What are the initial management recommendations for post ischemic stroke?

Post Ischemic Stroke Management

All patients with acute ischemic stroke should be immediately admitted to a specialized stroke unit, undergo non-contrast CT to rule out hemorrhage, receive aspirin 160-325 mg within 24-48 hours (unless thrombolysis given), and have blood pressure managed conservatively unless severely elevated (>220/120 mmHg). 1

Immediate Assessment and Diagnosis

Imaging and Cardiac Evaluation:

• Perform non-contrast CT immediately upon arrival to exclude hemorrhagic stroke and determine thrombolysis eligibility 1
• Obtain CT angiography from arch-to-vertex for patients arriving within 6 hours who may be candidates for endovascular thrombectomy to identify large vessel occlusions 1
• Complete a 12-lead ECG to assess for atrial fibrillation and cardiac arrhythmias, but do not delay thrombolysis assessment 1
• Initiate cardiac monitoring for at least 24 hours to screen for paroxysmal atrial fibrillation 2

Laboratory Workup:

• Obtain complete blood count, electrolytes, renal function, fasting lipids, ESR/CRP, and glucose levels 2
• Check blood glucose immediately and treat hypoglycemia to achieve normoglycemia 3

Blood Pressure Management

For Patients NOT Receiving Thrombolysis:

• Avoid routine blood pressure lowering unless systolic BP >220 mmHg or diastolic BP >120 mmHg 3, 1
• The goal when treating is to lower blood pressure by 15% during the first 24 hours 3
• Critical pitfall: Do not aggressively lower blood pressure in watershed or hypoperfusion-related strokes, as these require adequate perfusion pressure to maintain cerebral blood flow 2, 4

For Patients Receiving Thrombolysis:

• Maintain strict BP control with target <185/110 mmHg before alteplase administration 1
• Keep BP <180/105 mmHg for at least 24 hours after thrombolysis 1, 2

Management of Hypotension:

• Identify and correct the underlying cause of arterial hypotension 3
• Correct hypovolemia with normal saline and treat cardiac arrhythmias that reduce cardiac output 3

Glucose Management

• Treat hypoglycemia immediately to achieve normoglycemia 3
• Treat persistent hyperglycemia >140 mg/dL, as it is associated with poor outcomes in the first 24 hours 3
• Administer insulin for glucose levels >140-185 mg/dL with close monitoring to avoid hypoglycemia 3

Antiplatelet Therapy

Timing and Dosing:

• Administer oral aspirin 160-325 mg within 24-48 hours after stroke onset for patients not receiving thrombolysis 1, 5, 6
• Do not give aspirin within 24 hours of rtPA administration 1, 4
• Low-dose aspirin (75-150 mg/day) has equivalent efficacy to higher doses with less gastrointestinal bleeding for long-term secondary prevention 7, 8

Dual Antiplatelet Therapy:

• Consider dual antiplatelet therapy (aspirin plus clopidogrel) only for minor noncardioembolic strokes and high-risk transient ischemic attacks, converting to single antiplatelet therapy after 21-90 days 3, 9
• Long-term dual antiplatelet therapy is not recommended for secondary stroke prevention 3

Stroke Unit Care and Monitoring

Admission and Specialized Care:

• Admit all stroke patients to a geographically defined stroke unit with specialized interdisciplinary staff within 24 hours of hospital arrival 1, 2, 4
• Transfer to intensive care unit if critically ill or at risk for malignant cerebral edema 2

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
• Do not provide supplemental oxygen to non-hypoxic patients, as it is not beneficial 3

Swallowing Assessment:

• Perform swallowing assessment before allowing any oral intake to prevent aspiration pneumonia 2, 4

Management of Neurological Complications

Cerebral Edema and Increased Intracranial Pressure:

• Monitor patients with major hemispheric or cerebellar infarctions closely for signs of brain edema and neurological worsening 3
• Do not use corticosteroids for cerebral edema management, as they are not effective 1
• Use osmotherapy and hyperventilation for patients deteriorating due to increased intracranial pressure or herniation syndromes 1
• Consider early neurosurgical consultation for patients with large territorial infarcts at risk for malignant swelling 2

Hydrocephalus:

• Place a ventricular drain for patients with acute hydrocephalus secondary to ischemic stroke, most commonly affecting the cerebellum 3
• Perform surgical drainage of cerebrospinal fluid for hydrocephalus 1

Cerebellar Infarction:

• Decompressive surgical evacuation of space-occupying cerebellar infarction is potentially life-saving with good clinical recovery 3

Seizures:

• Treat recurrent seizures after stroke in a manner similar to other acute neurological conditions 3
• Do not use prophylactic anticonvulsants, as no data support their routine use after stroke 3

Prevention of Complications

Venous Thromboembolism Prophylaxis:

• Use intermittent pneumatic compression devices for patients who cannot receive anticoagulation 2

Early Mobilization:

• Initiate early mobilization when the patient is neurologically stable 2

Fever Management:

• Monitor and treat fever (temperature >38°C) 2

Secondary Prevention Strategies

Diagnostic Workup for Stroke Etiology:

• Complete a comprehensive diagnostic workup to define ischemic stroke etiology and identify targets for treatment to reduce recurrent stroke risk 3
• Group prevention recommendations by etiologic subtype 3

Vascular Risk Factor Management:

• Initiate high-intensity statin therapy regardless of baseline cholesterol levels 4
• Optimize management of diabetes, hypertension, and dyslipidemia through intensive medical management, often with multidisciplinary teams 3

Carotid Stenosis Evaluation:

• Evaluate for carotid stenosis and perform urgent carotid revascularization (endarterectomy or stenting) within 2 weeks if ≥70% symptomatic stenosis is identified 2, 4

Lifestyle Modifications:

• Recommend low-salt and Mediterranean diets for stroke risk reduction 3
• Encourage physical activity in a supervised and safe manner, as stroke patients are at high risk for sedentary behavior 3
• Use programs that employ theoretical models of behavior change, proven techniques, and multidisciplinary support rather than simple advice 3

Critical Pitfalls to Avoid

• Do not aggressively lower blood pressure in watershed or hemodynamic strokes, as these result from hypoperfusion and require adequate perfusion pressure 2, 4
• Avoid routine therapeutic anticoagulation in acute non-cardioembolic stroke, as it increases hemorrhagic risk without proven benefit 2, 4
• Do not use hyperbaric oxygen therapy (except for air embolization), as it may be harmful 3
• Do not use induced hypothermia, as insufficient evidence exists to recommend it for acute stroke treatment 3
• Avoid combining antiplatelet and anticoagulation therapy for secondary stroke prevention, with very few exceptions 3
• Do not use glycoprotein IIb/IIIa inhibitors, as they increase mortality without benefit 4