What is the protocol for a young patient with an ischemic stroke?

Young Patient Ischemic Stroke Protocol

Young patients with acute ischemic stroke should be managed with the same aggressive time-dependent protocols as older adults, including immediate evaluation for IV tPA within 3-4.5 hours and consideration for mechanical thrombectomy within 6 hours for large vessel occlusions. 1

Immediate Assessment and Stabilization

Time-Critical Evaluation

• Treat stroke as a life-threatening emergency requiring immediate action - the goal is door-to-tPA time of ≤60 minutes 1
• Establish exact time of symptom onset or last known normal time, as this determines all treatment eligibility 2
• Perform urgent non-contrast CT or MRI to differentiate ischemic from hemorrhagic stroke and assess for contraindications to thrombolysis 1
• Calculate NIHSS score immediately to quantify stroke severity and guide treatment decisions 1

Airway, Breathing, and Circulation

• Provide supplemental oxygen only if oxygen saturation is <94% or unknown - routine oxygen is not recommended 2
• Maintain airway patency, particularly in patients with decreased consciousness or severe deficits 1
• Do NOT aggressively lower blood pressure unless systolic BP >185/110 mmHg before tPA or >180/105 mmHg after tPA - permissive hypertension improves cerebral perfusion 1, 2
• Check blood glucose immediately, as hypoglycemia can mimic stroke symptoms 2

Thrombolytic Therapy (IV tPA)

Within 3 Hours of Symptom Onset

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) with 10% as bolus and 90% infused over 1 hour - this is a Level A recommendation with the strongest evidence for improved functional outcomes 1

• Favorable outcomes achieved in 31-50% of tPA-treated patients versus 20-38% with placebo 1
• Earlier treatment within 90 minutes yields even better outcomes (OR 2.81 for favorable outcome) 1
• Symptomatic hemorrhage risk is 6.4% versus 0.6% with placebo, but mortality rates are similar 1

Between 3-4.5 Hours of Symptom Onset

Consider IV tPA using ECASS III criteria - this is a Level B recommendation based on the ECASS III trial showing 52.4% excellent outcomes versus 45.2% with placebo 1

Additional exclusion criteria for the 3-4.5 hour window:

• Age >80 years
• NIHSS score >25
• Any oral anticoagulant use (regardless of INR)
• Combined history of both prior stroke AND diabetes 1

Critical tPA Management Points

• Symptomatic hemorrhage occurs in 2.4% in the 3-4.5 hour window 1
• Do NOT delay tPA to wait for endovascular therapy availability - observing for clinical response before pursuing thrombectomy is not recommended 1
• Administer aspirin 160-325 mg within 24-48 hours AFTER tPA (not before or during) 1, 3
• No heparin, warfarin, or other antithrombotics for 24 hours post-tPA 1

Mechanical Thrombectomy (Endovascular Treatment)

Indications for Thrombectomy in Young Patients

Strongly consider mechanical thrombectomy with stent retrievers for patients meeting ALL criteria: 1

1. Age ≥18 years (though case reports show benefit in younger patients, randomized data are lacking) 1
2. Pre-stroke mRS score 0-1 (functionally independent)
3. ICA or proximal MCA (M1) occlusion confirmed on imaging
4. NIHSS score ≥6
5. ASPECTS ≥6 on non-contrast CT
6. Groin puncture achievable within 6 hours of symptom onset
7. TICI 2b/3 reperfusion achieved as the technical goal 1

Thrombectomy Evidence and Outcomes

• Stent retriever trials showed 43.7% good outcomes (mRS 0-2) with thrombectomy versus 28.2% with medical therapy alone (adjusted OR 2.1) 1
• Recanalization rates of 66% with modern stent retrievers versus 27-41% with older devices 1
• Use stent retrievers preferentially over older MERCI devices (Class I recommendation) 1
• Consider proximal balloon guide catheter or large-bore distal access catheter to improve recanalization rates 1

Special Considerations for Young Patients

While no randomized trials exist specifically for patients <18 years, case reports demonstrate high recanalization rates and favorable outcomes with endovascular therapy in young patients 1. However, diagnostic delays are common in pediatric stroke (median 8.8-16 hours to imaging), making time-sensitive interventions challenging 1.

Post-Acute Management

Monitoring Protocol

For tPA-treated patients: 1

• Neurological assessment and vital signs every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours
• Continuous cardiac monitoring for up to 72 hours
• Monitor for bleeding complications continuously
• Temperature every 4 hours; treat fever >99.6°F with acetaminophen 1

For non-thrombolyzed patients: 1

• Neurological checks and vital signs every 4 hours minimum in non-ICU settings
• Continuous cardiac monitoring for 24-48 hours
• Start antiplatelet therapy within 24 hours of admission 1

Antiplatelet Therapy for Non-Thrombolyzed Patients

Administer aspirin 160-325 mg within 48 hours of stroke onset - this provides modest benefit with reasonable safety 1, 3

For long-term secondary prevention in noncardioembolic stroke, the American College of Chest Physicians recommends aspirin 50-100 mg daily, aspirin/extended-release dipyridamole 25/200 mg twice daily (preferred over aspirin alone), or clopidogrel 75 mg daily 3

Critical Pitfalls to Avoid

• Do NOT administer prophylactic anticonvulsants - only treat actual seizures 1
• Do NOT routinely use urgent anticoagulation - this increases hemorrhage risk without proven benefit for early recurrent stroke prevention 1
• Do NOT delay hospital notification - EMS pre-arrival notification is essential for rapid treatment 2
• Do NOT treat blood pressure aggressively unless >185/110 mmHg before tPA - permissive hypertension maintains cerebral perfusion 1, 2
• Do NOT give aspirin, heparin, or other antithrombotics within 24 hours of tPA administration 1
• Do NOT position head of bed flat if aspiration risk exists - individualize positioning based on ICP concerns versus aspiration risk 1

Systems of Care

Transport to comprehensive stroke centers when possible - these facilities have endovascular capabilities and organized stroke protocols that improve outcomes 1, 2. Regional stroke systems that expedite care increase the number of patients who can receive time-sensitive treatments 1.