What is the management for ischemic stroke?

Management of Ischemic Stroke

Administer IV alteplase (0.9 mg/kg, maximum 90 mg) to eligible patients within 3 hours of symptom onset, with 10% as bolus over 1 minute and 90% infused over 60 minutes, targeting door-to-needle time under 60 minutes, and perform endovascular thrombectomy for large vessel occlusions within 6-24 hours based on imaging selection. 1

Pre-Hospital Recognition and Rapid Transport

• EMS must use FAST (Face, Arms, Speech, Time) screening tools to identify stroke patients, as a single abnormality carries 72% probability of stroke 1
• Pre-notify the receiving hospital immediately to activate stroke protocols, prepare the stroke team, imaging suite, and interventional resources before patient arrival 1
• 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
• 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

Emergency Department Assessment (Parallel Processing)

• Perform immediate non-contrast CT scan to rule out hemorrhage and identify early infarction signs 1, 2
• Complete CT angiography immediately to identify large vessel occlusions and their location 1
• Assess NIHSS score during parallel processing while imaging is being obtained 1
• Obtain essential laboratory tests: CBC with platelets, PT/INR, aPTT, glucose, electrolytes, renal function, and ECG 2

IV Alteplase Administration Criteria

Inclusion Criteria

• Clearly defined symptom onset within 3 hours (standard window) 1, 3
• Measurable neurologic deficit on NIHSS 1
• Age ≥18 years 1
• CT scan showing no hemorrhage 1

Critical Exclusion Criteria

• Blood pressure >185/110 mmHg (must be lowered before treatment) 1, 3
• Platelet count <100,000 1
• INR >1.6 or PT >15 seconds 1
• Glucose <50 or >400 mg/dL 1
• Prior stroke or serious head injury within 3 months 1
• Major surgery within 14 days 1
• History of intracranial hemorrhage 1
• Rapidly improving or minor symptoms 1

Dosing Protocol

• 0.9 mg/kg (maximum 90 mg total): 10% given as IV bolus over 1 minute, remaining 90% infused over 60 minutes 1, 3

Important caveat: While ECASS III suggested benefit for alteplase administered 3-4.5 hours after onset 4, a reanalysis adjusting for baseline imbalances found no significant benefits and continued harms 5. The 3-hour window remains the most robustly supported timeframe 3, 1.

Blood Pressure Management

Before Alteplase

• Blood pressure must be <185/110 mmHg before initiating alteplase 1, 3
• 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 2.5 mg/hr every 5 minutes to maximum 15 mg/hr) 3
• Avoid sublingual nifedipine due to precipitous blood pressure drops 3, 2

During and After Alteplase

• Maintain blood pressure ≤180/105 mmHg 1
• Monitor every 15 minutes during infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly until 24 hours 1

Without Thrombolysis

• Withhold antihypertensive agents unless systolic BP >220 mmHg or diastolic BP >120 mmHg 3, 2
• Use labetalol or nicardipine with cautious titration when treatment is indicated 3

Endovascular Thrombectomy

Indications

• Proximal anterior circulation large vessel occlusion (ICA, M1, proximal M2) 1
• Standard window: within 6 hours of symptom onset 1
• Extended window: up to 24 hours in selected patients with favorable CT perfusion or MRI diffusion/perfusion mismatch 1

Optimal Technique

• Use combined stent-retriever and aspiration technique (BADDASS approach) 1
• Deploy stent-retriever with two-thirds beyond the thrombus 1
• Apply dual aspiration through balloon guide catheter and distal access catheter during retrieval 1

Critical point: Every 30-minute delay in recanalization decreases good functional outcome by 8-14% 1. Speed is paramount.

Post-Alteplase Monitoring and Hemorrhage Management

Neurological Monitoring

• Monitor every 15 minutes during and for 2 hours after infusion, every 30 minutes for next 6 hours, then hourly until 24 hours 1
• Immediately stop infusion and obtain emergent head CT if severe headache, acute hypertension, nausea, vomiting, or neurological worsening occurs 1

Symptomatic Intracranial Hemorrhage Management

• Stop alteplase infusion immediately 1
• Obtain emergent non-contrast head CT 1
• Check CBC, PT/INR, aPTT, fibrinogen, type and cross-match 1
• Administer cryoprecipitate and tranexamic acid or ε-aminocaproic acid 1
• Consult hematology and neurosurgery 1

Note: Symptomatic intracranial hemorrhage occurs in approximately 2.4% of alteplase-treated patients versus 0.2% with placebo 4, but does not increase overall mortality 6.

Physiological Parameter Management

Temperature Control

• Monitor temperature every 4 hours for first 48 hours 1
• Treat fever >37.5°C with antipyretics 1
• Identify and treat sources of hyperthermia 1, 3

Glucose Management

• Monitor blood glucose regularly 1
• Treat hyperglycemia to maintain 140-180 mg/dL 1
• Avoid hypoglycemia with close monitoring 1
• Lower markedly elevated glucose to <300 mg/dL 3

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 given 1
• Aspirin is not a substitute for acute interventions including IV alteplase 3
• Do not administer aspirin or other antiplatelet agents as adjunctive therapy within 24 hours of IV fibrinolysis 3

Stroke Unit Care

• Admit all stroke patients to a geographically defined stroke unit with specialized interdisciplinary staff within 24 hours 1, 2
• Stroke unit care reduces mortality and improves functional outcomes 2
• Begin rehabilitation assessment within 48 hours of admission 1

Early Mobilization and Complication Prevention

• Start frequent, brief out-of-bed activity within 24 hours if no contraindications 1, 2
• Screen swallowing, nutrition, and hydration status on day of admission 1
• Use intermittent external compression stockings to prevent deep vein thrombosis 7, 2
• Avoid indwelling bladder catheters when possible due to infection risk 2
• Monitor for and promptly treat infections, particularly pneumonia and urinary tract infections 7

Management of Cerebral Edema and Increased ICP

• Do not use corticosteroids for cerebral edema 1
• Use osmotherapy and hyperventilation for deteriorating patients 1, 2
• Perform decompressive hemicraniectomy urgently for malignant MCA infarction before significant GCS decline or pupillary changes, ideally within 48 hours of onset 1, 2
• Surgical decompression is life-saving for large cerebellar infarctions with brainstem compression 1, 2

Seizure Management

• Treat new-onset seizures with short-acting medications 1
• Do not use prophylactic anticonvulsants 1, 7

Common Pitfalls to Avoid

• Failure to obtain follow-up imaging at 24 hours before starting antiplatelets or anticoagulants increases hemorrhage risk 1
• Inadequate blood pressure control before thrombolysis significantly increases symptomatic intracranial hemorrhage 1
• Delaying treatment for "minor" or "rapidly improving" symptoms—these patients may still benefit from treatment if they meet criteria 1
• Using glycoprotein IIb/IIIa receptor inhibitors (not recommended outside clinical trials) 3
• Attempting induced hypertension or volume expansion without clear evidence of benefit 3