What is the standard treatment for post-stroke (cerebrovascular accident) patients?

Standard Treatment for Post-Stroke Patients

The standard treatment for post-stroke patients includes intravenous alteplase (rtPA) for eligible patients with acute ischemic stroke within 4.5 hours of symptom onset, followed by antiplatelet therapy, blood pressure management, and admission to a stroke unit for multidisciplinary care. 1, 2

Acute Management of Ischemic Stroke

Thrombolytic Therapy

• Eligible patients should receive intravenous alteplase as soon as possible after hospital arrival with a target door-to-needle time of less than 60 minutes in 90% of treated patients 1
• Alteplase should be administered at 0.9 mg/kg (maximum 90 mg), with 10% given as an intravenous bolus over one minute and the remaining 90% as an infusion over 60 minutes 1
• Treatment is most effective when initiated within 3 hours of symptom onset but can be administered up to 4.5 hours in selected patients 3, 4
• Patients should be monitored for complications, particularly angioedema and intracranial hemorrhage 1

Endovascular Thrombectomy (EVT)

• EVT is indicated for patients with large vessel occlusion, both for those who have received intravenous alteplase and those who are not eligible for intravenous thrombolysis 1
• Treatment should be offered within a coordinated system of care with access to rapid neurovascular imaging and specialized interventional expertise 1
• EVT is most effective when performed within 6 hours of symptom onset but may be beneficial in selected patients up to 24 hours 1

Blood Pressure Management

• During the first 24 hours after acute reperfusion treatment, blood pressure should be maintained below 180/105 mmHg 2
• For patients with extremely high blood pressure (>220/120 mmHg) who are not receiving thrombolysis, cautious reduction by no more than 15% during the first 24 hours is recommended 1
• For patients with intracerebral hemorrhage and hypertension, the goal is to achieve a systolic blood pressure of 130-150 mmHg 1

Post-Acute Management

Antiplatelet Therapy

• Aspirin (160-325 mg) should be given within 48 hours of stroke onset once hemorrhage has been excluded by imaging 2
• For patients treated with IV thrombolysis, aspirin administration should be delayed until 24 hours after thrombolysis and after repeat imaging has excluded hemorrhage 2
• Long-term maintenance therapy typically consists of aspirin 75-162 mg daily or clopidogrel 75 mg daily if aspirin is not tolerated 2
• For patients with recent minor noncardioembolic stroke or high-risk TIA, dual antiplatelet therapy (aspirin plus clopidogrel) should be initiated early and continued for 21-90 days, followed by single antiplatelet therapy 1

Stroke Unit Care

• All stroke patients should be admitted to a stroke unit for ongoing management by a multidisciplinary team 1
• Regular neurological assessments should be performed to detect clinical deterioration 1
• Early mobilization and adequate hydration should be encouraged 2
• Intermittent pneumatic compression devices are recommended for patients with limited mobility 2

Monitoring Requirements

• Cardiac monitoring for at least the first 24 hours to screen for atrial fibrillation and other arrhythmias 2
• Blood pressure monitoring every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours 2
• Comprehensive nursing care assessment within 4 hours of stroke unit admission for nutritional and hydration needs, positioning and mobilization needs, bladder control, pressure ulcer risk, and cognitive function 1

Secondary Prevention

• Optimize lifestyle practices including regular physical activity, weight management, smoking cessation, and avoidance of excessive alcohol 1
• High-intensity statin therapy to reduce LDL-C by ≥50% 1
• Blood pressure control to target 1
• For patients with atrial fibrillation, anticoagulation therapy is recommended unless contraindicated 1

Common Pitfalls to Avoid

• Delaying thrombolysis administration - "time is brain" and treatment should be initiated as quickly as possible 1
• Administering aspirin within 24 hours of intravenous fibrinolysis, which increases bleeding risk 2
• Using antiplatelet agents as a substitute for other acute interventions like IV rtPA 2
• Routine use of anticoagulation in unselected patients following ischemic stroke 2
• Very intense and rapid blood pressure lowering below the optimal range in the acute phase of intracerebral hemorrhage 1
• Platelet transfusions in patients receiving antiplatelet therapy who develop intracerebral hemorrhage 1