What is the treatment for stroke?

Stroke Treatment

For acute ischemic stroke, immediately administer intravenous alteplase (0.9 mg/kg, maximum 90 mg) as soon as possible within 3 hours of symptom onset, with consideration for treatment up to 4.5 hours in eligible patients, followed by early aspirin therapy and endovascular thrombectomy when indicated. 1, 2

Acute Phase Treatment (First Hours)

Thrombolytic Therapy

• Administer IV alteplase within 3 hours of symptom onset (Grade 1A evidence) with a target door-to-needle time under 60 minutes in 90% of patients and median time of 30 minutes 1, 2
• Dosing: 0.9 mg/kg (maximum 90 mg) with 10% given as IV bolus over one minute, remaining 90% infused over 60 minutes 1
• Treatment between 3-4.5 hours is also effective (Grade 2C evidence), though the benefit decreases as time increases 2, 3
• The ECASS III trial demonstrated that alteplase given at 3-4.5 hours significantly improved outcomes (52.4% favorable vs 45.2% placebo), though symptomatic intracranial hemorrhage increased (2.4% vs 0.2%) 3

Critical caveat: The risk of symptomatic intracranial hemorrhage rises with later treatment windows, with trends showing higher rates at 3-4.5 hours (7.8%) compared to under 3 hours (3.8%) 4

Endovascular Therapy

• Offer endovascular thrombectomy within a coordinated system for eligible patients with large vessel occlusions 1
• Intraarterial r-tPA may be considered for proximal cerebral artery occlusions in IV r-tPA-ineligible patients if initiated within 6 hours (Grade 2C) 1
• IV r-tPA is preferred over combination IV/IA therapy when patients are eligible (Grade 2C) 1

Early Antiplatelet Therapy

• Start aspirin 160-325 mg within 48 hours of stroke onset (Grade 1A) 1, 2
• Aspirin is preferred over therapeutic parenteral anticoagulation in the acute setting (Grade 1A) 1, 2

Secondary Prevention (Long-term Management)

Noncardioembolic Stroke

• Initiate long-term antiplatelet therapy with one of the following (Grade 1A): 1, 2
  • Clopidogrel 75 mg daily (preferred, Grade 2B) 2
  • Aspirin/extended-release dipyridamole 25/200 mg twice daily (preferred, Grade 2B) 2
  • Aspirin 75-100 mg daily 1
  • Cilostazol 100 mg twice daily (Grade 2C) 2

Minor Stroke or High-Risk TIA

• Dual antiplatelet therapy with aspirin 81 mg plus clopidogrel 75 mg daily should be initiated early, ideally within 12-24 hours 2

Cardioembolic Stroke with Atrial Fibrillation

• Oral anticoagulation is recommended over no therapy (Grade 1A), aspirin (Grade 1B), or dual antiplatelet therapy (Grade 1B) 1, 2
• Initiate anticoagulation within 1-2 weeks after stroke onset 1
• Dabigatran is contraindicated with creatinine clearance ≤30 mL/min 2

Embolic Stroke of Undetermined Source

• Antiplatelet therapy is recommended rather than oral anticoagulants 2

Supportive Care and Prophylaxis

DVT Prevention

• For restricted mobility, use prophylactic-dose subcutaneous LMWH (preferred over UFH, Grade 2B) or intermittent pneumatic compression devices (Grade 2B) 1
• Do not use elastic compression stockings (Grade 2B) 1

Comprehensive Management

• Implement measures to prevent complications and provide comprehensive rehabilitation 1

Key pitfall to avoid: The greatest benefit from alteplase occurs with earliest treatment—every minute counts. Do not delay treatment for non-essential testing or procedures 5. However, rigorous adherence to eligibility criteria is essential to minimize hemorrhagic complications 6.