Immediate Management of Acute Ischemic Stroke
Administer intravenous alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) immediately after lowering blood pressure to <185/110 mmHg, with 10% given as bolus over 1 minute and 90% infused over 60 minutes, while simultaneously obtaining CT angiography to evaluate for large vessel occlusion requiring mechanical thrombectomy. 1
Blood Pressure Management Before Thrombolysis
Your patient's BP of 160/110 mmHg must be lowered before initiating rtPA:
- Blood pressure must be reduced to <185/110 mmHg before starting thrombolysis and maintained <180/105 mmHg for at least 24 hours after treatment 2, 1
- Use labetalol or nicardipine as first-line agents for rapid BP reduction 3
- Ensure BP is stabilized at the target level before beginning rtPA infusion 2
Critical pitfall: Do not delay thrombolysis while attempting to achieve perfect BP control—once BP is <185/110 mmHg, proceed immediately with rtPA 1
Thrombolytic Therapy Administration
The patient is within the 2-hour window with clear NCCT, making him an excellent candidate:
- Door-to-needle time goal is <60 minutes, with optimal goal of <45 minutes 1
- Administer alteplase 0.9 mg/kg (maximum 90 mg): 10% as IV bolus over 1 minute, remaining 90% infused over 60 minutes 1, 4
- Every 30-minute delay in recanalization decreases chance of good functional outcome by 8-14% 1
Concurrent Vascular Imaging for Thrombectomy Evaluation
Given the aphasia and right-sided weakness suggesting left MCA territory involvement:
- Obtain CT angiography immediately (can be done while preparing rtPA) to identify large vessel occlusion 1, 5
- Do not delay IV rtPA while obtaining CTA—these should occur in parallel 5, 6
- If large vessel occlusion is confirmed, proceed directly to mechanical thrombectomy with goal of groin puncture within 6 hours of symptom onset 1
- Target reperfusion to modified TICI grade 2b/3 1
Essential Supportive Care
- Maintain oxygen saturation >94% with supplemental oxygen 2
- Check blood glucose immediately and correct if <60 mg/dL 2
- Treat hyperglycemia to maintain glucose 140-180 mg/dL 2
- Initiate continuous cardiac monitoring for at least 24 hours to detect arrhythmias 2
- Treat fever >38°C with antipyretics 2
Post-Thrombolysis Monitoring Protocol
- Neurological assessment and vital signs every 15 minutes during and for 2 hours after rtPA infusion, then every 30 minutes for 6 hours, then hourly for 16 hours 2
- Monitor closely for symptomatic intracranial hemorrhage (occurs in 6.4% of rtPA-treated patients) 2
- Avoid antiplatelet agents and anticoagulants for 24 hours after rtPA 2, 7
Key consideration: The combination of IV thrombolysis followed by mechanical thrombectomy (if large vessel occlusion confirmed) represents the current standard of care and provides the best chance for good functional outcome in this patient presenting within 2 hours 2, 1