What is the immediate treatment for a stroke?

Immediate Treatment for Stroke

For acute ischemic stroke, intravenous alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) is the priority treatment if the patient can be treated within 3 hours of symptom onset and meets eligibility criteria; if thrombolysis is not given or contraindicated, aspirin 160-300 mg should be started within 24-48 hours after excluding hemorrhage. 1

Initial Emergency Management

Immediate Assessment and Stabilization

• Treat stroke as a life-threatening emergency requiring immediate evaluation and treatment 1
• Protect airway, breathing, and circulation (ABCs), especially in seriously ill or comatose patients 1
• Manage elevated blood pressure cautiously—do not lower aggressively unless severely elevated 1
• Obtain urgent brain imaging (CT or MRI) to exclude hemorrhagic stroke before any antithrombotic therapy 1

Time-Critical Thrombolytic Therapy

Intravenous rtPA (Alteplase):

• Strongly recommended for carefully selected patients within 3 hours of symptom onset 1
• Dose: 0.9 mg/kg (maximum 90 mg) administered intravenously 1
• Requires strict adherence to NINDS selection criteria 1
• Do NOT substitute streptokinase or other thrombolytic agents for rtPA—they are not safe alternatives 1

Critical Caveat: Safe use of rtPA demands close observation and careful ancillary care; improper patient selection significantly increases hemorrhagic complications 1

Mechanical Thrombectomy

• Mechanical thrombectomy with stent retrievers is recommended for large vessel occlusions (ICA or proximal MCA) when treatment can be initiated within 6 hours 1
• Blood pressure should be maintained ≤180/105 mm Hg during and for 24 hours after the procedure 1
• Stent retrievers are preferred over older devices like MERCI 1

Antiplatelet Therapy

Aspirin Administration:

• Give aspirin 160-300 mg within 24-48 hours of stroke onset 1, 2
• Prevents approximately 5-10 deaths and recurrent strokes per 1000 patients treated 3, 4
• If rtPA was given, delay aspirin for 24 hours 1
• Can be administered orally, rectally, or via nasogastric tube if swallowing is unsafe 4
• Small increase in hemorrhagic risk (approximately 2 per 1000) is outweighed by benefits 5

Important: Aspirin is NOT a substitute for thrombolytic therapy in eligible patients 1

Anticoagulation—NOT Recommended Acutely

• Urgent anticoagulation (heparin, low-molecular-weight heparin, heparinoids) is NOT recommended for routine acute stroke treatment 1
• Does not reduce early recurrent stroke or improve outcomes 1
• Significantly increases risk of symptomatic hemorrhagic transformation, especially in moderate-to-severe strokes 1
• Do not initiate anticoagulation within 24 hours of rtPA administration 1

Supportive Care and Monitoring

Temperature Management

• Monitor temperature every 4 hours for first 48 hours 1
• For temperature >37.5°C, investigate infection and initiate antipyretics 1

Early Mobilization

• Begin rehabilitation assessment within 48 hours 1
• Frequent, brief out-of-bed activity (sitting, standing, walking) within 24 hours if no contraindications 1

Seizure Management

• Do NOT give prophylactic anticonvulsants to patients without seizures 1
• Treat acute seizures with short-acting medications (e.g., lorazepam IV) 1
• Single self-limiting seizure at onset does not require long-term anticonvulsant therapy 1

Cerebral Edema Management

• Corticosteroids are NOT recommended for cerebral edema 1
• Osmotherapy and hyperventilation for deteriorating patients with increased intracranial pressure 1
• Surgical decompression for large cerebellar infarctions causing brainstem compression 1

Treatments NOT Recommended

• Neuroprotective medications have not been shown effective 1
• Routine anticoagulation for acute stroke 1
• Prophylactic anticonvulsants 1
• Corticosteroids for edema 1