What is the recommended management for ischemic stroke inpatients?

Acute Ischemic Stroke Inpatient Management

Immediate Reperfusion Therapy

For eligible patients presenting within 4.5 hours of symptom onset, intravenous alteplase (0.9 mg/kg, maximum 90 mg) should be administered immediately, with a target door-to-needle time under 60 minutes. 1, 2

IV Alteplase Administration Protocol

• Dosing: Administer 0.9 mg/kg (maximum 90 mg) over 60 minutes, with 10% given as bolus over 1 minute 1, 3
• Time windows:
  • Within 3 hours: Strongly recommended for all eligible patients 1, 3
  • 3-4.5 hours: Recommended, though ECASS III excluded patients >80 years, those on warfarin regardless of INR, combined diabetes/prior stroke history, and NIHSS >25 1, 4
  • Beyond 4.5 hours: Consider only with MRI showing DWI-FLAIR mismatch in wake-up or unclear onset strokes 3

Critical caveat: A 2020 reanalysis of ECASS III found that after adjusting for baseline imbalances, benefits in the 3-4.5 hour window were not statistically significant 5. However, current guidelines continue to recommend treatment in this window based on pooled analyses 1, 3.

Pre-treatment Requirements

• Blood pressure control: Must be <185/110 mmHg before initiating alteplase and maintained <180/105 mmHg for 24 hours post-treatment 1, 2, 3
• Only glucose testing must precede alteplase initiation; do not delay for other laboratory results 3
• Neuroimaging: Non-contrast CT to exclude hemorrhage is mandatory, but additional studies should not delay treatment 1

Contraindications and Special Populations

• DOACs: Do not routinely administer alteplase to patients on direct oral anticoagulants; consider endovascular thrombectomy instead 1, 3
• Warfarin: May treat if INR ≤1.7 3
• Age >80 years: Safe and effective within 3 hours; reasonable in 3-4.5 hour window despite ECASS III exclusion 3
• Mild symptoms: May consider within 3 hours if symptoms are non-disabling 3

Endovascular Thrombectomy (EVT)

Patients with large vessel occlusions should receive mechanical thrombectomy regardless of alteplase eligibility, and alteplase administration should never be delayed to assess clinical response before proceeding to EVT. 1, 2, 3

EVT Eligibility Criteria (0-6 hours)

All of the following must be met 3:

• Age ≥18 years
• Pre-stroke mRS 0-1
• ICA or MCA-M1 occlusion on CTA
• NIHSS ≥6
• ASPECTS ≥6
• Groin puncture possible within 6 hours of last known well

Extended Window EVT (6-24 hours)

• Requires advanced imaging (CTP or DWI-MRI) showing salvageable tissue 1, 3
• Must demonstrate mismatch between ischemic core and clinical deficits or hypoperfusion area 3
• Target reperfusion grade: mTICI 2b/3 3

Blood Pressure Management During EVT

• Maintain BP ≤180/105 mmHg during and for 24 hours after procedure 1
• In successfully reperfused patients, keeping BP <180/105 mmHg is reasonable 1
• ESCAPE protocol suggests systolic BP ≥150 mmHg may maintain collaterals while vessel remains occluded 1

Post-Alteplase Monitoring

Admit to intensive care or stroke unit with the following monitoring schedule 1:

• First 2 hours: BP and neurological assessments every 15 minutes
• Next 6 hours: Every 30 minutes
• Until 24 hours: Hourly assessments
• Imaging: Obtain follow-up CT or MRI at 24 hours before starting any antithrombotics 1

Managing Complications

For symptomatic intracranial hemorrhage 1:

• Stop alteplase immediately
• Obtain emergent non-contrast head CT
• Administer cryoprecipitate 10 units over 10-30 minutes; repeat if fibrinogen <200 mg/dL
• Consider tranexamic acid 1000 mg IV over 10 minutes OR ε-aminocaproic acid 4-5 g over 1 hour
• Obtain hematology and neurosurgery consultations

For angioedema: Use staged response with antihistamines, glucocorticoids, and standard airway management 1

Important: Routine use of cryoprecipitate, FFP, prothrombin complex concentrates, tranexamic acid, factor VIIa, or platelet transfusions for alteplase-associated bleeding lacks evidence and should be individualized 1

Supportive Care Measures

Blood Pressure Management (Non-thrombolysis Patients)

• Markedly elevated BP: Lower by 15% during first 24 hours 2
• Treatment threshold: Withhold medications unless SBP >220 mmHg or DBP >120 mmHg 2

Glucose Control

• Hypoglycemia (glucose <60 mg/dL): Treat immediately 1, 2
• Hyperglycemia: Target glucose 140-180 mg/dL with close monitoring to prevent hypoglycemia 1, 2

Temperature and Oxygenation

• Fever: Identify and treat sources if temperature >38°C 2
• Oxygen: Maintain saturation >94% with supplemental oxygen as needed 2
• Hypothermia: Not recommended outside clinical trials 1

Fluid Management

• Correct hypovolemia with IV normal saline 2
• Avoid hypotonic fluids

Antiplatelet Therapy

Administer aspirin 160-300 mg within 24-48 hours of stroke onset for patients not receiving thrombolysis. 1, 2

• Post-alteplase: Delay aspirin for 24 hours after thrombolysis 1
• Not a substitute: Aspirin should never replace acute reperfusion therapy in eligible patients 1
• Alternative route: Use rectal or nasogastric administration if patient cannot swallow 1

Preventing Secondary Complications

Invasive Procedures

• Delay placement of nasogastric tubes, indwelling catheters, and intra-arterial pressure catheters if patient can be safely managed without them 1

Seizure Management

• Treat recurrent seizures as with any acute neurological condition 1
• Do not use prophylactic anticonvulsants in patients without seizures 1

Cerebral Edema and Increased ICP

• Corticosteroids: Not recommended 1, 2
• Osmotherapy and hyperventilation: Use for deteriorating patients with increased ICP or herniation 1, 2
• Surgical decompression: Recommended for large cerebellar infarctions causing brainstem compression and hydrocephalus 1, 2
• CSF drainage: Consider for hydrocephalus 1

System of Care Requirements

EVT must be delivered within a coordinated system including 1, 2:

• Agreements with EMS for rapid transport
• Access to rapid neurovascular imaging (CTA to identify large vessel occlusions)
• Coordination between EMS, emergency department, stroke team, and radiology
• Local neurointerventional expertise
• Access to stroke unit for ongoing management