What is the approach for managing stuttering stroke and when to consider thrombolysis with tissue plasminogen activator (tPA)?

Management of Stuttering Stroke and Thrombolysis Decision-Making

In stuttering stroke (progressive or fluctuating neurological deficits), thrombolysis should be administered if the patient meets standard eligibility criteria and presents within the appropriate time window, treating the time of maximal deficit onset as the reference point for the therapeutic window. 1

Defining Stuttering Stroke

Stuttering stroke refers to acute ischemic stroke with stepwise progression or fluctuating neurological symptoms, often indicating evolving thrombosis or recurrent embolization. 1 The key challenge is determining symptom onset time and whether deficits are truly worsening versus resolving spontaneously.

Critical Decision Algorithm for Thrombolysis

Time Window Assessment

• Within 3 hours of maximal deficit onset: Administer IV rtPA (0.9 mg/kg, maximum 90 mg) if all eligibility criteria are met—this is a Class I, Level A recommendation. 1

• Between 3-4.5 hours of maximal deficit onset: Consider IV rtPA using ECASS III criteria (Grade 2C recommendation), though this remains off-label FDA use. 1

• Beyond 4.5 hours: Do not administer IV rtPA (Grade 1B recommendation against use). 1

Determining "Symptom Onset" in Fluctuating Deficits

The critical pitfall in stuttering stroke is incorrectly calculating the time window. Use the time when the patient reached their current maximal neurological deficit as the reference point, not the time of initial mild symptoms. 1

• If symptoms are actively worsening at presentation, the "clock" starts when they reach their peak severity. 1

• If symptoms have stabilized after fluctuation, use the time they last worsened to maximal deficit. 1

Exclusion Criteria Specific to Stuttering Presentation

Do NOT thrombolyse if:

• Neurological signs are clearing spontaneously at the time of evaluation—this suggests TIA rather than completed stroke. 1

• Symptoms are minor and isolated (though recent evidence suggests even minor strokes may benefit from dual antiplatelet therapy rather than thrombolysis). 2

• Blood pressure cannot be controlled below 185/110 mmHg before treatment initiation. 1, 3, 4

• INR ≥1.7 if on warfarin, or if on novel oral anticoagulants with prolonged thrombin time or aPTT (no reliable reversal available). 1, 5

• CT shows hypodensity >1/3 of MCA territory or evidence of hemorrhagic transformation. 1, 6

Standard Eligibility Checklist

All standard NINDS criteria must be met 1:

• Measurable neurological deficit on examination
• No intracranial hemorrhage on CT
• No recent major surgery (14 days), GI/GU bleeding (21 days), or arterial puncture at non-compressible site (7 days)
• No head trauma or prior stroke in previous 3 months
• Platelet count >100,000/mm³
• Blood glucose >50 mg/dL
• No seizure with postictal residual deficits

Treatment Protocol

Once the decision to thrombolyse is made, treat with maximum urgency—every 30-minute delay decreases probability of good functional outcome by 8-14%. 3

Dosing and Administration

• Administer 0.9 mg/kg IV rtPA (maximum 90 mg total dose). 1, 3
• Give 10% as bolus over 1 minute, remaining 90% infused over 60 minutes. 1, 6

Post-Thrombolysis Monitoring

• Neurological assessments every 15 minutes during infusion, every 30 minutes for 6 hours, then hourly until 24 hours. 1, 3
• Blood pressure monitoring every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly. 1
• Maintain BP <180/105 mmHg post-thrombolysis. 1, 3
• Delay antiplatelet and anticoagulant therapy for 24 hours. 1, 6
• Obtain follow-up CT at 24 hours before starting antithrombotics. 1

Alternative Management if Thrombolysis Contraindicated

If the patient does not meet thrombolysis criteria:

• Initiate aspirin 160-325 mg within 24-48 hours (Grade 1A). 1
• Consider mechanical thrombectomy if large vessel occlusion documented and patient presents within 6-24 hours with favorable imaging. 3, 4, 6
• Consider intraarterial thrombolysis for basilar artery occlusion up to 6-12 hours (Grade 2C). 3, 6

Common Pitfalls to Avoid

• Do not delay treatment to obtain "perfect" history in fluctuating symptoms—use best clinical judgment on maximal deficit timing. 1, 3

• Do not withhold thrombolysis solely because symptoms fluctuated earlier if patient now has stable, significant deficit within time window. 1

• Do not administer thrombolysis if actively witnessing symptom resolution, as this suggests TIA. 1

• Do not use overly restrictive criteria that exclude patients who could benefit—the NINDS criteria are designed to be inclusive. 3

• Do not proceed if unable to adequately control blood pressure below 185/110 mmHg pre-treatment, as this dramatically increases hemorrhage risk. 1, 3