What are the guidelines for managing acute ischemic and hemorrhagic stroke?

Acute Stroke Management

Initial Assessment and Imaging

All patients with suspected stroke must undergo immediate non-contrast CT scan to differentiate ischemic from hemorrhagic stroke before initiating any therapy, with a target door-to-needle time of less than 60 minutes in 90% of treated patients. 1

• ECG should be performed to assess baseline cardiac rhythm, but this must not delay thrombolysis assessment 1
• CT angiography should be performed immediately after non-contrast CT in patients presenting within 6 hours who are potential candidates for endovascular thrombectomy to identify large vessel occlusions 1, 2

---

Acute Ischemic Stroke Management

Intravenous Thrombolysis with Alteplase (rtPA)

Eligible patients must receive intravenous alteplase as soon as possible after hospital arrival, ideally within 3 hours of symptom onset, with extension to 4.5 hours in selected patients. 1, 2

Dosing and administration:

• Standard dose is 0.9 mg/kg (maximum 90 mg total): 10% as IV bolus over 1 minute, remaining 90% as IV infusion over 60 minutes 1, 2
• Lower doses (0.6 mg/kg) are NOT recommended despite reduced hemorrhage risk, as they failed to demonstrate non-inferiority for death and disability outcomes 3

Critical blood pressure requirements:

• Blood pressure MUST be lowered and maintained below 185/110 mmHg BEFORE rtPA administration 1, 2
• Blood pressure MUST be maintained below 180/105 mmHg for at least 24 hours AFTER treatment 1, 2
• These strict thresholds are non-negotiable for thrombolysis eligibility 1

Key contraindications and risk factors for hemorrhagic transformation:

• Severe initial clinical deficit (higher NIHSS scores) increases hemorrhagic infarction risk 2.5-fold 4
• Early ischemic changes on CT increase hemorrhagic infarction risk 3.5-fold 4
• Increasing age and rtPA treatment itself increase parenchymal hemorrhage risk 4
• Symptomatic intracerebral hemorrhage occurs in approximately 2% of standard-dose treated patients 3

Endovascular Thrombectomy (EVT)

EVT is indicated for patients with large vessel occlusions, including both those who have received IV alteplase and those ineligible for IV alteplase. 1, 2

• CT angiography must be performed to identify large vessel occlusions amenable to EVT 1, 2
• EVT should be delivered within a coordinated system with rapid neurovascular imaging access and specialized neurointerventional expertise 1

Antiplatelet Therapy

Oral aspirin 325 mg should be administered within 24-48 hours after stroke onset for patients NOT receiving thrombolysis. 1, 2

• Aspirin must NOT be administered within 24 hours of rtPA treatment 1, 2
• Urgent anticoagulation is NOT recommended for acute ischemic stroke due to increased bleeding risk 2

Blood Pressure Management in Ischemic Stroke

For patients NOT receiving thrombolysis, withhold antihypertensive medications unless systolic BP >220 mmHg or diastolic BP >120 mmHg. 1, 2

• A reasonable goal is to lower BP by 15% during the first 24 hours in patients with markedly elevated BP not receiving thrombolysis 1
• Very high BP (>185/110 mmHg) must be treated in patients eligible for thrombolytic therapy 1, 2

---

Acute Hemorrhagic Stroke Management

Blood Pressure Management in Intracerebral Hemorrhage (ICH)

For ICH patients with systolic BP between 150-220 mmHg without contraindications, acute lowering of systolic BP to 140 mmHg is safe and may improve functional outcomes. 2

• Blood pressure should be assessed upon ED arrival and every 15 minutes until stable 2

Reversal of Coagulopathy

Patients with severe coagulation factor deficiency or severe thrombocytopenia must receive appropriate factor replacement therapy or platelets. 2

For patients on vitamin K antagonists with elevated INR:

• Immediately discontinue the medication 2
• Administer therapy to replace vitamin K-dependent factors 2
• Correct INR 2
• Give intravenous vitamin K 2

Management of Increased Intracranial Pressure

Surgical decompression and evacuation is recommended for large cerebellar infarctions causing brainstem compression and hydrocephalus. 1, 2

• Osmotherapy and hyperventilation are recommended for patients deteriorating from increased intracranial pressure 1, 2
• Corticosteroids are NOT recommended for managing cerebral edema following ischemic stroke 1

---

Supportive Care (Both Stroke Types)

Temperature Management

• Normothermia is preferred; treat fever >38°C (sources recommend >37.5°C or >38°C) 1, 2

Glucose Management

• Treat hypoglycemia (blood glucose <60 mg/dL) to achieve normoglycemia 1, 2
• Treat hyperglycemia to achieve blood glucose 140-180 mg/dL 1, 2

Airway and Oxygenation

• Provide airway support and ventilatory assistance for patients with decreased consciousness or bulbar dysfunction 1, 2
• Administer supplemental oxygen to maintain oxygen saturation >94% 1, 2

Hydration and Nutrition

• Correct hypovolemia with intravenous normal saline 1, 2
• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 2

Complication Prevention

• Initiate intermittent pneumatic compression for venous thromboembolism prevention on day of hospital admission 2
• Early mobilization is strongly recommended to prevent complications 1, 2

Stroke Unit Care

• Comprehensive stroke unit care with specialized rehabilitation should be initiated as early as medically possible 1
• Manage modifiable risk factors including blood pressure and cholesterol 1
• Prescribe appropriate antithrombotic therapy based on stroke etiology 1