From the Guidelines
Ischemic stroke treatment requires immediate medical attention to restore blood flow to the brain and minimize damage, with the primary treatment being intravenous thrombolysis with recombinant tissue plasminogen activator (tPA, alteplase) administered at 0.9 mg/kg (maximum 90 mg) with 10% given as a bolus and the remainder infused over 60 minutes, given within 4.5 hours of symptom onset 1.
Key Considerations
- For patients with large vessel occlusions presenting within 24 hours of symptom onset, mechanical thrombectomy is recommended to physically remove the clot 1.
- After the acute phase, antiplatelet therapy is initiated, typically with aspirin 81-325 mg daily or clopidogrel 75 mg daily 1.
- For secondary prevention, high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) is recommended along with blood pressure control targeting <130/80 mmHg.
- Patients with atrial fibrillation require anticoagulation, typically with direct oral anticoagulants like apixaban 5 mg twice daily or rivaroxaban 20 mg daily.
Treatment Approach
- The treatment approach should prioritize minimizing onset-to-treatment times, as earlier treatments are associated with increased benefits 1.
- A combined endovascular therapy approach using stent-retrievers and aspiration is the most effective way to achieve fast first-pass complete reperfusion and should thus be used 1.
- Rehabilitation including physical, occupational, and speech therapy should begin as soon as the patient is medically stable to maximize functional recovery and independence.
Important Considerations
- The organization of existing systems of care, and particularly pre-hospital transfer systems, have to be changed to diagnose and treat patients as fast as possible 1.
- Several different transport models are currently in use because the optimal patient transfer paradigm is highly dependent on local geography and hospital efficiency 1.
From the Research
Ischemic Stroke Treatment Options
- Intravenous administration of recombinant tissue plasminogen activator (rtPA) is an approved treatment for acute ischemic stroke within 3 hours of symptom onset 2.
- The timing and degree of recanalization after rtPA infusion can impact clinical outcome, with early recanalization associated with better outcomes 2.
- Idarucizumab can be used to reverse dabigatran, allowing for intravenous thrombolytic therapy with rtPA in patients with acute ischemic stroke 3.
Antiplatelet Therapy
- Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin may provide greater protection against subsequent stroke than monotherapy 4, 5.
- Short-duration DAPT (≤ 1 month) started during the early acute ischemic phase may be associated with less bleeding and greater reduction of recurrent strokes compared to monotherapy 4.
- The addition of clopidogrel to aspirin may reduce the risk of ischemic stroke recurrence, but may also increase the risk of bleeding 5.
Management and Outcomes
- Time from stroke symptom onset to thrombolysis is crucial and probably the most important determinant of success of IV therapy 6.
- Optimal care of patients with acute stroke should include community education and standardized protocols to guide immediate patient assessment and triage to medical centers with capability for efficient neurologic assessment, brain imaging, drug administration, and specialized postthrombolysis care 6.
- Patients treated with rtPA thrombolysis should be under close observation for 6-24 hours, with corresponding treatment considered once delayed recanalization appears 2.