What is the management and treatment approach for a patient with 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 consideration up to 4.5 hours in selected patients, and perform endovascular thrombectomy for large vessel occlusions within 6-24 hours based on advanced imaging criteria. 1, 2

Pre-Hospital Recognition and Rapid Transport

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

Emergency Department Evaluation

• 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 precise location. 2
• Assess National Institutes of Health Stroke Scale (NIHSS) score during parallel processing while imaging is being obtained. 1, 2
• Maintain airway, breathing, and circulation with tracheal intubation for patients with compromised airway or inadequate ventilation. 3, 4
• Provide supplemental oxygen to maintain saturation ≥94%. 3, 4

IV Alteplase Administration Criteria

Inclusion Criteria

• Clearly defined symptom onset within 3 hours (up to 4.5 hours in selected patients). 1, 2, 3
• Measurable neurologic deficit on NIHSS. 2
• Age ≥18 years. 1, 2
• CT scan showing no hemorrhage. 1, 2

Critical Exclusion Criteria

• Blood pressure >185/110 mmHg (must be lowered before treatment). 1, 2
• Platelet count <100,000/mm³. 1, 2
• INR >1.5 (if on warfarin) or PT >15 seconds. 1, 2
• Glucose <50 mg/dL or >400 mg/dL. 2
• Prior stroke or serious head injury within 3 months. 2
• Major surgery within 14 days. 2
• History of intracranial hemorrhage. 1, 2
• Rapidly improving or minor symptoms. 2
• CT showing multilobar infarction (hypodensity >1/3 cerebral hemisphere). 1

Dosing Protocol

• Administer 0.9 mg/kg (maximum 90 mg total) over 60 minutes, with 10% given as IV bolus over 1 minute. 1, 2, 3
• Infuse the remaining 90% over the subsequent 60 minutes. 1, 2

Blood Pressure Management

Before Alteplase Administration

• Blood pressure must be <185/110 mmHg before initiating alteplase. 1, 2, 4
• Use labetalol 10 mg IV over 1-2 minutes (may repeat or double every 10 minutes to maximum 300 mg) or nicardipine 5 mg/hr IV infusion (titrate by increasing 2.5 mg/hr every 5 minutes to maximum 15 mg/hr). 1, 2

During and After Alteplase Administration

• Maintain blood pressure ≤180/105 mmHg during and for 24 hours after alteplase. 1, 2
• Monitor blood pressure every 15 minutes during infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly until 24 hours. 1, 2
• If systolic BP >180 mmHg or diastolic BP >105 mmHg, increase monitoring frequency and administer antihypertensive medications. 1, 2

Without Reperfusion Therapy

• Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg. 1, 3, 4
• Treat emergently if concomitant acute myocardial infarction, aortic dissection, acute renal failure, acute pulmonary edema, or hypertensive encephalopathy. 1, 3, 4

Endovascular Thrombectomy

Indications

• Proximal anterior circulation large vessel occlusion (internal carotid artery, M1 segment of middle cerebral artery, proximal M2 segment). 2, 3
• Standard window: within 6 hours of symptom onset. 2, 3
• Extended window: up to 24 hours in selected patients with favorable CT perfusion or MRI diffusion/perfusion mismatch showing significant salvageable tissue. 2, 3

Technique

• Use combined stent-retriever and aspiration technique for optimal first-pass complete reperfusion. 2
• Deploy stent-retriever with two-thirds beyond the thrombus. 2
• Apply dual aspiration through balloon guide catheter and distal access catheter during retrieval. 2

Post-Alteplase Monitoring and Complication Management

Neurological Monitoring

• Monitor neurological status every 15 minutes during and for 2 hours after infusion, every 30 minutes for the next 6 hours, then hourly until 24 hours. 1, 2
• Immediately stop infusion and obtain emergency head CT if severe headache, acute hypertension, nausea, vomiting, or neurological worsening occurs. 1, 2
• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if the patient can be safely managed without them. 1

Symptomatic Intracranial Hemorrhage Management

• Stop alteplase infusion immediately. 1, 2
• Obtain emergent non-contrast head CT. 1, 2
• Check CBC, PT/INR, aPTT, fibrinogen level, and type and cross-match. 1, 2
• Administer cryoprecipitate 10 units infused over 10-30 minutes (administer additional dose if fibrinogen <200 mg/dL). 1, 2
• Give tranexamic acid 1000 mg IV over 10 minutes OR ε-aminocaproic acid 4-5 g over 1 hour, followed by 1 g IV until bleeding is controlled. 1, 2
• Obtain immediate hematology and neurosurgery consultations. 1, 2

Physiological Parameter Management

Temperature Control

• Monitor temperature every 4 hours for the first 48 hours. 2
• Treat fever >37.5°C with antipyretics and identify sources of hyperthermia. 2, 4

Glucose Management

• Monitor blood glucose regularly. 2, 4
• Treat hyperglycemia to maintain 140-180 mg/dL (avoid levels >300 mg/dL). 2, 4
• Avoid hypoglycemia with close monitoring. 2

Early Antiplatelet Therapy

• Start aspirin 160-325 mg within 24-48 hours after ruling out hemorrhage on follow-up imaging. 1, 2
• Delay aspirin for 24 hours if alteplase was administered. 2
• Obtain follow-up CT or MRI scan at 24 hours after IV alteplase before starting anticoagulants or antiplatelet agents. 1

Stroke Unit Care and Early Rehabilitation

• Admit all stroke patients to a geographically defined stroke unit with specialized staff within 24 hours of arrival. 2
• Admit to intensive care or stroke unit for monitoring after alteplase administration. 1
• Begin rehabilitation assessment within 48 hours of admission. 2, 3, 4
• Start frequent, brief out-of-bed activity within 24 hours if no contraindications exist. 2, 4
• Screen swallowing, nutrition, and hydration status on the day of admission. 2

Management of Cerebral Edema and Increased Intracranial Pressure

• Do not use corticosteroids for cerebral edema and increased intracranial pressure following ischemic stroke. 1, 3, 4
• Use osmotherapy (mannitol or hypertonic saline) and hyperventilation for patients deteriorating secondary to increased intracranial pressure, including those with herniation syndromes. 1, 3, 4
• Perform surgical decompression and evacuation for large cerebellar infarctions causing brainstem compression and hydrocephalus. 1, 3, 4
• Consider decompressive hemicraniectomy urgently for malignant middle cerebral artery infarction before significant Glasgow Coma Scale decline or pupillary changes, ideally within 48 hours of onset. 2

Seizure Management

• Treat new-onset seizures with short-acting medications (e.g., lorazepam IV) if not self-limiting. 1, 4
• Do not use prophylactic anticonvulsants in patients who have had stroke but not seizures. 1

Prevention of Subacute Complications

• Administer subcutaneous anticoagulants (low-molecular-weight heparin or unfractionated heparin) or use intermittent external compression stockings for deep vein thrombosis prophylaxis in immobilized patients. 1
• Use aspirin for patients who cannot receive anticoagulants. 1
• Treat pneumonia and urinary tract infections promptly with appropriate antibiotics. 1
• Avoid indwelling bladder catheters when possible due to infection risk; use intermittent catheterization or acidification of urine instead. 1

Critical Time-Dependent Considerations

• Every 30-minute delay in recanalization decreases good functional outcome by 8-14%. 2, 4
• Target door-to-needle time under 60 minutes for IV alteplase. 2
• Parallel processing of clinical assessment, imaging, and team mobilization is essential to avoid unnecessary delays. 1, 2
• Do not delay treatment to pursue additional diagnostic studies beyond essential non-contrast CT and CT angiography. 1