What is the management plan for acute ischemic stroke?

Management of Acute Ischemic Stroke

Administer IV alteplase (0.9 mg/kg, maximum 90 mg) to eligible patients within 3 hours of symptom onset, with a target door-to-needle time under 60 minutes, and consider endovascular thrombectomy for large vessel occlusions within 6-24 hours based on imaging selection. 1, 2, 3

Pre-Hospital Recognition and Transport

• EMS should use FAST (Face, Arms, Speech, Time) screening tools to rapidly identify stroke patients, as even a single abnormality has 72% probability of stroke 2, 3
• Pre-notify the receiving hospital immediately to activate stroke protocols and prepare the stroke team, imaging, and necessary resources before patient arrival 2, 3
• Document the exact time the patient was last known to be normal (last known well time), as this determines treatment eligibility, not when symptoms were discovered 1, 3
• Transport directly to comprehensive stroke centers capable of endovascular therapy when large vessel occlusion is suspected, rather than routing through primary stroke centers ("mothership" approach preferred over "drip-and-ship" when feasible) 1

Emergency Department Assessment (Target: Door-to-Imaging <25 minutes)

• Perform immediate non-contrast CT scan to rule out hemorrhage and identify early infarction signs 1, 2, 3
• Complete CT angiography immediately to identify large vessel occlusions and their location 2, 3
• Assess NIHSS score during parallel processing while imaging is being obtained 1
• Obtain essential labs: CBC, PT/INR, aPTT, glucose, electrolytes, renal function (but do not delay treatment waiting for results unless anticoagulation use is suspected) 1, 2

IV Alteplase Administration (0-3 Hours Window)

Inclusion criteria 1:

• Clearly defined symptom onset within 3 hours
• Measurable neurologic deficit on NIHSS
• Age ≥18 years
• CT scan showing no hemorrhage

Critical exclusion criteria 1:

• Blood pressure >185/110 mmHg (must lower before treatment)
• Platelet count <100,000
• INR >1.6 or PT >15 seconds
• Glucose <50 or >400 mg/dL
• Prior stroke or serious head injury within 3 months
• Major surgery within 14 days
• History of intracranial hemorrhage
• Rapidly improving or minor symptoms

Dosing protocol 1, 3:

• 0.9 mg/kg (maximum 90 mg total)
• Give 10% as IV bolus over 1 minute
• Infuse remaining 90% over 60 minutes
• Administer directly in CT room after excluding hemorrhage to minimize door-to-needle time 1

Extended Window Alteplase (3-4.5 Hours)

Additional exclusion criteria beyond standard 0-3 hour criteria 1:

• Age >80 years
• NIHSS >25
• Combination of prior stroke AND diabetes
• ANY oral anticoagulant use (regardless of INR)

Note: The 3-4.5 hour window shows more modest benefits with higher comorbidity patients excluded 1. For wake-up strokes with unknown onset time, alteplase may be considered if DWI/FLAIR mismatch is present on MRI 1.

Blood Pressure Management

Before alteplase administration 1, 3:

• Must achieve BP <185/110 mmHg before giving alteplase
• Use labetalol, nicardipine, or clevidipine to lower BP if needed

During and after alteplase (first 24 hours) 1, 3:

• Maintain BP ≤180/105 mmHg
• Monitor BP every 15 minutes during infusion and for 2 hours after
• Then every 30 minutes for 6 hours
• Then hourly until 24 hours

For patients NOT receiving alteplase 2:

• Avoid treating hypertension unless systolic BP >220 mmHg or diastolic BP >120 mmHg
• Permissive hypertension supports cerebral perfusion in acute phase

Endovascular Thrombectomy (EVT)

Indications 1, 2:

• Proximal anterior circulation large vessel occlusion (ICA, M1, proximal M2)
• Standard window: within 6 hours of symptom onset
• Extended window: up to 24 hours in selected patients with favorable CT perfusion or MRI diffusion/perfusion mismatch

Optimal technique (BADDASS approach) 1:

• Use combined stent-retriever and aspiration technique
• Deploy stent-retriever with two-thirds beyond thrombus
• Apply dual aspiration through balloon guide catheter and distal access catheter during retrieval
• Goal: first-pass complete reperfusion to minimize time-dependent injury

System considerations 1:

• Activate neuro-interventional team in parallel with stroke team at CT scanner
• Have standardized angiography tray (Brisk Recanalization Ischemic Stroke Kit) ready
• Consider tenecteplase over alteplase for patients undergoing EVT (improved fibrin-specificity, longer half-life, single bolus administration) 1

Post-Alteplase Monitoring and Complications

Neurological monitoring 1, 3:

• Assess every 15 minutes during and for 2 hours after infusion
• Every 30 minutes for next 6 hours
• Hourly until 24 hours
• If severe headache, acute hypertension, nausea, vomiting, or neurological worsening occurs: stop infusion immediately and obtain emergency head CT 1

Symptomatic intracranial hemorrhage management 1, 3:

• Stop alteplase infusion
• Obtain emergent non-contrast head CT
• Check CBC, PT/INR, aPTT, fibrinogen, type and cross-match
• Administer cryoprecipitate 10 units over 10-30 minutes (additional dose if fibrinogen <200 mg/dL)
• Give tranexamic acid 1000 mg IV over 10 minutes OR ε-aminocaproic acid 4-5 g over 1 hour
• Consult hematology and neurosurgery

Orolingual angioedema 1, 3:

• Discontinue alteplase and hold ACE inhibitors
• Maintain airway (awake fiberoptic intubation if needed)
• Give IV methylprednisolone 125 mg
• Give IV diphenhydramine 50 mg
• Give ranitidine 50 mg IV or famotidine

Physiological Parameter Management

Temperature control 2, 3:

• Monitor temperature every 4 hours for first 48 hours
• Treat fever >37.5°C with antipyretics (acetaminophen)
• Identify and treat sources of hyperthermia (infections)
• Hypothermia only in clinical trial context

Glucose management 2, 3:

• Monitor blood glucose regularly
• Treat hyperglycemia to maintain 140-180 mg/dL
• Avoid hypoglycemia with close monitoring

Avoid routine interventions 1:

• Delay nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters for 24 hours if patient can be safely managed without them

Early Antiplatelet Therapy

• Start aspirin 160-325 mg within 24-48 hours after ruling out hemorrhage on follow-up imaging 2, 3, 4
• If alteplase was given, wait 24 hours before starting aspirin 3
• Do NOT use urgent anticoagulation (IV heparin) for unselected acute ischemic stroke patients—hemorrhage risks exceed benefits 3, 4

Stroke Unit Care and Early Rehabilitation

• Admit all stroke patients to a geographically defined stroke unit with specialized staff within 24 hours of arrival (reduces mortality OR 0.76 and dependency OR 0.80) 2
• Begin rehabilitation assessment within 48 hours of admission 2
• Start frequent, brief out-of-bed activity (active sitting, standing, walking) within 24 hours if no contraindications 2
• Screen swallowing, nutrition, and hydration status on day of admission; provide alternative feeding (NG, ND, or PEG) if unable to take oral intake safely 2

Management of Cerebral Edema and Increased ICP

• Do NOT use corticosteroids for cerebral edema 2
• Use osmotherapy and hyperventilation for deteriorating patients 2
• For large cerebellar infarctions with brainstem compression: surgical decompression may be life-saving 2
• For malignant MCA infarction: proceed urgently to decompressive hemicraniectomy before significant GCS decline or pupillary changes, ideally within 48 hours of onset 3

Seizure Management

• Treat new-onset seizures with short-acting medications (lorazepam IV) if not self-limiting 2
• Do NOT use prophylactic anticonvulsants 2

Common Pitfalls to Avoid

• Every 30-minute delay in recanalization decreases good functional outcome by 8-14%—speed is critical 2
• Do not be overly restrictive with treatment criteria—current practice often extends beyond strict guideline recommendations based on individualized risk-benefit assessment 1
• Failure to obtain follow-up imaging at 24 hours before starting antiplatelets or anticoagulants increases hemorrhage risk 1
• Inadequate blood pressure control before thrombolysis significantly increases symptomatic ICH risk 1
• Missing swallowing dysfunction leads to aspiration pneumonia—screen early 2
• Delaying rehabilitation worsens functional outcomes—begin within 24-48 hours 2