Management of Acute Cerebral Infarct
Administer IV alteplase (0.9 mg/kg, maximum 90 mg) to eligible patients within 3 hours of symptom onset with a door-to-needle time under 60 minutes, and perform endovascular thrombectomy for large vessel occlusions within 6-24 hours based on imaging selection. 1, 2
Pre-Hospital Recognition and Emergency Transport
- EMS personnel must use the FAST (Face, Arms, Speech, Time) screening tool immediately, as a single abnormality carries 72% probability of stroke 1, 3
- Document the exact time the patient was last known neurologically normal (last known well time), not when symptoms were discovered, as this determines all treatment eligibility windows 1, 2
- Pre-notify the receiving hospital immediately to activate stroke protocols and prepare the stroke team, imaging, and necessary resources before patient arrival 1, 3
- Transport directly to comprehensive stroke centers capable of endovascular therapy when large vessel occlusion is suspected, rather than routing through primary stroke centers ("mothership" approach preferred over "drip-and-ship" when feasible) 1
Emergency Department Parallel Processing
Perform non-contrast CT scan immediately upon arrival to rule out hemorrhage (absolute contraindication to thrombolysis) and identify early infarction signs 4, 1, 2. The brain imaging study should be interpreted within 45 minutes of patient arrival by a physician with expertise in reading CT and MRI studies 4.
Complete CT angiography simultaneously to identify large vessel occlusions and their precise location, which guides decisions about endovascular thrombectomy 4, 1. This should not delay IV alteplase administration if indicated 4.
Assess NIHSS score during parallel processing while imaging is being obtained 1.
IV Alteplase Administration Protocol
Inclusion Criteria
- Clearly defined symptom onset within 3 hours (extended to 4.5 hours in selected patients) 4, 1, 2
- Measurable neurologic deficit on NIHSS 1, 2
- Age ≥18 years 1
- CT scan showing no hemorrhage 4, 1
Critical Exclusion Criteria
- Blood pressure >185/110 mmHg (must be lowered before treatment) 1, 2
- 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
- Frank hypodensity involving more than one third of the MCA territory on CT 4
Dosing Protocol
Total dose is 0.9 mg/kg (maximum 90 mg total), with 10% given as IV bolus over 1 minute and the remaining 90% infused over 60 minutes 1, 2. This standard dose should be used rather than lower doses, as a 2016 trial of 3310 patients showed that low-dose alteplase (0.6 mg/kg) failed to demonstrate noninferiority to standard dose for death or disability at 90 days 5.
Target door-to-needle time is under 60 minutes 1, 2.
Extended Time Window Considerations
For patients presenting 4.5 to 24 hours after onset, the 2025 HOPE trial (372 patients) demonstrated that IV alteplase can provide functional benefit in patients with salvageable brain tissue identified by perfusion imaging, with 40% achieving functional independence versus 26% with standard treatment (adjusted RR 1.52,95% CI 1.14-2.02, P=0.004) 6. However, this came with increased symptomatic ICH (3.8% vs 0.51%, P=0.01) 6.
For patients with wake-up stroke (last seen well >4.5 hours earlier) who have MRI DWI-FLAIR mismatch and for whom mechanical thrombectomy is not planned, IV alteplase is recommended 7.
Blood Pressure Management
Before alteplase administration, blood pressure must be reduced to <185/110 mmHg using labetalol, nicardipine, or clevidipine 1, 3, 2.
During and after alteplase administration, maintain blood pressure ≤180/105 mmHg for at least 24 hours after treatment 1, 2. Monitor blood pressure every 15 minutes during infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly until 24 hours 1.
Endovascular Thrombectomy
Indications
Proximal anterior circulation large vessel occlusion (internal carotid artery, M1 segment, proximal M2 segment) 1, 2:
- Standard window: within 6 hours of symptom onset 4, 1, 2
- Extended window: up to 24 hours in selected patients with favorable CT perfusion or MRI diffusion/perfusion mismatch 4, 1
Optimal Technique
Use combined stent-retriever and aspiration technique (BADDASS approach) 1, 2:
- Deploy the stent-retriever with two-thirds beyond the thrombus 1
- Apply dual aspiration through a balloon guide catheter and distal access catheter during retrieval 1
- Target reperfusion to modified TICI grade 2b/3 2
Outcomes are directly related to quality of reperfusion, and treatment techniques have improved to allow for faster and better reperfusion 4.
Post-Alteplase Monitoring and Hemorrhage Management
Monitor neurological status every 15 minutes during and for 2 hours after infusion, then every 30 minutes for 6 hours, then hourly until 24 hours 1, 2.
Immediately stop infusion and obtain emergency head CT if severe headache, acute hypertension, nausea, vomiting, or neurological worsening occurs 1.
Symptomatic Intracranial Hemorrhage Management
- Stop alteplase infusion immediately 1
- Obtain emergent non-contrast head CT 1
- Check CBC, PT/INR, aPTT, fibrinogen, and type and cross-match 1
- Administer cryoprecipitate and tranexamic acid or ε-aminocaproic acid 1
- Consult hematology and neurosurgery 1
Physiological Parameter Management
Temperature Control
- Monitor temperature every 4 hours for the first 48 hours 1, 3, 2
- Treat fever >37.5°C with antipyretics 1, 2
- Identify and treat sources of hyperthermia 1, 3
- Avoid hypothermia except in clinical trial contexts 3
Glucose Management
- Monitor blood glucose regularly 1, 3
- Treat hyperglycemia to maintain 140-180 mg/dL 1, 3
- Avoid hypoglycemia with close monitoring 1
Oxygenation and Cardiac Monitoring
- Maintain oxygen saturation >94% with supplemental oxygen 2
- Initiate continuous cardiac monitoring for at least 24 hours to detect arrhythmias 2
Early Antiplatelet Therapy
Start aspirin 160-325 mg within 24-48 hours after ruling out hemorrhage on follow-up imaging at 24 hours 1, 2. Delay aspirin for 24 hours if alteplase was given 1.
Stroke Unit Care and Early Rehabilitation
All stroke patients should be admitted to a geographically defined stroke unit with specialized staff within 24 hours of arrival, as stroke unit care significantly reduces mortality (OR 0.76) and dependency (OR 0.80) compared to general ward care 1, 3, 2.
Rehabilitation assessment should begin within 48 hours of admission 1, 3.
Frequent, brief out-of-bed activity should be started within 24 hours if no contraindications exist 1, 3.
Screen swallowing, nutrition, and hydration status on the day of admission, and provide appropriate feeding (nasogastric, nasoduodenal, or PEG) for patients who cannot take food and fluids orally 1, 3.
Management of Cerebral Edema and Increased ICP
Do not use corticosteroids for cerebral edema 1, 3, 2.
Use osmotherapy and hyperventilation for deteriorating patients 1, 3, 2.
Surgical decompression may be life-saving for large cerebellar infarctions with brainstem compression 1, 3.
Perform decompressive hemicraniectomy urgently for malignant MCA infarction before significant GCS decline or pupillary changes, ideally within 48 hours of onset 1, 3, 2.
Seizure Management
Treat new-onset seizures with short-acting medications (e.g., lorazepam IV) if not self-limiting 1, 3.
Do not use prophylactic anticonvulsants 1, 3.
Critical Time-Dependent Pitfalls to Avoid
Every 30-minute delay in recanalization decreases good functional outcome by 8-14% 4, 1, 2. Speed is absolutely critical in acute stroke management.
Failure to obtain follow-up imaging at 24 hours before starting antiplatelets or anticoagulants significantly increases hemorrhage risk 1, 2.
Inadequate blood pressure control before thrombolysis significantly increases symptomatic ICH risk 1, 2.
Overly selective treatment criteria may exclude patients who could benefit from therapy, as treatment delays and patient overselection should be avoided 4.
Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) can worsen outcomes 3.