What is the management of ischemic stroke?

Management of Ischemic Stroke

Immediate Evaluation and Triage

All patients with suspected acute ischemic stroke require immediate neurological evaluation and emergent brain imaging (CT or MRI) to exclude hemorrhage and determine reperfusion therapy eligibility. 1, 2

• Activate stroke protocols immediately upon patient arrival—stroke is a medical emergency requiring the same urgency as myocardial infarction 1
• Assess stroke severity using the National Institutes of Health Stroke Scale (NIHSS) to guide treatment decisions 1, 2
• Determine the exact time of symptom onset or when the patient was last known to be neurologically normal—this is critical for treatment window determination 1
• Obtain noncontrast CT immediately to rule out hemorrhage before any reperfusion therapy 1, 2

Airway, Breathing, and Circulation Management

• Maintain airway patency and perform tracheal intubation for patients with compromised airway or inadequate ventilation 2, 3
• Provide supplemental oxygen only if oxygen saturation is <94% 2, 3
• Correct hypotension and hypovolemia to maintain adequate cerebral perfusion 3

Reperfusion Therapies

Intravenous Alteplase (rtPA)

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) to eligible patients within 4.5 hours of symptom onset—this is the single most effective proven intervention for acute ischemic stroke. 1, 2, 4

Administration protocol: 1

• Give 10% of total dose as IV bolus over 1 minute
• Infuse remaining 90% over 60 minutes
• Blood pressure must be <185/110 mmHg before starting alteplase 1, 2

Monitoring requirements: 1

• Admit to intensive care or stroke unit
• Perform neurological assessments every 15 minutes during and for 2 hours after infusion
• Then every 30 minutes for 6 hours, then hourly until 24 hours
• Monitor blood pressure with same frequency
• If systolic BP >180 mmHg or diastolic >105 mmHg, administer antihypertensives immediately 1

Critical restrictions: 1

• Do NOT administer anticoagulants or antiplatelet agents for 24 hours after alteplase
• Delay placement of nasogastric tubes, bladder catheters, or arterial lines unless absolutely necessary 1
• Obtain follow-up CT or MRI at 24 hours before starting any antithrombotic therapy 1

Mechanical Thrombectomy

Perform endovascular thrombectomy for patients with large vessel occlusion within 6-24 hours based on advanced imaging showing salvageable tissue. 3, 4

• Intra-arterial thrombolysis is an option for basilar artery occlusion up to 6-12 hours from onset 2
• Treatment requires immediate access to cerebral angiography and experienced interventional neuroradiology 2
• Pre-notification and parallel processing are essential—activate the neuro-interventional team while obtaining CT imaging 1

Blood Pressure Management

For Patients Receiving Alteplase:

• Must lower BP to <185/110 mmHg before treatment 1, 2
• Maintain BP ≤180/105 mmHg for 24 hours after alteplase 1

For Patients NOT Receiving Reperfusion Therapy:

• Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg 1, 2, 3
• Treat hypertension emergently only if there is: 2, 3
  • Acute myocardial infarction
  • Aortic dissection
  • Acute renal failure
  • Acute pulmonary edema
  • Preeclampsia/eclampsia

Critical pitfall: Overly aggressive blood pressure lowering in patients not receiving thrombolysis can worsen cerebral perfusion and outcomes 4

Antiplatelet Therapy

Administer aspirin 300 mg within 48 hours of stroke onset for patients NOT receiving alteplase—this provides modest but significant benefit. 1

• Do NOT give aspirin or other antiplatelet agents within 24 hours of alteplase administration 1
• Aspirin reduces early recurrent stroke by a small but significant margin 1
• There is a small (0.1% absolute) increase in intracranial hemorrhage risk with aspirin 1

Anticoagulation

Urgent anticoagulation with heparin, low-molecular-weight heparin, or heparinoids is NOT recommended for routine acute ischemic stroke treatment. 1

• These agents increase symptomatic intracerebral hemorrhage risk, especially in moderate-to-severe strokes 1
• Do not improve neurological outcomes or prevent early recurrent stroke 1
• Never initiate anticoagulation within 24 hours of alteplase administration 1
• Always obtain brain imaging to exclude hemorrhage before any anticoagulation 1

Management of Cerebral Edema and Increased Intracranial Pressure

Corticosteroids are NOT recommended for cerebral edema following ischemic stroke. 1, 2

For patients deteriorating from increased intracranial pressure: 1, 2

• Administer osmotic therapy (mannitol or hypertonic saline) 1, 2
• Use hyperventilation as a temporizing measure 1, 2
• Consider surgical drainage of cerebrospinal fluid for hydrocephalus 1

For large cerebellar infarctions causing brainstem compression: 1, 2, 3

• Perform urgent surgical decompression and evacuation—this is life-saving 1, 2

For massive hemispheric infarction: 1

• Surgical decompression can be life-saving but survivors have severe residual neurological impairments 1

Glucose and Temperature Management

• Monitor blood glucose regularly and treat hyperglycemia to maintain levels <300 mg/dL (<16.63 mmol/L) 2, 3
• Identify and treat sources of fever 2, 3
• Use antipyretics for elevated temperatures 2, 3

Seizure Management

• Treat recurrent seizures with appropriate short-acting anticonvulsants (e.g., lorazepam IV) 1, 2
• Do NOT use prophylactic anticonvulsants in patients without seizures 1

Management of Symptomatic Intracranial Hemorrhage After Alteplase

If patient develops severe headache, acute hypertension, nausea, vomiting, or neurological worsening during or after alteplase: 1

• Stop alteplase infusion immediately 1
• Obtain emergent noncontrast head CT 1
• Send CBC, PT/INR, aPTT, fibrinogen level, type and cross-match 1
• Administer cryoprecipitate 10 units over 10-30 minutes; give additional dose if fibrinogen <200 mg/dL 1
• Consider tranexamic acid 1000 mg IV over 10 minutes OR ε-aminocaproic acid 4-5 g over 1 hour 1
• Obtain immediate hematology and neurosurgery consultations 1

Rehabilitation

• Perform initial assessment by rehabilitation professionals within 48 hours of admission 2, 3, 4
• Begin rehabilitation therapy as soon as the patient is medically stable 2, 3, 4
• Initiate frequent, brief out-of-bed activity (sitting, standing, walking) within 24 hours if no contraindications 2

Deep Vein Thrombosis Prophylaxis

• Administer subcutaneous heparin or low-molecular-weight heparin for immobile patients 4
• Enoxaparin 40 mg once daily is more effective than unfractionated heparin 5000 IU twice daily 4

Critical Time-Dependent Considerations

Every 30 minutes of delay in recanalization decreases the probability of good functional outcome by 8-14%. 2, 4

• Pre-notify stroke teams before patient arrival 1
• Use parallel processing—activate CT scanner and interventional team simultaneously 1
• Administer alteplase immediately after hemorrhage is ruled out on CT, before obtaining additional imaging 1
• Do NOT delay treatment to pursue additional diagnostic studies 1

Interventions NOT Recommended

• Emergency carotid endarterectomy (high risk of adverse events, especially with large deficits) 3, 4
• Immediate extracranial-intracranial arterial bypass (high hemorrhage risk) 4
• Induced hypothermia (utility not established) 3
• Neuroprotective pharmacological agents (none proven effective) 1, 3
• Intravenous streptokinase (unacceptably high mortality and hemorrhage rates) 1