can be safely managed without them 1
• Obtain follow-up CT or MRI at 24 hours after IV alteplase before starting anticoagulants or antiplatelet agents 1

Management of Symptomatic Intracranial Bleeding

If symptomatic intracranial bleeding occurs within 24 hours after administration of IV alteplase:

• Stop alteplase infusion immediately 1
• Obtain CBC, PT (INR), aPTT, fibrinogen level, and type and cross-match 1
• Perform emergent non-enhanced head CT 1
• Administer cryoprecipitate (10 units infused over 10-30 minutes) 1
• Consider tranexamic acid 1000 mg IV or ε-aminocaproic acid 4-5 g over 1 hour 1
• Obtain hematology and neurosurgery consultations 1
• Provide supportive therapy including BP management 1

Antiplatelet Therapy

• Administer aspirin (160-300 mg) within 24-48 hours after stroke onset 1
• For patients treated with IV alteplase, delay aspirin administration for 24 hours 1
• Aspirin is not a substitute for acute stroke treatment in patients eligible for IV alteplase 1
• For minor stroke, treatment for 21 days with dual antiplatelet therapy (aspirin and clopidogrel) begun within 24 hours can be beneficial for early secondary stroke prevention for up to 90 days (Class IIa; Level B-R) 1

Special Considerations

• Patients with cerebral microbleeds (1-10) on MRI can reasonably receive IV alteplase (Class IIa; Level B-NR) 1
• Patients with high burden of cerebral microbleeds (>10) may have increased risk of symptomatic intracerebral hemorrhage; benefits of treatment are uncertain (Class IIb; Level B-NR) 1
• For patients with major stroke likely to produce severe disability and known left atrial or ventricular thrombus, treatment with IV alteplase may be reasonable (Class IIb; Level C-LD) 1

Common Pitfalls and Caveats

• Delaying treatment reduces effectiveness - "time is brain" 1
• Aspirin should not be given before thrombolysis as it increases bleeding risk 1
• Routine urgent anticoagulation has not been shown to reduce early recurrent stroke risk and may increase brain hemorrhage risk, especially in moderate-severe strokes 1
• Prophylactic anticonvulsants are not recommended for patients who have not had seizures 1, 2
• Careful monitoring for infections, particularly pneumonia and urinary tract infections, is essential as these are common complications after stroke 3

Evidence Quality Considerations

The strongest evidence supports IV alteplase within 3 hours of symptom onset, with a number needed to treat of 8.3 patients to achieve one additional favorable outcome 1. Treatment in the 3-4.5 hour window is supported by ECASS III trial data but with a higher number needed to treat of approximately 25 4. The ATLANTIS trial did not show benefit in the 3-5 hour window 5, but meta-analyses including this trial still demonstrate overall benefit in the extended time window 4.