What is the management plan for an acutely ischemic stroke?

Management of Acute Ischemic Stroke

Intravenous alteplase (rtPA) at 0.9 mg/kg (maximum 90 mg) is the cornerstone of acute ischemic stroke management and must be administered within 3 hours of symptom onset, with a door-to-needle time goal of less than 60 minutes. 1, 2

Immediate Assessment and Stabilization

Time-Critical Evaluation

• Perform rapid neurological examination using the NIHSS scale to assess stroke severity and guide treatment decisions 1
• Obtain non-contrast CT scan immediately to exclude hemorrhage—this is the single most critical test before thrombolysis 1
• The evaluation must not delay rtPA administration; only essential tests should precede treatment 1

Airway, Breathing, and Circulation

• Provide supplemental oxygen to maintain saturation >94% 1
• Secure airway and provide ventilatory support for patients with decreased consciousness or bulbar dysfunction 1
• Check blood glucose immediately and treat if <60 mg/dL to achieve normoglycemia 1

Blood Pressure Management

Pre-Thrombolysis Requirements

Blood pressure must be <185/110 mmHg before initiating rtPA and maintained <180/105 mmHg for at least 24 hours after treatment. 1, 2

For patients with BP >185/110 mmHg who are otherwise eligible for rtPA 1:

• Labetalol 10-20 mg IV over 1-2 minutes, may repeat once, OR
• Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes to maximum 15 mg/h
• If BP cannot be controlled below 185/110 mmHg, do not administer rtPA 1

Post-Thrombolysis BP Monitoring

Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1

If systolic BP 180-230 mmHg or diastolic BP 105-120 mmHg 1:

• Labetalol 10 mg IV followed by continuous infusion 2-8 mg/min, OR
• Nicardipine 5 mg/h IV, titrate by 2.5 mg/h every 5-15 minutes to maximum 15 mg/h

Patients NOT Receiving Thrombolysis

• Withhold antihypertensive medications unless systolic BP >220 mmHg or diastolic BP >120 mmHg 1
• When treatment is indicated, lower BP by 15% during the first 24 hours 1

Thrombolytic Therapy Protocol

Dosing and Administration

Administer rtPA 0.9 mg/kg (maximum 90 mg) with 10% as bolus over 1 minute and remaining 90% infused over 60 minutes. 1, 2, 3

Time Windows

• Primary window: 0-3 hours from symptom onset—strongest evidence for benefit 1, 3
• Extended window: 3-4.5 hours—reasonable to administer based on ECASS III trial showing improved outcomes (mRS 0-1 in 52.4% vs 45.2% placebo) 1
• Health systems should achieve door-to-needle time ≤60 minutes in at least 80% of patients 1, 2

Exclusion Criteria

• Intracranial hemorrhage on CT 1
• BP persistently >185/110 mmHg despite treatment 1
• Early ischemic changes involving >1/3 of MCA territory (associated with 8-fold increased hemorrhage risk) 1
• Patients taking direct thrombin inhibitors (dabigatran) or direct factor Xa inhibitors (rivaroxaban, apixaban) without reliable reversal testing 1

Hemorrhage Risk

• Symptomatic intracranial hemorrhage occurs in 6.4% of rtPA-treated patients vs 0.6% placebo 1, 3
• Despite hemorrhage risk, 3-month mortality is similar (17% rtPA vs 21% placebo) with significantly better functional outcomes 1, 3

Mechanical Thrombectomy

Perform CT angiography immediately to identify large vessel occlusion, particularly in anterior circulation strokes involving the carotid artery or MCA. 2

• Initiate mechanical thrombectomy (groin puncture) within 6 hours of symptom onset for confirmed large vessel occlusion 2
• Target reperfusion to mTICI grade 2b/3 2
• Combination of IV thrombolysis followed by mechanical thrombectomy represents current standard of care for large vessel occlusions 2
• Every 30-minute delay in recanalization decreases chance of good functional outcome by 8-14% 2

Antiplatelet Therapy

Administer aspirin 325 mg orally within 24-48 hours after stroke onset. 1

Critical timing restrictions 1:

• Do NOT give aspirin within 24 hours of rtPA administration—increases hemorrhage risk
• Aspirin is not a substitute for acute reperfusion therapies 1
• Clopidogrel efficacy in acute stroke is not well established 1
• Intravenous glycoprotein IIb/IIIa inhibitors (abciximab, eptifibatide) are not recommended outside clinical trials 1

Temperature and Metabolic Management

• Identify and treat sources of hyperthermia >38°C with antipyretics 1
• Treat hyperglycemia to maintain blood glucose 140-180 mg/dL while closely monitoring to prevent hypoglycemia 1
• Persistent hyperglycemia during first 24 hours is associated with worse outcomes 1

Monitoring Protocol

Post-rtPA Surveillance

• Perform neurological assessment and vital signs every 15 minutes during and for 2 hours after rtPA, then every 30 minutes for 6 hours, then hourly for 16 hours 2
• Initiate continuous cardiac monitoring for at least 24 hours to detect arrhythmias 1
• Obtain baseline ECG and cardiac biomarkers (troponin preferred) to identify concurrent myocardial ischemia 1

Contraindications to Anticoagulation

• Avoid antiplatelet agents and anticoagulants for 24 hours after rtPA 2
• Urgent anticoagulation is not recommended in acute stroke—increases hemorrhage risk without reducing early recurrent stroke 1

Organized Stroke Care

• Admit to comprehensive stroke unit—organized stroke care improves outcomes across broad patient spectrum 1
• Implement stroke protocols with multidisciplinary teams to expedite evaluation and treatment 1, 2
• Restart premorbid antihypertensive medications after first 24 hours in neurologically stable patients 1

Common Pitfalls to Avoid

• Do not delay rtPA for extensive vascular imaging—CT angiography can be performed concurrently but should not postpone thrombolysis 1
• Do not withhold rtPA for "minor" symptoms—one-third of untreated patients with mild symptoms have poor outcomes 1
• Do not give aspirin as substitute for rtPA—aspirin provides only small benefit compared to thrombolysis 1
• Do not aggressively lower BP in non-thrombolysis candidates—cautious approach unless severely elevated 1