Management of Acute Ischemic Stroke with Clear NCCT
The next step is to immediately initiate IV thrombolysis with alteplase while simultaneously obtaining CT angiography (CTA) to assess for large vessel occlusion—do not delay alteplase administration to wait for CTA results. 1, 2, 3
Immediate Actions Required
Blood Pressure Management First
- The patient's BP of 160/110 mmHg must be lowered to <185/110 mmHg before initiating IV alteplase 1
- Use antihypertensive agents to achieve this target safely and assess BP stability before starting thrombolysis 1
- This is a Class I, Level B-NR recommendation and represents an absolute requirement before alteplase administration 1
IV Alteplase Administration
- Administer alteplase 0.9 mg/kg (maximum 90 mg) immediately after BP control, with 10% as bolus over 1 minute, followed by the remaining dose over 60 minutes 1
- The patient is within the 2-hour window from symptom onset, well within the 4.5-hour treatment window 1, 4
- Time to treatment is strongly associated with outcomes—every minute counts (Class I, Level A evidence) 1
- The clear NCCT scan excludes hemorrhage and extensive early ischemic changes, making the patient eligible 1
Simultaneous CT Angiography
- Obtain CTA (arch-to-vertex) immediately without delaying alteplase administration 2, 3, 5
- The aphasia and left-sided hemiparesis suggest a large vessel occlusion in the right hemisphere, likely involving the middle cerebral artery or internal carotid artery 2, 5
- CTA is essential to identify large vessel occlusion for potential mechanical thrombectomy 1, 2, 3
- This is a Class I, Level A recommendation for patients who may be candidates for endovascular therapy 1
Critical Management Principle
Do NOT wait to evaluate the response to IV alteplase before proceeding with mechanical thrombectomy evaluation—if CTA confirms large vessel occlusion, proceed directly to catheter angiography 2, 3, 5
- Eligible patients should receive IV thrombolysis even when mechanical thrombectomy is being considered 2, 3, 5
- Any delay in mechanical thrombectomy worsens outcomes significantly 2
- The combined approach (IV alteplase followed by mechanical thrombectomy without waiting) is the standard of care for suspected large vessel occlusion 2, 3
Why Both Interventions Are Needed
IV Alteplase Benefits
- Provides immediate systemic thrombolysis that may achieve early recanalization 1, 4
- The ECASS III trial demonstrated significant benefit when administered 3-4.5 hours after symptom onset (odds ratio 1.34 for favorable outcome) 4
- Does not preclude subsequent mechanical thrombectomy 2, 3
CTA Benefits
- Identifies large vessel occlusion requiring mechanical thrombectomy 1, 2, 5
- Provides information on vessel tortuosity and collateral status for procedural planning 2, 5
- Allows assessment of clot burden and location 2, 5
Common Pitfall to Avoid
The most critical error would be delaying IV alteplase to obtain CTA first, or waiting to see if alteplase works before pursuing mechanical thrombectomy 2, 3
- Multimodal CT imaging should not delay administration of IV alteplase (Class III: Harm, Level B-NR) 1
- For patients potentially eligible for endovascular thrombectomy within 6 hours, both non-contrast CT and CTA should be obtained without delay, but alteplase should be started as soon as BP is controlled and hemorrhage is excluded 2
Post-Thrombolysis Monitoring
- Admit to intensive care or stroke unit 1
- Monitor BP and perform neurological assessments every 15 minutes during and for 2 hours after infusion, then every 30 minutes for 6 hours, then hourly until 24 hours 1
- Maintain BP ≤180/105 mmHg after alteplase administration 1, 5
- If large vessel occlusion is confirmed on CTA, proceed immediately to mechanical thrombectomy without delay 2, 3, 5