What is the initial management for a patient with acute ischemic stroke?

Initial Management of Acute Ischemic Stroke

Immediately 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 and Emergency Department Recognition

Rapid Assessment Protocol

• Use the FAST screening tool (Face, Arms, Speech, Time) 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
• Activate 9-1-1 immediately when stroke is suspected, as EMS transport shortens time to CT imaging and increases rtPA utilization 2
• EMS should provide advance notification to the receiving hospital to expedite evaluation 2

Immediate Diagnostic Workup

• Perform non-contrast CT scan immediately upon arrival to rule out hemorrhage and identify early infarction signs 1
• Complete CT angiography simultaneously to identify large vessel occlusions and their precise location 1
• Obtain essential laboratory tests: complete blood count, electrolytes, renal function, glucose, coagulation studies (PT/INR, aPTT), troponin, and ECG 3

IV Alteplase Administration (Within 3-4.5 Hours)

Eligibility Criteria

Inclusion criteria include: 1

• Clearly defined symptom onset within 3 hours (extended to 4.5 hours in selected patients)
• Measurable neurologic deficit on NIHSS
• Age ≥18 years
• CT scan showing no hemorrhage

Dosing Protocol

• Total dose: 0.9 mg/kg (maximum 90 mg total) 1
• 10% given as IV bolus over 1 minute
• Remaining 90% infused over 60 minutes 1

Blood Pressure Management for Thrombolysis

Before starting alteplase: 1

• Blood pressure must be reduced to <185/110 mmHg using labetalol 10-20 mg IV over 1-2 minutes (may repeat once), or nicardipine 5 mg/h IV titrated up by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h) 2
• If BP cannot be controlled below 185/110 mmHg, do not administer rtPA 2

During and after alteplase: 2, 1

• Maintain blood pressure ≤180/105 mmHg for at least 24 hours
• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours 2
• If systolic BP >180-230 mmHg or diastolic BP >105-120 mmHg, use labetalol 10 mg IV followed by continuous infusion 2-8 mg/min, or nicardipine 5 mg/h IV titrated to effect 2

Endovascular Thrombectomy (Within 6-24 Hours)

Indications

• Proximal anterior circulation large vessel occlusion (internal carotid artery, M1 segment, proximal M2 segment) 1
• Standard window within 6 hours of symptom onset, extended to 24 hours with appropriate imaging selection showing salvageable tissue 1

Technique

• Use combined stent-retriever and aspiration technique (BADDASS approach) 1
• Target reperfusion to modified TICI grade 2b/3 1

Post-Thrombolysis Monitoring

Neurological Surveillance

• Monitor neurological status every 15 minutes during and for 2 hours after infusion, then every 30 minutes for 6 hours, then hourly until 24 hours 1
• Perform follow-up CT or MRI at 24 hours before starting antiplatelet or anticoagulation therapy to rule out hemorrhage 1
• Every 30-minute delay in recanalization decreases good functional outcome by 8-14% 1

Physiological Parameter Management

• Monitor temperature every 4 hours for 48 hours; treat fever >37.5°C with antipyretics 1
• Maintain oxygen saturation >94% with supplemental oxygen 1
• Initiate continuous cardiac monitoring for at least 24 hours to detect arrhythmias 1

Blood Pressure Management in Non-Thrombolysis Candidates

General Approach

• Avoid antihypertensive agents unless systolic BP >220 mmHg or diastolic BP >120 mmHg 3
• Avoid sublingual nifedipine and other agents causing precipitous BP reductions 3
• The brain is especially vulnerable to hypotension during acute ischemic stroke due to impaired cerebral autoregulation 2

Management of Hypotension

• Arterial hypotension (systolic BP <100 mmHg) is rare but suggests cardiac arrhythmia, aortic dissection, or shock 2
• Urgent evaluation and correction of the cause is needed; use vasopressor agents if hypotension cannot be corrected rapidly 2

Early Antiplatelet Therapy

• Start aspirin 160-325 mg within 24-48 hours after ruling out hemorrhage on follow-up imaging at 24 hours 1, 3
• Aspirin can be administered within the first 48 hours due to its reasonable safety profile and modest benefit 3

Stroke Unit Admission

• Admit all stroke patients to a geographically defined stroke unit with specialized staff within 24 hours of arrival, as this reduces mortality and dependency 1, 3
• Stroke unit care should include an interdisciplinary team with physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 3

Prevention of Acute Complications

Swallowing and Nutrition

• Perform swallowing assessment before allowing oral intake to prevent aspiration pneumonia 3
• Insert nasogastric or nasoduodenal tubes if prolonged feeding support is needed 3

Venous Thromboembolism Prevention

• Use subcutaneous anticoagulants or intermittent external compression stockings for immobilized patients 3

Infection Prevention

• Avoid indwelling bladder catheters when possible due to infection risk 3
• Treat pneumonia promptly with antibiotics, as it is an important cause of death following stroke 3

Management of Cerebral Edema

• Do not use corticosteroids for cerebral edema 1
• Use osmotherapy and hyperventilation for deteriorating patients with increased intracranial pressure 1
• Consider hemicraniectomy within 48 hours for selected patients (18-60 years old) with extensive hemispheric infarcts 3

Early Rehabilitation

• Begin early mobilization to prevent complications 3
• Assess and manage mobility, activities of daily living, incontinence, and mood early after stroke 3
• Speech-language pathologists should evaluate all stroke patients for residual communication difficulties 3

Critical Pitfalls to Avoid

• Failure to obtain follow-up imaging at 24 hours before starting antiplatelets or anticoagulants significantly increases hemorrhage risk 1
• Do not use drug-induced hypertension or hypervolemic hemodilution, as these strategies are not established as useful and carry risk of serious complications 2
• Emergency carotid endarterectomy is generally not performed for acute ischemic stroke with large deficits due to high risk of hemorrhagic transformation and brain edema 2, 1
• Extracranial-intracranial bypass has not been shown to be of benefit and carries hemorrhagic complications 2