What are the treatment options for stroke?

Acute Stroke Treatment

For acute ischemic stroke, intravenous alteplase (0.9 mg/kg, maximum 90 mg) within 4.5 hours of symptom onset combined with mechanical thrombectomy for large vessel occlusions within 6-24 hours (based on imaging criteria) represents the evidence-based standard of care that directly reduces mortality and disability. 1, 2, 3

Immediate Recognition and Pre-Hospital Management

• Emergency Medical Services (EMS) must be activated immediately when stroke symptoms are recognized, as every 30-minute delay in recanalization decreases the probability of good functional outcome by 8-14%. 1, 4

• EMS should use validated stroke assessment tools (such as FAST: Face, Arms, Speech, Time) and implement a "recognize and mobilize" approach to minimize on-scene time. 4

• Pre-notification of the receiving hospital by EMS is essential to activate stroke protocols and prepare the stroke team, imaging, and necessary resources. 4

Emergency Department Evaluation

Immediate Imaging Requirements

• All suspected stroke patients require urgent brain CT or MRI immediately upon arrival to rule out intracranial hemorrhage, identify vessel occlusion location, and assess treatment eligibility. 1, 2, 3, 4

• Non-contrast CT (NCCT) is the most widely used modality because it is time-efficient, widely available, and effectively excludes hemorrhage with acceptable radiation dose (3 mSv). 1

• CT angiography (CTA) should be performed to visualize vessel occlusion and guide treatment decisions, as large vessel occlusions (intracranial carotid artery and M1 occlusions) are less likely to recanalize with alteplase alone. 1

Initial Assessment

• A validated stroke severity scale (such as NIHSS) must be used to assess neurological deficit severity. 2, 3

• Airway, breathing, and circulation should be monitored and maintained, with tracheal intubation for patients with compromised airway or inadequate ventilation. 2, 3

• Supplemental oxygen should be provided to maintain saturation ≥94%. 2, 3

• Initial laboratory tests should include complete blood count, electrolytes, renal function, glucose, lipids, and coagulation studies. 4

Reperfusion Therapies

Intravenous Thrombolysis

• Intravenous alteplase (0.9 mg/kg, maximum 90 mg) is strongly recommended for carefully selected patients within 4.5 hours of symptom onset. 1, 2, 3

• Blood pressure must be <185/110 mmHg before administering alteplase, and medications such as labetalol, nicardipine, or clevidipine can be used to lower blood pressure in eligible candidates. 2, 3, 4

• Blood pressure must be maintained ≤180/105 mmHg during and after thrombolysis treatment. 4

• The dose of alteplase for acute ischemic stroke (0.9 mg/kg) is lower than that recommended for myocardial infarction or pulmonary embolism. 2

Endovascular Therapy

• Mechanical thrombectomy using combined stent-retrievers and aspiration techniques should be performed for large vessel occlusions within 6-24 hours, based on specific imaging criteria showing significant mismatch between ischemic core and at-risk tissue. 1, 3

• Combined endovascular therapy approaches achieve the fastest first-pass complete reperfusion and should be used preferentially. 1

• For basilar artery occlusion, intra-arterial thrombolysis is an option even in longer time intervals (up to 6-12 hours), though this requires an experienced stroke center with immediate access to cerebral angiography and interventional neuroradiology. 2

Physiological Parameter Management

Blood Pressure Control

• In patients NOT receiving reperfusion therapies, avoid antihypertensive treatment unless systolic blood pressure is >220 mmHg or diastolic >120 mmHg. 2, 3, 4

• Emergency treatment of hypertension is recommended only if there is concomitant acute myocardial infarction, aortic dissection, acute renal failure, acute pulmonary edema, or preeclampsia/eclampsia. 2, 3

Glucose Management

• Blood glucose should be monitored regularly and hyperglycemia treated to maintain levels between 140-180 mg/dL (<300 mg/dL at minimum), as glucose levels >8 mmol/l predict poor prognosis. 2, 3, 4, 5

• Close monitoring is essential to prevent hypoglycemia. 4

Temperature Control

• Sources of fever should be identified and treated, with antipyretics administered for elevated temperatures. 2, 3, 4

• For temperatures >37.5°C, increase monitoring frequency and investigate possible infections. 4

• Hypothermia should be offered only in the context of ongoing clinical trials, as its utility is not well established. 3, 4

Complication Management

Cerebral Edema and Increased Intracranial Pressure

• Corticosteroids are NOT recommended for cerebral edema and increased intracranial pressure. 2, 3, 4

• Osmotic therapy and hyperventilation are recommended for patients who deteriorate. 2, 3, 4

• For patients selected for decompressive hemicraniectomy, proceed urgently to surgery prior to significant decline in Glasgow Coma Scale or pupillary change, ideally within 48 hours from stroke onset. 4

• Surgical decompression is life-saving for large cerebellar infarctions causing brainstem compression and hydrocephalus. 2, 3, 4

Seizure Management

• New-onset seizures should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limiting. 2, 4

• Prophylactic anticonvulsants are NOT recommended. 4

Early Rehabilitation and Supportive Care

• Initial assessment by rehabilitation professionals should be performed within 48 hours of admission. 2, 3, 4

• Rehabilitation therapy should begin as soon as possible once the patient is medically stable. 2, 3, 4

• Frequent, brief, out-of-bed activity involving active sitting, standing, and walking should begin within 24 hours if no contraindications exist. 2, 4

• Swallowing, nutritional, and hydration status should be screened as early as possible, ideally on the day of admission. 4

• Patients who cannot take food and fluids orally should receive appropriate feeding (nasogastric, nasoduodenal, or PEG) to maintain hydration and nutrition. 4

Stroke Unit Care

• All stroke patients should be admitted to a geographically defined stroke unit with specialized staff as soon as possible, ideally within 24 hours of hospital arrival, as stroke unit care significantly reduces mortality (odds ratio 0.76) and dependency (odds ratio 0.80) compared to general ward care. 4

Secondary Prevention Considerations

• Identify stroke etiology to guide secondary prevention strategies. 4

• For patients with nonvalvular atrial fibrillation who are candidates for anticoagulation, warfarin with target INR 2.0-3.0 is the drug of choice (Grade A recommendation). 1, 6

• For patients with transient ischemic attack and minor stroke, aspirin is effective in reducing stroke risk (Grade A recommendation), though the benefit-to-risk ratio is approximately 5:2. 1

• For symptomatic patients with anterior circulation TIAs or minor completed strokes and carotid stenosis >70%, carotid endarterectomy is beneficial when performed in a low-risk setting (perioperative stroke and death rate <6%). 1

Critical Pitfalls to Avoid

• Time-consuming imaging methods and overly selective treatment selection criteria should be avoided, as treatment effect is highly time-dependent and delays significantly worsen outcomes. 1

• Inadequate blood pressure control before thrombolysis increases hemorrhagic risk. 4

• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) can worsen outcomes. 4

• Overlooking the need for early rehabilitation can delay recovery. 4

• Most stroke patients present late because they perceive their symptoms as "not serious," even when they correctly interpret them as stroke, emphasizing the critical importance of public education about stroke as an emergency. 7, 8