What is the initial management for a patient presenting with acute ischemic stroke, left corona radiata?

Initial Management of Acute Ischemic Stroke, Left Corona Radiata

Patients with acute ischemic stroke in the left corona radiata should receive intravenous recombinant tissue plasminogen activator (rtPA) at 0.9 mg/kg (maximum 90 mg) if they present within 4.5 hours of symptom onset and have no contraindications. 1, 2

Immediate Assessment and Stabilization

• All patients with suspected acute ischemic stroke should undergo immediate neurological evaluation using a validated stroke severity scale such as NIHSS 3, 2
• Urgent brain imaging (CT or MRI) must be performed to rule out hemorrhage and determine eligibility for reperfusion therapies 3, 2
• Maintain airway, breathing, and circulation, with supplemental oxygen to maintain saturation ≥94% 2
• Monitor vital signs frequently, with initial checks every 15 minutes during and after rtPA infusion for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours after treatment 1

Blood Pressure Management

• For patients eligible for thrombolysis, blood pressure must be <185/110 mmHg before administering rtPA 1, 2
• If blood pressure exceeds this threshold, use the following medications to lower it:
  • Labetalol 10-20 mg IV over 1-2 minutes (may repeat once) 1
  • Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h 1
• After rtPA administration, maintain blood pressure ≤180/105 mmHg 1, 3
• For patients not receiving reperfusion therapy, avoid treating hypertension unless systolic BP >220 mmHg or diastolic BP >120 mmHg 1, 2

Reperfusion Therapy

• Intravenous rtPA (0.9 mg/kg, maximum 90 mg) with 10% given as bolus over 1 minute and remainder infused over 60 minutes is the standard treatment for eligible patients within 4.5 hours of symptom onset 1, 4
• If the patient presents within 3 hours of symptom onset, the benefit of rtPA is strongest (Grade 1A evidence) 1, 5, 6
• For patients presenting between 3-4.5 hours, rtPA is still beneficial but with more selective criteria (excluding patients >80 years old, those with NIHSS >25, those taking oral anticoagulants even with INR <1.7, and those with both previous stroke and diabetes) 1

Endovascular Therapy Consideration

• For patients with large vessel occlusion (which may be the cause of corona radiata infarct), mechanical thrombectomy should be considered, particularly if:
  • The patient presents within 6 hours of symptom onset 1, 2
  • The patient has contraindications to intravenous rtPA 1
  • The patient has failed to respond to intravenous rtPA 1
• Stent retrievers such as Solitaire FR and Trevo are preferred over coil retrievers for mechanical thrombectomy 1

Antithrombotic Therapy

• For patients not receiving thrombolysis, administer aspirin (initial dose 325 mg) within 24-48 hours after stroke onset 1, 5, 6
• Aspirin should NOT be administered within 24 hours of rtPA administration 1
• Clopidogrel and glycoprotein IIb/IIIa inhibitors are not recommended in the acute phase 1

Management of Physiological Parameters

• Monitor blood glucose regularly and treat hyperglycemia to maintain levels <300 mg/dL 3, 2
• Identify and treat sources of fever, using antipyretics for temperatures >37.5°C 3, 2
• For patients with restricted mobility, use prophylactic low-dose subcutaneous heparin or low molecular weight heparins to prevent deep vein thrombosis 1, 5, 6

Management of Complications

• Corticosteroids are NOT recommended for cerebral edema and increased intracranial pressure following ischemic stroke 1, 2
• For patients deteriorating due to increased intracranial pressure, use osmotherapy and hyperventilation 1, 2
• Surgical decompression may be necessary for large cerebellar infarctions causing brainstem compression 1, 3
• Treat recurrent seizures as with any other acute neurological condition, but prophylactic anticonvulsants are not recommended 1

Early Rehabilitation

• Initial assessment by rehabilitation professionals should be conducted within 48 hours of admission 3, 2
• Begin rehabilitation therapy as soon as the patient is medically stable 3, 2
• Start frequent, brief, out-of-bed activity within 24 hours if no contraindications exist 3, 2

Common Pitfalls to Avoid

• Delays in treatment significantly worsen outcomes - every 30-minute delay in recanalization decreases the chance of good functional outcome by 8-14% 3, 2
• Inadequate blood pressure control before thrombolysis increases hemorrhagic risk 3, 2
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) can worsen outcomes 3
• Overly selective treatment criteria may exclude patients who could benefit from therapy 2