What is the management of ischemic stroke?

Management of Ischemic Stroke

Immediate Recognition and Transport

All suspected stroke patients require immediate activation of emergency protocols with direct transport to comprehensive stroke centers capable of endovascular therapy when large vessel occlusion is suspected, rather than routing through primary stroke centers. 1

• EMS personnel should use FAST (Face, Arms, Speech, Time) screening, as a single abnormality indicates 72% probability of stroke 1
• Pre-notify the receiving hospital immediately to activate stroke protocols before patient arrival 1
• Document the exact time the patient was last known to be normal (last known well time), not when symptoms were discovered, as this determines treatment eligibility 1
• The "mothership" approach (direct transport to comprehensive centers) is preferred over "drip-and-ship" when feasible 2, 1

Emergency Department Evaluation

Perform immediate non-contrast CT scan and CT angiography in parallel with clinical assessment to identify hemorrhage and large vessel occlusions within minutes of arrival. 3, 1

• Complete NIHSS scoring during parallel processing while imaging is obtained 2, 1
• Brain imaging (CT or MRI) must be performed immediately to rule out hemorrhage and determine reperfusion therapy eligibility 3
• CT angiography identifies large vessel occlusions and their location 1
• Target door-to-needle time under 60 minutes for IV alteplase 1

Intravenous Alteplase Administration

Administer IV alteplase (0.9 mg/kg, maximum 90 mg) to eligible patients within 3 hours of symptom onset, with 10% given as IV bolus over 1 minute and 90% infused over 60 minutes. 2, 3, 1

Inclusion Criteria

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

Critical Exclusion Criteria

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

Important caveat: While the ECASS III trial suggested benefit for alteplase 3-4.5 hours after onset 4, a rigorous reanalysis adjusting for baseline imbalances found no significant benefits and continued harms 5. The 3-hour window remains the strongest evidence-based recommendation 2, 1.

Blood Pressure Management

Before alteplase, blood pressure must be lowered to <185/110 mmHg using labetalol, nicardipine, or clevidipine. 3, 1

• During and after alteplase, maintain blood pressure ≤180/105 mmHg 1
• Monitor every 15 minutes during infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly until 24 hours 1
• For patients NOT receiving reperfusion therapy, avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg 3
• Critical pitfall: Overly aggressive blood pressure lowering in patients not receiving thrombolysis worsens outcomes 3, 1

Endovascular Thrombectomy

Perform mechanical thrombectomy for proximal anterior circulation large vessel occlusions (ICA, M1, proximal M2) within 6 hours, or up to 24 hours in selected patients with favorable perfusion imaging. 3, 1

• Stent retrievers (Solitaire FR and Trevo) are preferred over coil retrievers (Merci) 2
• Use combined stent-retriever and aspiration technique with dual aspiration through balloon guide catheter and distal access catheter 1
• Patients eligible for IV rtPA should receive it even if endovascular treatment is planned 2
• Time to reperfusion directly correlates with outcomes; every 30-minute delay decreases good functional outcome by 8-14% 3, 1

Post-Alteplase Monitoring

Monitor neurological status every 15 minutes during and for 2 hours after infusion, every 30 minutes for the next 6 hours, then hourly until 24 hours. 1

• Stop infusion immediately if severe headache, acute hypertension, nausea, vomiting, or neurological worsening occurs 1
• Obtain emergent non-contrast head CT if any concerning symptoms develop 1

Management of Symptomatic Intracranial Hemorrhage

• Stop alteplase infusion immediately 1
• Obtain emergent non-contrast head CT 1
• Check CBC, PT/INR, aPTT, fibrinogen, type and cross-match 1
• Administer cryoprecipitate and tranexamic acid or ε-aminocaproic acid 1
• Consult hematology and neurosurgery 1

Early Antiplatelet Therapy

Start aspirin 160-325 mg within 24-48 hours after ruling out hemorrhage on follow-up imaging, but delay for 24 hours if alteplase was given. 2, 1

• Aspirin should not be administered within 24 hours of thrombolytic use 2
• Aspirin should not substitute for acute interventions, especially IV rtPA 2

Physiological Parameter Management

Control temperature, treating fever >37.5°C with antipyretics, and maintain blood glucose 140-180 mg/dL. 3, 1

• Monitor temperature every 4 hours for the first 48 hours 1
• Identify and treat sources of hyperthermia 1
• Monitor blood glucose regularly and avoid hypoglycemia 1

Management of Cerebral Edema and Increased Intracranial Pressure

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

• Use osmotherapy and hyperventilation for patients deteriorating from increased intracranial pressure 2, 1
• Perform decompressive hemicraniectomy urgently for malignant MCA infarction before significant GCS decline, ideally within 48 hours 1
• Surgical decompression is recommended for large cerebellar infarctions causing brainstem compression and hydrocephalus 2, 1

Deep Vein Thrombosis Prophylaxis

Administer subcutaneous enoxaparin 40 mg once daily for immobile patients, as it is more effective than unfractionated heparin 5000 IU twice daily. 3

Stroke Unit Care and Rehabilitation

Admit all stroke patients to a geographically defined stroke unit with specialized staff within 24 hours of arrival. 1

• Begin rehabilitation assessment within 48 hours of admission 3, 1
• Start frequent, brief out-of-bed activity within 24 hours if no contraindications 1
• Screen swallowing, nutrition, and hydration status on day of admission 1

Seizure Management

Treat new-onset seizures with short-acting medications, but do not use prophylactic anticonvulsants. 2, 1

Surgical Interventions

Emergency carotid endarterectomy is not recommended for most patients with acute ischemic stroke due to high risk. 3

• Immediate extracranial-intracranial (EC-IC) arterial bypass is not recommended due to high risk of intracranial hemorrhage 3

Critical Pitfalls to Avoid

• Time delays: Every 30-minute delay in recanalization decreases good functional outcome by 8-14%; speed is absolutely critical 3, 1
• Failure to obtain 24-hour follow-up imaging: Must obtain imaging before starting antiplatelets or anticoagulants to avoid hemorrhage risk 1
• Inadequate blood pressure control before thrombolysis: Significantly increases symptomatic intracranial hemorrhage risk 1
• Overly aggressive blood pressure lowering in non-thrombolysis patients: Worsens outcomes 3