What is the immediate management of a patient presenting with an acute ischemic stroke?

Immediate Management of Acute Ischemic Stroke

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) within 3 hours of symptom onset to all eligible patients, with 10% as a bolus over 1 minute and 90% infused over 60 minutes, while simultaneously evaluating for endovascular thrombectomy if large vessel occlusion is present. 1, 2

Pre-Hospital and Emergency Department Recognition

• Time is brain: Every 30-minute delay in recanalization decreases good functional outcome by 8-14%, making speed the single most critical factor 2
• Document the exact time the patient was last known to be normal (last known well time), not when symptoms were discovered—this determines treatment eligibility 2, 3
• Perform immediate non-contrast CT scan to rule out hemorrhage and identify early infarction signs 2, 3
• Complete CT angiography immediately to identify large vessel occlusions and their location 2
• Assess NIHSS score during parallel processing while imaging is being obtained 2

Blood Pressure Management Before Alteplase

Blood pressure must be reduced to <185/110 mmHg before administering alteplase. 1, 2, 3

• Use labetalol, nicardipine, or clevidipine to lower blood pressure if needed 2, 3
• Do not delay alteplase administration for minor BP elevations that can be quickly controlled 1

IV Alteplase Administration Criteria

Inclusion Criteria:

• Clearly defined symptom onset within 3 hours 1, 2
• Measurable neurologic deficit on NIHSS 2
• Age ≥18 years 2
• CT scan showing no hemorrhage 2

Critical Exclusion Criteria:

• Blood pressure >185/110 mmHg (despite treatment) 1, 2
• Platelet count <100,000 2
• INR >1.6 or PT >15 seconds 1, 2
• Glucose <50 or >400 mg/dL 1, 2
• Prior stroke or serious head injury within 3 months 2
• Major surgery within 14 days 1, 2
• History of intracranial hemorrhage 2

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, 2

Extended Window (3-4.5 Hours)

For patients presenting between 3-4.5 hours, IV alteplase may be administered using ECASS III criteria, which adds additional exclusions: 1, 4

• Age >80 years is excluded 1
• NIHSS >25 is excluded 1
• Combination of prior stroke AND diabetes is excluded 1
• Any oral anticoagulant use regardless of INR is excluded 1

The ECASS III trial demonstrated that alteplase administered between 3-4.5 hours improved favorable outcomes (52.4% vs 45.2%, OR 1.34, P=0.04), though symptomatic ICH increased (2.4% vs 0.2%) 4

Blood Pressure Management During and After Alteplase

Maintain BP ≤180/105 mmHg during and after thrombolysis 1, 2, 3

• Monitor BP every 15 minutes during infusion and for 2 hours after 1, 2
• Monitor every 30 minutes for the next 6 hours 1, 2
• Monitor hourly until 24 hours after treatment 1, 2
• If BP exceeds 180/105 mmHg, increase monitoring frequency and administer antihypertensives 1

Endovascular Thrombectomy

Perform endovascular thrombectomy for proximal anterior circulation large vessel occlusions (ICA, M1, proximal M2) within 6 hours of symptom onset 2

• Extended window up to 24 hours is appropriate in selected patients with favorable CT perfusion or MRI diffusion/perfusion mismatch 2
• Use combined stent-retriever and aspiration technique (BADDASS approach) for optimal recanalization 2
• Endovascular therapy should not delay alteplase administration—both can be given in eligible patients 1, 2

Post-Alteplase Monitoring

Admit to intensive care or stroke unit for close monitoring 1

Neurological Monitoring:

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

If Neurological Worsening Occurs:

Immediately stop alteplase infusion and obtain emergency head CT 1, 2

Management of Symptomatic Intracranial Hemorrhage

If symptomatic ICH develops within 24 hours of alteplase: 1, 2

• Stop alteplase infusion immediately 1, 2
• Obtain emergent non-contrast head CT 1, 2
• Check CBC, PT/INR, aPTT, fibrinogen, type and cross-match 1, 2
• Administer cryoprecipitate 10 units over 10-30 minutes 1, 2
• Give tranexamic acid 1000 mg IV over 10 minutes OR ε-aminocaproic acid 4-5 g over 1 hour 1, 2
• Consult hematology and neurosurgery urgently 1, 2

Physiological Parameter Management

Temperature Control:

• Monitor temperature every 4 hours for first 48 hours 2, 3
• Treat fever >37.5°C with antipyretics 2, 3
• Identify and treat sources of hyperthermia 2, 3

Glucose Management:

• Monitor blood glucose regularly 2, 3
• Treat hyperglycemia to maintain 140-180 mg/dL 2, 3
• Avoid hypoglycemia with close monitoring 2, 3

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, 2
• Do not administer aspirin or other antiplatelet agents within 24 hours of IV alteplase 1
• Obtain follow-up CT or MRI at 24 hours before starting antiplatelets 1, 2

Stroke Unit Care

Admit all stroke patients to a geographically defined stroke unit with specialized staff within 24 hours of arrival 2, 3

• Begin rehabilitation assessment within 48 hours of admission 2, 3
• Start frequent, brief out-of-bed activity within 24 hours if no contraindications 2, 3
• Screen swallowing, nutrition, and hydration status on day of admission 2, 3

Critical Pitfalls to Avoid

• Never delay alteplase to pursue additional diagnostic studies beyond essential CT/CTA 1
• Never administer aspirin as a substitute for alteplase or within 24 hours of thrombolysis 1, 2
• Never use anticoagulation within 24 hours of IV alteplase 1
• Never delay treatment for mild or rapidly improving symptoms if patient remains moderately impaired—these patients still benefit from treatment 1
• Failure to obtain 24-hour follow-up imaging before starting antiplatelets increases hemorrhage risk 2
• Inadequate blood pressure control before thrombolysis significantly increases symptomatic ICH risk 2