What are the management strategies for acute stroke?

Acute Stroke Management

Immediate Recognition and Pre-Hospital Response

All suspected stroke patients must be transported immediately to a stroke-capable hospital with EMS pre-notification to activate stroke protocols before arrival. 1, 2

• EMS should use the FAST screening tool (Face drooping, Arm weakness, Speech difficulty, Time to call 911) to identify stroke—even a single abnormality indicates 72% probability of stroke 2
• Document the exact time the patient was last known to be normal (last known well time), not when symptoms were discovered, as this determines treatment eligibility 2
• For suspected large vessel occlusions, transport directly to comprehensive stroke centers capable of endovascular therapy rather than routing through primary stroke centers when feasible 2

Emergency Department Assessment and Imaging

Non-contrast CT scan must be performed immediately upon arrival to rule out hemorrhage, with a target door-to-imaging time under 25 minutes. 1, 2

• Complete CT angiography immediately to identify large vessel occlusions and their location 2
• Assess NIHSS score during parallel processing while imaging is being obtained 2
• Initial laboratory tests should include complete blood count, electrolytes, renal function, glucose, coagulation studies (PT/INR, aPTT), and cardiac biomarkers 3, 1

Intravenous Alteplase Administration

Administer IV alteplase (0.9 mg/kg, maximum 90 mg) to eligible patients within 3 hours of symptom onset, with a target door-to-needle time under 60 minutes. 3, 1, 2

Critical Inclusion Criteria:

• Clearly defined symptom onset within 3 hours 2
• Measurable neurologic deficit on NIHSS 2
• Age ≥18 years 2
• CT scan showing no hemorrhage 2

Absolute Exclusion Criteria:

• Blood pressure >185/110 mmHg (must be lowered first) 2
• Platelet count <100,000 2
• INR >1.6 or PT >15 seconds 2
• Glucose <50 or >400 mg/dL 2
• Prior stroke or serious head injury within 3 months 2
• Major surgery within 14 days 2
• History of intracranial hemorrhage 2
• Rapidly improving or minor symptoms 2

Dosing Protocol:

• Total dose: 0.9 mg/kg (maximum 90 mg) 2
• Give 10% as IV bolus over 1 minute 2
• Infuse remaining 90% over 60 minutes 2

Note on the 3-4.5 hour window: While the 2018 AHA guidelines 3 and ECASS III trial 4 support alteplase use up to 4.5 hours, a 2020 reanalysis adjusting for baseline imbalances found no significant benefits and continued harms in this extended window 5. The strongest evidence supports treatment within 3 hours, where benefit is unequivocal.

Blood Pressure Management

Before alteplase, blood pressure must be <185/110 mmHg; use labetalol, nicardipine, or clevidipine to achieve this target. 1, 2

• During and after alteplase infusion, maintain BP ≤180/105 mmHg 1, 2
• Monitor BP every 15 minutes during infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly until 24 hours 2
• For patients NOT receiving alteplase, avoid treating hypertension unless systolic BP >220 mmHg or diastolic BP >120 mmHg 1

Caveat: Low initial diastolic blood pressure and administration of IV antihypertensive medication have been associated with unfavorable outcomes 6, so avoid overly aggressive BP reduction.

Endovascular Thrombectomy

For proximal anterior circulation large vessel occlusions (ICA, M1, proximal M2), perform endovascular thrombectomy within 6 hours of symptom onset. 1, 2, 7

• Extended window up to 24 hours is appropriate in selected patients with favorable CT perfusion or MRI diffusion/perfusion mismatch 2
• Use combined stent-retriever and aspiration technique (BADDASS approach) for optimal recanalization 2
• Deploy stent-retriever with two-thirds beyond the thrombus and apply dual aspiration through balloon guide catheter and distal access catheter during retrieval 2
• Multiple randomized trials demonstrate substantial recanalization rates and improved outcomes compared with IV rtPA alone 7

Post-Alteplase Monitoring

Monitor neurological status every 15 minutes during and for 2 hours after infusion, every 30 minutes for the next 6 hours, then hourly until 24 hours. 2

Immediate Actions if Neurological Worsening Occurs:

• Stop alteplase infusion immediately 2
• Obtain emergent non-contrast head CT 2
• Check CBC, PT/INR, aPTT, fibrinogen, type and cross-match 2
• Administer cryoprecipitate and tranexamic acid or ε-aminocaproic acid 2
• Consult hematology and neurosurgery 2

Physiological Parameter Management

Temperature Control:

• Monitor temperature every 4 hours for the first 48 hours 1, 2
• Treat fever >37.5°C with antipyretics 1, 2
• Identify and treat sources of hyperthermia (infections, aspiration pneumonia) 1, 2
• Avoid hypothermia except in clinical trial contexts 2

Glucose Management:

• Monitor blood glucose regularly 1, 2
• Treat hyperglycemia to maintain 140-180 mg/dL 1, 2
• Avoid hypoglycemia with close monitoring 2

Early Antiplatelet Therapy

Start aspirin 160-325 mg within 24-48 hours after ruling out hemorrhage on follow-up imaging; delay for 24 hours if alteplase was given. 2

Stroke Unit Care

All stroke patients should be admitted to a geographically defined stroke unit with specialized staff within 24 hours of hospital arrival. 1, 2

• Stroke unit care significantly reduces mortality (OR 0.76) and dependency (OR 0.80) compared to general ward care 1
• Up to 30% of stroke patients deteriorate in the first 24 hours, supporting the need for intensive monitoring by nurses specifically trained in acute stroke care 3

Early Rehabilitation and Supportive Care

Begin rehabilitation assessment within 48 hours of admission and start frequent, brief out-of-bed activity within 24 hours if no contraindications exist. 1, 2

• Screen swallowing, nutrition, and hydration status on the day of admission 1, 2
• Patients who cannot take food and fluids orally should receive appropriate feeding (nasogastric, nasoduodenal, or PEG) 1

Management of Cerebral Edema and Increased ICP

Do not use corticosteroids for cerebral edema; use osmotherapy and hyperventilation for deteriorating patients. 1, 2

• For large cerebellar infarctions with brainstem compression, surgical decompression may be life-saving 1, 2
• For malignant MCA infarction, perform decompressive hemicraniectomy urgently before significant GCS decline or pupillary changes, ideally within 48 hours of onset 1, 2

Seizure Management

Treat new-onset seizures with short-acting medications (e.g., lorazepam IV) if not self-limiting; do not use prophylactic anticonvulsants. 1, 2

Telemedicine Support

For sites without in-house imaging interpretation expertise, FDA-approved teleradiology systems are recommended for timely review of brain imaging. 3

• Telestroke consultations, which include teleradiology, result in significantly more accurate IV alteplase eligibility decision making compared with telephone-only consultations 3
• IV alteplase administered guided by telestroke consultation may be as safe and beneficial as that of stroke centers 3

Critical Pitfalls to Avoid

Every 30-minute delay in recanalization decreases the chance of good functional outcome by 8-14%. 1, 2

• Failure to obtain follow-up imaging at 24 hours before starting antiplatelets increases hemorrhage risk 2
• Inadequate blood pressure control before thrombolysis significantly increases symptomatic intracranial hemorrhage risk 2
• Overly selective treatment criteria may exclude patients who could benefit from therapy 3
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) worsens outcomes 3, 1
• Overlooking the need for early rehabilitation delays recovery 1