What is the management of ischemic stroke?

Management of Ischemic Stroke

Immediate intravenous administration of recombinant tissue plasminogen activator (rtPA) at 0.9 mg/kg (maximum 90 mg) is strongly recommended for carefully selected patients who can receive the medication within 3 hours of stroke onset, followed by mechanical thrombectomy for those with large vessel occlusion within 6-24 hours according to specific imaging criteria. 1, 2, 3

Initial Evaluation and Management

• All patients with suspected acute ischemic stroke should undergo immediate neurological evaluation and brain imaging (CT or MRI) to rule out hemorrhage and determine eligibility for reperfusion therapies 2
• A validated stroke severity scale (such as NIHSS) should be used to assess the severity of neurological deficit 2
• Maintain airway, breathing, and circulation, with tracheal intubation indicated for patients with compromised airway or inadequate ventilation 2
• Provide supplemental oxygen to maintain saturation ≥94% 2
• Correct hypotension and hypovolemia to maintain adequate systemic perfusion 3

Reperfusion Therapies

• Intravenous rtPA (0.9 mg/kg, maximum 90 mg) should be administered to eligible patients within 3 hours of stroke onset 1
• Blood pressure must be <185/110 mmHg before administering rtPA 2
• Mechanical thrombectomy is recommended for patients with large vessel occlusion within 6-24 hours based on advanced imaging criteria showing salvageable tissue 3
• Combined stent-retriever and aspiration techniques provide optimal results for mechanical thrombectomy 1
• Intra-arterial thrombolysis may be considered for patients with basilar artery occlusion even in longer time intervals (up to 6-12 hours) 2

Blood Pressure Management

• For patients not receiving reperfusion therapies, avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg 1, 2
• For patients eligible for rtPA, blood pressure should be lowered to <185/110 mmHg before treatment 1
• Use short-acting agents with minimal effect on cerebral blood vessels when treatment is necessary 1
• Avoid sublingual nifedipine and other agents causing precipitous reductions in blood pressure 1
• Emergency treatment of hypertension is recommended if there is concomitant acute myocardial infarction, aortic dissection, acute renal failure, acute pulmonary edema, or preeclampsia/eclampsia 2

Management of Physiological Parameters

• Control body temperature: treat sources of fever and use antipyretics to control elevated temperatures 1
• Glucose management: monitor blood glucose regularly and treat hyperglycemia to maintain levels <300 mg/dL 1, 2
• Avoid intravenous administration of glucose-containing solutions 1
• Cardiac monitoring is recommended during initial evaluation to detect atrial fibrillation and potentially life-threatening arrhythmias 1

Management of Cerebral Edema

• Cerebral edema typically peaks 3-4 days after injury but can accelerate within 24 hours with early reperfusion of large infarcts 1
• Corticosteroids are not recommended for cerebral edema and increased intracranial pressure 2
• For patients who deteriorate due to edema, use osmotic therapy and hyperventilation 2
• Surgical decompression may be necessary for large cerebellar infarcts causing brainstem compression and hydrocephalus 2, 3

Prevention of Complications

• Deep vein thrombosis prophylaxis: subcutaneous heparin or low molecular weight heparin for immobile patients 1
• Enoxaparin 40 mg once daily is more effective than unfractionated heparin 5000 IU twice daily for DVT prevention 1
• Monitor for and treat seizures if they occur; routine prophylactic anticonvulsants are not recommended 1
• Early mobilization and rehabilitation help prevent complications and improve outcomes 2

Rehabilitation and Supportive Care

• Initial assessment by rehabilitation professionals should be performed within 48 hours of admission 2
• Rehabilitation therapy should begin as soon as possible once the patient is medically stable 2, 3
• Frequent and brief out-of-bed activity involving active sitting, standing, and walking should begin within 24 hours if no contraindications exist 2

Surgical Interventions

• Emergency carotid endarterectomy is generally not recommended for most patients with acute ischemic stroke due to high risk 1, 3
• Immediate extracranial-intracranial (EC-IC) arterial bypass has failed to improve outcomes and is associated with high risk of intracranial hemorrhage 1

Common Pitfalls to Avoid

• Delays in recognition and treatment significantly worsen outcomes - every 30 minutes of delay decreases the probability of good functional outcome by 8-14% 2
• Overly aggressive blood pressure lowering in patients not receiving thrombolysis can worsen outcomes 1
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) can worsen outcomes 2
• Strategies to improve blood flow by changing rheological characteristics of blood or increasing perfusion pressure are not recommended outside clinical trials 1