What is the management of acute ischemic stroke?

Management of Acute Ischemic Stroke

Administer IV alteplase (0.9 mg/kg, maximum 90 mg) to eligible patients within 3 hours of symptom onset with a 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 personnel should use the FAST (Face, Arms, Speech, Time) screening tool immediately upon patient contact, as a single abnormality carries 72% probability of stroke. 1
• Document the exact time the patient was last known to be neurologically normal (last known well time), not when symptoms were discovered, as this determines all treatment eligibility windows. 1
• Pre-notify the receiving hospital immediately to activate stroke protocols and prepare the stroke team, imaging suite, and pharmacy resources before patient arrival. 1, 2
• Transport directly to comprehensive stroke centers capable of endovascular therapy when large vessel occlusion is suspected based on severe deficits, rather than routing through primary stroke centers first. 1

Emergency Department Parallel Processing

• Perform non-contrast CT scan immediately upon arrival to rule out hemorrhage and identify early infarction signs. 1, 2
• Complete CT angiography simultaneously to identify large vessel occlusions and their precise location. 1, 3
• Assess NIHSS score during parallel processing while imaging is being obtained, not sequentially. 1
• Obtain immediate laboratory tests including complete blood count (platelets must be >100,000), PT/INR (INR must be <1.6, PT <15 seconds), glucose, and electrolytes. 1, 2

IV Alteplase Administration Protocol

Inclusion criteria:

• Clearly defined symptom onset within 3 hours (extended to 4.5 hours in selected patients). 1, 4
• Measurable neurologic deficit on NIHSS that is not rapidly improving or minor. 1
• Age ≥18 years. 1
• CT scan showing no hemorrhage. 1

Critical exclusion criteria:

• Blood pressure >185/110 mmHg despite treatment. 1
• 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

Dosing protocol:

• Total dose: 0.9 mg/kg (maximum 90 mg total). 1, 3
• Give 10% as IV bolus over 1 minute. 1, 3
• Infuse remaining 90% over 60 minutes. 1, 3

Blood Pressure Management

Before alteplase:

• Blood pressure must be reduced to <185/110 mmHg before starting thrombolysis using labetalol, nicardipine, or clevidipine. 1, 3

During and after alteplase:

• Maintain blood pressure ≤180/105 mmHg for at least 24 hours after treatment. 1, 3
• Monitor every 15 minutes during infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly until 24 hours. 1, 3

Endovascular Thrombectomy

Indications:

• Proximal anterior circulation large vessel occlusion (internal carotid artery, M1 segment, proximal M2 segment). 1
• Standard window: within 6 hours of symptom onset. 1, 3
• Extended window: up to 24 hours in selected patients with favorable CT perfusion or MRI diffusion/perfusion mismatch showing salvageable tissue. 1

Optimal technique:

• Use combined stent-retriever and aspiration technique (BADDASS approach). 1
• Deploy stent-retriever with two-thirds of the device beyond the thrombus. 1
• Apply dual aspiration through both a balloon guide catheter and distal access catheter during retrieval. 1
• Target reperfusion to modified TICI grade 2b/3. 3

Note on evidence: While the ECASS III trial showed benefit for alteplase in the 3-4.5 hour window 4, a reanalysis adjusting for baseline imbalances questioned this finding 5. However, current AHA guidelines continue to support treatment in this extended window for carefully selected patients. 1

Post-Alteplase Monitoring and Hemorrhage Management

Neurological monitoring schedule:

• Every 15 minutes during and for 2 hours after infusion. 1, 3
• Every 30 minutes for the next 6 hours. 1, 3
• Hourly until 24 hours post-infusion. 1, 3

If severe headache, acute hypertension, nausea, vomiting, or neurological worsening occurs:

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

Physiological Parameter Management

Temperature control:

• Monitor temperature every 4 hours for the first 48 hours. 1, 2
• Treat fever >37.5°C with antipyretics and identify sources of hyperthermia. 1, 2
• Avoid hypothermia except in clinical trial contexts. 1, 2

Glucose management:

• Monitor blood glucose regularly and treat hyperglycemia to maintain 140-180 mg/dL. 1, 2
• Correct hypoglycemia immediately with IV dextrose. 3
• Avoid hypoglycemia with close monitoring. 1

Oxygen and cardiac monitoring:

• Maintain oxygen saturation >94% with supplemental oxygen. 3
• Initiate continuous cardiac monitoring for at least 24 hours to detect arrhythmias. 3

Early Antiplatelet Therapy

• Start aspirin 160-325 mg within 24-48 hours after ruling out hemorrhage on follow-up imaging at 24 hours. 1
• Critical pitfall: Delay aspirin for 24 hours if alteplase was given and avoid all antiplatelet agents and anticoagulants during this period. 1, 3

Stroke Unit Care and Early Rehabilitation

• Admit all stroke patients to a geographically defined stroke unit with specialized staff within 24 hours of arrival, as this reduces mortality (OR 0.76) and dependency (OR 0.80) compared to general ward care. 2
• Begin rehabilitation assessment within 48 hours of admission. 1, 2
• Start frequent, brief out-of-bed activity within 24 hours if no contraindications exist. 1, 2
• Screen swallowing, nutrition, and hydration status on the day of admission. 1, 2

Management of Cerebral Edema and Increased ICP

• Do not use corticosteroids for cerebral edema. 1, 2
• 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
• Consider surgical decompression for large cerebellar infarctions with brainstem compression, as this may be life-saving. 1, 2

Seizure Management

• Treat new-onset seizures with short-acting medications (e.g., lorazepam IV) if not self-limiting. 1, 2
• Do not use prophylactic anticonvulsants. 1, 2

Emergency Carotid Endarterectomy Considerations

• Emergency CEA generally is not performed for acute ischemic stroke with large deficits due to high risk of adverse events from acute restoration of flow to damaged tissue. 6
• The exception is when clinical parameters or imaging suggests the actual infarcted area is small and the penumbra is large. 6
• For neurologically stable patients after nondisabling stroke or TIA, early CEA (within 2 weeks) provides maximum benefit without incremental risk compared to delayed surgery. 6
• Emergency CEA is most commonly indicated for new deficits occurring immediately after CEA to correct technical issues causing flow attenuation or acute thrombosis. 6

Critical Time-Dependent Pitfalls

• Every 30-minute delay in recanalization decreases good functional outcome by 8-14%—speed is absolutely critical. 1, 3
• Failure to obtain follow-up imaging at 24 hours before starting antiplatelets or anticoagulants significantly increases hemorrhage risk. 1
• Inadequate blood pressure control before thrombolysis significantly increases symptomatic intracranial hemorrhage risk (2.4% with alteplase vs 0.2% with placebo). 4
• Overly selective treatment criteria may exclude patients who could benefit from therapy. 2
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) worsens outcomes. 2