What are the guidelines for managing ischemic stroke?

Ischemic Stroke Management Guidelines

Immediate Assessment and Diagnosis

All patients with suspected acute ischemic stroke must undergo non-contrast CT immediately to rule out hemorrhage and determine thrombolysis eligibility. 1, 2 This imaging should not be delayed for any reason, as time is critical for treatment decisions.

• Perform CT angiography (CTA) from arch-to-vertex for patients arriving within 6 hours who may be candidates for endovascular thrombectomy to identify large vessel occlusions 2
• Obtain 12-lead ECG to assess cardiac rhythm and identify atrial fibrillation, but do not delay thrombolysis assessment 1, 2

Intravenous Thrombolysis (rtPA/Alteplase)

Administer intravenous alteplase 0.9 mg/kg (maximum 90 mg) to eligible patients within 3 hours of symptom onset, with treatment extending to 4.5 hours for selected patients. 1, 2 This is the standard of care with the strongest evidence for improving outcomes.

Dosing Protocol

• Give 10% of total dose as intravenous bolus over 1 minute 1
• Infuse remaining 90% over 60 minutes 1
• Target door-to-needle time of less than 60 minutes in 90% of treated patients 1

Blood Pressure Requirements

• Before alteplase: Lower BP to <185/110 mmHg 1, 2
• During and after alteplase: Maintain BP <180/105 mmHg for 24 hours 1, 2
• Check BP every 15 minutes during and for 2 hours after infusion 2

Key Eligibility Criteria

• Age ≥18 years, all stroke severities 2
• Patients on antiplatelet monotherapy or dual antiplatelet therapy are eligible 2
• End-stage renal disease patients on hemodialysis with normal aPTT are eligible 2

Important caveat: The evidence strongly supports standard-dose (0.9 mg/kg) over low-dose (0.6 mg/kg) alteplase. A large trial predominantly in Asian patients showed that low-dose alteplase failed to meet noninferiority criteria for death or disability at 90 days, despite fewer symptomatic hemorrhages. 3 Do not substitute lower doses.

Endovascular Thrombectomy (EVT)

Perform EVT with stent retrievers as first-line therapy for patients with large vessel occlusions within 6 hours of onset. 2 This applies to both patients who received IV alteplase and those ineligible for it. 1, 2

• EVT should be delivered within a coordinated system with rapid neurovascular imaging access and specialized neurointerventional expertise 1

Antiplatelet Therapy

Administer oral aspirin 325 mg within 24-48 hours after stroke onset for patients not receiving thrombolysis. 4, 1, 2 This provides a small but significant reduction in early recurrent stroke and mortality.

Critical Timing Rules

• Do NOT give aspirin within 24 hours of rtPA administration 4, 2
• Aspirin is not a substitute for acute interventions like IV rtPA 4
• For minor stroke patients not receiving thrombolysis, dual antiplatelet therapy (aspirin plus clopidogrel) for 21 days begun within 24 hours can be beneficial for early secondary prevention 2

Agents NOT Recommended

• Clopidogrel alone for acute treatment is not well established 4
• Intravenous glycoprotein IIb/IIIa receptor inhibitors (abciximab, eptifibatide, tirofiban) are not recommended outside clinical trials 4

Blood Pressure Management

For Patients NOT Receiving Thrombolysis

Do not routinely treat blood pressure unless extremely elevated (SBP >220 mmHg or DBP >120 mmHg). 1, 2 When treatment is needed:

• Lower BP by approximately 15% (not more than 25%) over the first 24 hours 1, 2
• Target reduction helps prevent hemorrhagic transformation while maintaining cerebral perfusion

For Patients Receiving Thrombolysis

• Strict BP control as outlined above (<185/110 before, <180/105 after) 1, 2

Supportive Care and Monitoring

Admit all stroke patients to a geographically defined stroke unit with specialized staff within 24 hours of hospital arrival. 2 This comprehensive stroke unit care improves outcomes across a broad spectrum of patients. 4

Airway and Oxygenation

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

Temperature Management

• Identify and treat sources of hyperthermia (temperature >38°C) with antipyretics 1, 2

Glucose Management

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

Fluid Management

• Correct hypovolemia with intravenous normal saline 1

Early Mobilization

• Begin frequent, brief, out-of-bed activity within 24 hours if no contraindications 2
• Screen swallowing, nutritional, and hydration status on day of admission 2

Management of Complications

Cerebral Edema and Increased Intracranial Pressure

Do NOT use corticosteroids for cerebral edema management following ischemic stroke. 4, 1 Instead:

• Use osmotherapy and hyperventilation for patients deteriorating due to increased intracranial pressure, including herniation syndromes 4, 1
• Perform surgical drainage of cerebrospinal fluid for hydrocephalus 4, 1

Large Cerebellar Infarctions

Perform surgical decompression and evacuation for large cerebellar infarctions causing brain stem compression and hydrocephalus. 4, 1 This is a life-saving measure.

Seizure Management

• Treat recurrent seizures as with any acute neurological condition 4
• Do NOT give prophylactic anticonvulsants to patients without seizures 4

Hemorrhagic Transformation

• If symptomatic hemorrhage occurs within 24 hours of alteplase, stop infusion immediately and obtain emergent non-enhanced head CT 2
• The risk of symptomatic intracerebral hemorrhage with standard-dose alteplase is approximately 2.1%, with fatal events in 1.5% within 7 days 3

Common Pitfalls to Avoid

• Never delay imaging for any reason - CT must be performed immediately to determine treatment eligibility
• Never give aspirin within 24 hours of rtPA - this significantly increases hemorrhage risk 4, 2
• Never use low-dose alteplase (0.6 mg/kg) as standard practice - it failed noninferiority testing for primary outcomes 3
• Never treat blood pressure aggressively in non-thrombolysis candidates unless extremely elevated - overly aggressive BP lowering can worsen outcomes 1, 2
• Never use intravenous streptokinase - it cannot be safely substituted for rtPA 4