What are the guidelines for managing ischemic stroke patients not treated with thrombolysis?

Management of Acute Ischemic Stroke Without Thrombolysis

For patients with acute ischemic stroke who are not receiving thrombolytic therapy, immediate admission to a specialized stroke unit with early aspirin therapy (160-325 mg within 24-48 hours), permissive hypertension (avoiding blood pressure treatment unless >220/120 mmHg), and aggressive prevention of complications represents the evidence-based standard of care. 1, 2, 3

Immediate Stabilization and Assessment

Airway, Breathing, and Circulation

• Rapidly assess and secure airway, breathing, and circulation as the first priority 2
• Provide supplemental oxygen only if oxygen saturation falls below 94% 1, 2
• Support airway and provide ventilatory assistance for patients with decreased consciousness or bulbar dysfunction 4

Neurological Assessment

• Perform standardized neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to determine stroke severity and focal deficits 2
• Obtain urgent non-contrast CT scan to exclude hemorrhage and assess for structural causes 2
• Consider CT angiography to identify large vessel occlusions that may still be eligible for endovascular thrombectomy even without thrombolysis 2

Blood Pressure Management

Permissive Hypertension Approach

Do not treat blood pressure unless it exceeds 220/120 mmHg, as permissive hypertension is the standard approach for the first 48-72 hours. 5, 2 The rationale is that cerebral autoregulation is impaired in acute stroke, making cerebral perfusion directly dependent on systemic blood pressure—aggressive lowering can extend the infarct 5

When Treatment Is Required

• If blood pressure reaches ≥220/120 mmHg, lower blood pressure carefully by approximately 15% (not more than 25%) over the first 24 hours 1, 5
• Use easily titrated parenteral agents such as labetalol (10-20 mg IV over 1-2 minutes, may repeat) or nicardipine (5 mg/hr IV infusion) 5
• Avoid sublingual nifedipine due to risk of precipitous blood pressure decline 1
• Avoid excessive acute drops in systolic blood pressure >70 mmHg, as this may cause acute renal injury and early neurological deterioration 5

Hypotension Management

• Promptly investigate causes including aortic dissection, volume depletion, myocardial ischemia, or cardiac arrhythmias 1
• Correct hypovolemia with normal saline and optimize cardiac output 1, 4
• Use vasopressor agents such as dopamine if volume replacement is ineffective 1

Antiplatelet Therapy

Initiate early aspirin therapy at 160-325 mg daily within 24-48 hours of stroke onset for patients not receiving thrombolysis. 2, 3 This represents a Grade 1A recommendation with strong evidence for reducing early recurrence 3

Stroke Unit Care

Admit all patients to a specialized comprehensive stroke unit as soon as possible, ideally within 3 hours of hospital arrival. 1, 2 Stroke unit care incorporating comprehensive rehabilitation reduces mortality and improves functional outcomes with benefits comparable to IV thrombolysis 2

Prevention of Acute Complications

Deep Vein Thrombosis Prophylaxis

• Administer subcutaneous anticoagulants (low-dose heparin or low-molecular-weight heparin) for immobilized patients 1, 3
• Use intermittent external compression stockings or aspirin for patients who cannot receive anticoagulants 1
• Initiate intermittent pneumatic compression on the day of hospital admission 4

Aspiration and Pneumonia Prevention

• Perform bedside dysphagia screening before allowing any oral intake 2, 4
• Use formal screening procedures to reduce risk of aspiration pneumonia 4
• Patients with brain stem infarctions, multiple strokes, large hemispheric lesions, or depressed consciousness are at greatest risk 1
• A water swallow test at bedside is useful for screening; videofluoroscopic modified barium swallow can be performed if indicated 1

Nutrition Support

• Maintain adequate nutrition as malnutrition interferes with stroke recovery 1
• Insert nasogastric or nasoduodenal tube when necessary for feedings and medication administration 1
• Consider percutaneous endoscopic gastric tube if prolonged feeding support is anticipated 1
• Correct hypovolemia with intravenous normal saline 4

Infection Management

• Administer antibiotics early for pneumonia, which is an important cause of death following stroke 1
• Treat urinary tract infections promptly as secondary sepsis develops in approximately 5% of patients 1
• Avoid indwelling bladder catheters when possible due to infection risk; use intermittent catheterization or urinary acidification instead 1

Temperature Management

• Monitor temperature routinely and treat if above 37.5°C (some guidelines use >38°C threshold) as hyperthermia is associated with increased morbidity and mortality 2, 4
• Normothermia is preferred 4

Glucose Management

• Rapidly measure and correct hypoglycemia (glucose <60 mg/dL) as it can cause focal neurological signs mimicking stroke and lead to brain injury 1, 4
• Treat hyperglycemia to achieve blood glucose levels in the range of 140-180 mg/dL 4
• While hyperglycemia is associated with poor outcomes, the optimal management strategy remains uncertain 1

Early Mobilization

• Implement early mobilization to prevent subacute complications including pressure sores, orthopedic complications, and contractures 1, 4

Management of Neurological Complications

Cerebral Edema and Increased Intracranial Pressure

• Brain edema typically peaks at 3-5 days after stroke and affects less than 10-20% of patients 1
• Patients with multilobar infarctions from major intracranial artery occlusions are at highest risk 1
• Use osmoterapi and hyperventilation for patients deteriorating from increased intracranial pressure 4
• Perform decompressive surgery and evacuation for large cerebellar infarctions causing brain stem compression and hydrocephalus 4

Seizure Management

• Treat seizures as they represent an important acute neurological complication 1

Hemorrhagic Transformation

• Monitor for hemorrhagic transformation of the infarction with or without hematoma formation 1

Consideration for Endovascular Therapy

Evaluate all patients for potential endovascular thrombectomy, as patients with large vessel occlusion may still be candidates even when IV thrombolysis is contraindicated. 2 Eligible patients with large vessel occlusion who can be treated within 6 hours of symptom onset should receive endovascular therapy 2

Secondary Prevention After Stabilization

Long-term Blood Pressure Management

• Initiate or restart antihypertensive therapy if blood pressure remains ≥140/90 mmHg in stable patients after 3 days post-stroke for long-term secondary prevention 5

Evaluation for Stroke Etiology

• Perform evaluation to determine the most likely cause of stroke 1
• Obtain baseline ECG to assess for atrial fibrillation or structural heart disease 2
• Initiate appropriate medical or surgical therapies to prevent recurrent ischemic events 1

Critical Pitfalls to Avoid

• Do not treat blood pressure <220/120 mmHg in acute ischemic stroke not receiving thrombolysis, as this is ineffective and potentially harmful 5
• Do not lower blood pressure rapidly or aggressively; avoid precipitous falls 5
• Do not use urgent anticoagulation for acute ischemic stroke due to increased bleeding risk 4
• Do not forget to restart antihypertensive medications after 3 days in patients with pre-existing hypertension 5
• Do not allow oral intake before dysphagia screening 2, 4