What is the treatment for ischemic brain injury?

Treatment of Ischemic Brain Injury

Intravenous alteplase (0.9 mg/kg, maximum 90 mg) should be administered as soon as possible within 4.5 hours of symptom onset to eligible patients with acute ischemic stroke, as this is the only proven treatment to reduce disability and improve functional outcomes. 1

Immediate Hyperacute Management (First Hours)

Airway, Breathing, and Circulation

• Perform tracheal intubation if the airway is compromised or ventilation is insufficient due to impaired alertness or bulbar dysfunction 1
• Provide supplemental oxygen to maintain oxygen saturation ≥94% 1
• Correct hypotension and hypovolemia to maintain systemic perfusion necessary for organ function 1

Emergency Evaluation

• Obtain capillary blood glucose immediately; treat hypoglycemia (glucose <60 mg/dL or 3.3 mmol/L) with IV dextrose before any other intervention 1
• Perform brain imaging (head CT or brain MRI) without delay upon hospital arrival and before any specific stroke treatment 1
• Obtain electrocardiography, complete blood count, serum electrolytes, creatinine, INR, partial thromboplastin time, and serum troponin, but do not delay reperfusion therapy for these results 1
• Use a validated stroke severity rating scale (e.g., NIHSS) in the emergency department 1

Blood Pressure Management Before Thrombolysis

• Lower blood pressure below 185/110 mm Hg before initiating IV thrombolysis in patients who are otherwise eligible 1
• Emergency treatment of hypertension is indicated only if there is concomitant acute myocardial ischemia, aortic dissection, or preeclampsia/eclampsia 1

Reperfusion Therapy

Intravenous Thrombolysis

Administer IV alteplase 0.9 mg/kg (maximum dose 90 mg) over 60 minutes with initial 10% of dose given as bolus over 1 minute to selected patients within 4.5 hours of symptom onset or last known well. 1

• The only assessment that must precede IV alteplase is blood glucose measurement 1
• Initiate treatment as soon as possible; earlier treatment produces better outcomes 1, 2
• For patients who awake with stroke symptoms or have unclear time of onset >4.5 hours from last known well, IV alteplase can be beneficial if MRI shows diffusion-weighted imaging (DWI)-FLAIR mismatch 1
• For patients with acute ischemic stroke within 4.5–9 hours of symptom onset who have CT or MRI core/perfusion mismatch, consider intravenous thrombolysis with alteplase if mechanical thrombectomy is not indicated or planned 1
• The standard dose of 0.9 mg/kg represents best practice; lower doses (0.6 mg/kg) have not demonstrated noninferiority and are associated with similar disability rates 3, 4

Key contraindications to IV thrombolysis include: 1

• Treatment beyond 4.5 hours (except in specific imaging-selected cases)
• Blood pressure ≥185/110 mm Hg that cannot be controlled
• Active internal bleeding
• Recent intracranial or intraspinal surgery
• History of intracranial hemorrhage
• Platelet count <100,000/mm³
• Current anticoagulant use with INR >1.7

Mechanical Thrombectomy

Patients should receive mechanical thrombectomy with stent retriever or direct aspiration if they meet all criteria: 1

• Age ≥18 years

• Pre-stroke modified Rankin Scale (mRS) score 0–1

• Causative occlusion of internal carotid artery or middle cerebral artery (M1)

• NIHSS score ≥6

• Alberta Stroke Program Early CT Score (ASPECTS) ≥6

• Treatment can be initiated (groin puncture) within 6 hours of symptom onset

• Perform non-invasive angiography (e.g., CTA) in patients with clinically suspected large vessel occlusion (LVO) 1

• For patients within 6–24 hours of last known well with anterior circulation LVO, obtain advanced imaging (CTP or DW-MRI) to determine eligibility 1

• Administer IV thrombolysis to eligible patients even if mechanical thrombectomy is being considered 1

• Do NOT wait to evaluate response to IV thrombolysis before proceeding with catheter angiography for mechanical thrombectomy 1

General Supportive Care

Monitoring and Admission

• Admit patients to a comprehensive stroke unit for specialized care and close neurological monitoring 1, 5
• Assess neurological status and vital signs frequently during the first 24 hours 1
• Use standardized stroke severity assessment tools for serial monitoring 5

Prevention of Complications

• Perform swallowing assessment before allowing oral intake to prevent aspiration 5
• Use intermittent external compression stockings to prevent deep vein thrombosis 5
• Implement early mobilization as tolerated to prevent deep vein thrombosis, pulmonary embolism, and pressure sores 5
• Monitor for and promptly treat infections, particularly pneumonia and urinary tract infections 5
• Assess for seizures and treat if they occur, but avoid prophylactic anticonvulsants 5

Antiplatelet Therapy

• Administer aspirin 325 mg within 24–48 hours of stroke onset in patients who did not receive thrombolysis 5
• If alteplase was administered, wait 24 hours before starting antiplatelet therapy 6

Interventions NOT Recommended

No neuroprotective agent (including citicoline, tirilazad, or other putative neuroprotective drugs) can be recommended for treatment of acute ischemic stroke, as multiple high-quality trials have failed to demonstrate efficacy. 1, 7

• Drug-induced hypertension outside clinical trials is not recommended for most patients with acute ischemic stroke 1
• Urgent anticoagulation has not shown benefits that exceed hemorrhage risks in the acute setting 6

Critical Pitfalls to Avoid

• Do not delay imaging or thrombolysis to obtain complete laboratory results beyond glucose measurement 1
• Do not treat beyond 4.5 hours unless specific imaging criteria are met (DWI-FLAIR mismatch or perfusion mismatch) 1, 8
• Do not use doses other than 0.9 mg/kg for IV alteplase, as lower doses have not proven noninferior 3, 4
• Do not withhold mechanical thrombectomy while waiting to assess response to IV thrombolysis 1
• Do not administer aspirin within 24 hours of thrombolytic therapy 6