What are the latest guidelines for managing acute ischemic and hemorrhagic stroke?

Latest Guidelines on Stroke Management

Acute Ischemic Stroke

Immediate Assessment and Imaging

All patients with suspected acute ischemic stroke must undergo non-contrast CT (NCCT) immediately to rule out hemorrhage and determine eligibility for thrombolysis. 1

• Patients arriving within 6 hours who are potentially eligible for endovascular thrombectomy (EVT) should undergo CT angiography (CTA) from arch-to-vertex without delay to identify large vessel occlusions 1
• A 12-lead ECG should be performed to assess cardiac rhythm and identify atrial fibrillation, but this must not delay thrombolysis assessment 1, 2
• Advanced imaging such as CT perfusion may be considered for patient selection but must not substantially delay treatment decisions 1

Intravenous Alteplase (tPA) - The Gold Standard

Intravenous alteplase (0.9 mg/kg, maximum 90 mg) is strongly recommended for eligible patients within 3 hours of symptom onset, with treatment extending to 4.5 hours for selected patients. 1, 2

Eligibility Criteria (0-3 hours):

• Age ≥18 years (including patients >80 years old) 1
• All stroke severities, including severe strokes (despite increased hemorrhage risk, clinical benefit persists) 1
• Patients on antiplatelet monotherapy or dual antiplatelet therapy 1
• End-stage renal disease patients on hemodialysis with normal aPTT 1

Extended Window (3-4.5 hours):

• Age ≤80 years 1
• No history of both diabetes AND prior stroke 1
• NIHSS score ≤25 1
• Not taking oral anticoagulants 1
• No imaging evidence of ischemic injury involving >1/3 of MCA territory 1

Critical Blood Pressure Requirements:

Blood pressure must be lowered to <185/110 mmHg before alteplase administration and maintained <180/105 mmHg for 24 hours after treatment. 1, 2 This is non-negotiable—failure to control blood pressure increases hemorrhagic transformation risk substantially.

Dosing and Administration:

• 10% of total dose given as IV bolus over 1 minute 1
• Remaining 90% infused over 60 minutes 1
• Treatment should be initiated as quickly as possible—every minute counts, as time to treatment is strongly associated with outcomes 1, 2

Extended Time Window (4.5-24 hours):

Emerging evidence from the 2025 HOPE trial demonstrates that alteplase administered 4.5 to 24 hours after onset provides functional benefit in patients with salvageable brain tissue identified by perfusion imaging. 3 This represents a paradigm shift, though symptomatic intracranial hemorrhage increased from 0.51% to 3.8% 3. However, this approach requires perfusion imaging to identify salvageable tissue and should be considered for carefully selected patients 3.

Endovascular Thrombectomy (EVT)

EVT with stent retrievers is recommended as first-line therapy over intra-arterial thrombolysis for patients with large vessel occlusions within 6 hours of onset. 1, 2

• EVT is indicated for patients with large vessel occlusions, including those who received IV alteplase and those ineligible for IV alteplase 2
• Treatment should occur within a coordinated system with rapid access to neurovascular imaging and specialized neurointerventional expertise 2
• Validated triage tools (such as ASPECTS) should be used to rapidly identify EVT-eligible patients 1

Antiplatelet Therapy

Oral aspirin (160-325 mg) should be administered within 24-48 hours after stroke onset for patients not receiving thrombolysis. 1, 2

• For patients treated with IV alteplase, aspirin is generally delayed until 24 hours later 1
• Aspirin is NOT a substitute for acute interventions like IV alteplase or EVT 1
• For minor stroke patients, dual antiplatelet therapy (aspirin plus clopidogrel) for 21 days begun within 24 hours can be beneficial for early secondary prevention up to 90 days. 1
• Ticagrelor is not recommended over aspirin in acute minor stroke treatment 1

Blood Pressure Management

For patients NOT receiving thrombolysis, blood pressure should generally not be routinely treated unless extremely elevated. 1, 2

• Extreme elevation (SBP >220 mmHg or DBP >120 mmHg) should be treated to reduce BP by approximately 15% (not more than 25%) over the first 24 hours 1, 2
• Avoid rapid or excessive lowering—this can exacerbate ischemia, particularly with arterial occlusion 1

Monitoring After Alteplase

Intensive monitoring is mandatory after alteplase administration: 1

• Neurological assessments and BP checks every 15 minutes during and for 2 hours after infusion 1
• Then every 30 minutes for 6 hours 1
• Then hourly until 24 hours after treatment 1
• Obtain follow-up CT or MRI at 24 hours before starting anticoagulants or antiplatelet agents 1

Management of Symptomatic Intracranial Hemorrhage

If symptomatic hemorrhage occurs within 24 hours of alteplase: 1

• Stop alteplase infusion immediately 1
• Obtain CBC, PT/INR, aPTT, fibrinogen level, type and cross-match 1
• Emergent non-enhanced head CT 1
• Administer cryoprecipitate 10 units over 10-30 minutes 1
• Consider tranexamic acid 1000 mg IV over 10 minutes OR ε-aminocaproic acid 4-5 g over 1 hour 1
• Obtain hematology and neurosurgery consultations 1

Hemorrhagic Stroke

Surgical decompression and evacuation is recommended for large cerebellar infarctions causing brainstem compression and hydrocephalus. 2, 4

• Osmotherapy and hyperventilation are recommended for patients deteriorating due to increased intracranial pressure 2, 4
• Corticosteroids are NOT recommended for managing cerebral edema and increased intracranial pressure 2, 4

Supportive Care and Stroke Unit Management

All stroke patients should be admitted to a geographically defined stroke unit with specialized staff as soon as possible, ideally within 24 hours of hospital arrival. 4

Physiological Parameters:

• Maintain oxygen saturation >94% with supplemental oxygen 2
• Treat hyperthermia (>38°C) with antipyretics and identify sources 2, 4
• Correct hypoglycemia (<60 mg/dL) immediately 2
• Treat hyperglycemia to achieve blood glucose 140-180 mg/dL 2, 4
• Correct hypovolemia with IV normal saline 2

Early Rehabilitation:

• Initial assessment by rehabilitation professionals within 48 hours of admission 4
• Begin frequent, brief, out-of-bed activity within 24 hours if no contraindications 4
• Screen swallowing, nutritional, and hydration status on day of admission 4

Common Pitfalls to Avoid

• Time delays are devastating: Every 30-minute delay in recanalization decreases good functional outcome by 8-14% 4
• Don't be overly restrictive: The eligibility criteria are designed to identify appropriate candidates—don't exclude patients who could benefit 4
• Blood pressure control is critical: Inadequate control before thrombolysis dramatically increases hemorrhagic risk 1
• Don't give aspirin within 24 hours of alteplase: This increases hemorrhage risk without proven benefit 1
• Monitor for complications: Swallowing difficulties, infections, and venous thromboembolism can worsen outcomes if missed 4