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

Acute Stroke Management

Initial Assessment and Imaging

All patients with suspected stroke must undergo immediate non-contrast CT scan to differentiate ischemic from hemorrhagic stroke before initiating any treatment, with a target door-to-needle time of less than 60 minutes. 1, 2

• Perform CT angiography immediately after non-contrast CT in patients presenting within 6 hours who are potential candidates for endovascular thrombectomy to identify large vessel occlusions 1, 2
• Obtain 12-lead ECG to assess cardiac rhythm and identify atrial fibrillation, but do not delay thrombolysis assessment 1, 2

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Acute Ischemic Stroke Management

Intravenous Thrombolysis (Alteplase/rtPA)

Administer IV alteplase 0.9 mg/kg (maximum 90 mg total) to eligible patients as soon as possible within 3 hours of symptom onset, with treatment extending to 4.5 hours only in carefully selected patients. 1, 2

• Give 10% of total dose as IV bolus over 1 minute, followed by 90% as continuous infusion over 60 minutes 1, 3
• Blood pressure must be lowered to below 185/110 mmHg BEFORE rtPA administration and maintained below 180/105 mmHg for at least 24 hours AFTER treatment 1, 3, 2
• Eligibility includes age ≥18 years, all stroke severities, patients on antiplatelet monotherapy or dual antiplatelet therapy, and end-stage renal disease patients on hemodialysis with normal aPTT 2
• Monitor neurological status and blood pressure every 15 minutes during and for 2 hours after infusion 2

Common pitfall: Do not use IV alteplase beyond 4.5 hours from symptom onset, as this increases hemorrhagic risk without proven benefit and is associated with increased mortality. 4

Endovascular Thrombectomy (EVT)

Perform EVT with stent retrievers for patients with large vessel occlusions within 6 hours of onset, including those who received IV alteplase and those ineligible for IV alteplase. 1, 2

• EVT should be delivered within a coordinated system with rapid neurovascular imaging access and specialized neurointerventional expertise 1

Antiplatelet Therapy

Administer oral aspirin 160-325 mg within 24-48 hours after stroke onset for patients NOT receiving thrombolysis. 1, 2

• Critical caveat: Do not give aspirin within 24 hours of rtPA treatment 1, 2
• Consider dual antiplatelet therapy (aspirin plus clopidogrel) for 21 days started within 24 hours for minor stroke patients to reduce early recurrence risk up to 90 days 2
• Do not use urgent anticoagulation for acute ischemic stroke due to increased bleeding risk 3

Blood Pressure Management in Ischemic Stroke

For patients NOT receiving thrombolysis, withhold antihypertensive medications unless systolic BP >220 mmHg or diastolic BP >120 mmHg. 1, 3

• When treating extreme elevation, reduce BP by approximately 15% (not more than 25%) over the first 24 hours 2
• For patients receiving thrombolysis, treat BP >185/110 mmHg immediately 3, 2

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Acute Hemorrhagic Stroke Management

Blood Pressure Control in Intracerebral Hemorrhage (ICH)

For ICH patients with systolic BP between 150-220 mmHg without contraindications, acutely lower systolic BP to 140 mmHg, as this is safe and may improve functional outcomes. 3

• Assess BP immediately upon emergency department arrival and every 15 minutes until stable 3

Reversal of Coagulopathy

For patients on vitamin K antagonists with elevated INR, immediately discontinue the medication, administer therapy to replace vitamin K-dependent factors, correct INR, and give IV vitamin K. 3

• Provide appropriate factor replacement therapy or platelets for patients with severe coagulation factor deficiency or severe thrombocytopenia 3

Management of Increased Intracranial Pressure

Perform surgical decompression and evacuation for large cerebellar infarctions causing brainstem compression and hydrocephalus. 1, 3

• Use osmotherapy and hyperventilation for patients deteriorating from increased intracranial pressure 1, 3
• Do not use corticosteroids for managing cerebral edema and increased intracranial pressure following ischemic stroke 1

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Supportive Care (Both Stroke Types)

Airway and Oxygenation

• Provide airway support and ventilatory assistance for patients with decreased consciousness or bulbar dysfunction 1, 3
• Administer supplemental oxygen to maintain oxygen saturation >94% 1, 3

Temperature Management

• Treat hyperthermia >38°C with antipyretics and identify underlying sources 1, 3

Glucose Management

• Immediately treat hypoglycemia (blood glucose <60 mg/dL) to achieve normoglycemia 1, 3
• Treat hyperglycemia to achieve blood glucose levels between 140-180 mg/dL 1, 3

Hydration and Nutrition

• Correct hypovolemia with IV normal saline 1, 3
• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 3, 2

Venous Thromboembolism Prophylaxis

• Initiate intermittent pneumatic compression on day of hospital admission for patients with restricted mobility 3, 5
• Use prophylactic low-dose subcutaneous heparin or low-molecular-weight heparin for acute stroke patients with restricted mobility 5

Early Mobilization

Begin frequent, brief out-of-bed activity within 24 hours if no contraindications to prevent complications. 1, 3, 2

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Stroke Unit Care

Admit all stroke patients to a geographically defined stroke unit with specialized staff as soon as possible, ideally within 24 hours of hospital arrival. 1, 2

• Initiate comprehensive rehabilitation as early as medically possible 1