What is the immediate management of ischemic stroke in the emergency room (ER)?

Immediate Management of Ischemic Stroke in the Emergency Department

Administer intravenous tissue plasminogen activator (tPA) at 0.9 mg/kg (maximum 90 mg) with 10% as bolus and remainder over 60 minutes for eligible patients within 3 hours of symptom onset, as this improves neurological outcomes with 11-13 additional patients per 100 achieving normal or near-normal function at 3 months. 1, 2, 3

Time-Critical Initial Actions

Immediate Triage and Team Activation

• Triage stroke patients with the same priority as acute myocardial infarction or serious trauma, regardless of neurological deficit severity 2
• Activate the designated acute stroke team (physicians, nurses, laboratory/radiology personnel) immediately upon patient arrival 2
• Document the exact time of symptom onset—defined as when the patient was last known to be at baseline or symptom-free—as this determines treatment eligibility 2, 4

Stabilization (Simultaneous with Evaluation)

• Ensure airway, breathing, and circulation are stable while beginning stroke evaluation 2, 4
• Assess using the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity and guide treatment decisions 2, 4

Diagnostic Imaging Protocol

Non-Contrast CT Brain (Door-to-Scan Goal: ≤25 minutes)

• Perform non-contrast CT within 25 minutes of arrival to exclude hemorrhage and identify early ischemic changes 2, 4
• Achieve CT interpretation within 45 minutes of arrival for thrombolytic candidates 2, 4
• Consider multimodal imaging (CT perfusion, CT angiography) to evaluate cerebral blood flow and identify large vessel occlusion for potential endovascular therapy 2, 4

Essential Laboratory Tests

• Obtain blood glucose, electrolytes, renal function, and coagulation studies (PT/INR, aPTT) during initial evaluation 2, 4
• Perform 12-lead ECG due to high incidence of cardiac disease in stroke patients 2, 4

Acute Reperfusion Therapy

Intravenous tPA (3-Hour Window)

• Administer IV tPA 0.9 mg/kg (maximum 90 mg): 10% as bolus over 1 minute, remainder infused over 60 minutes 1, 2, 5
• This is a Grade 1A recommendation with strong evidence of benefit 1, 5
• Accept the 6% risk of symptomatic intracranial hemorrhage and 3% risk of fatal hemorrhage, as overall benefit outweighs risk 3

Extended Window (3-4.5 Hours)

• Consider tPA for patients presenting between 3-4.5 hours if they meet ECASS III criteria 2
• This represents a reasonable treatment option based on guideline evidence 1, 2

Endovascular Thrombectomy

• For large vessel occlusion, perform mechanical thrombectomy with stent retrievers aiming for TICI grade 2b/3 recanalization 1, 2
• Use proximal balloon guide catheter or large-bore distal-access catheter with stent retrievers for optimal results 1
• Intra-arterial thrombolysis is an option for major MCA occlusions <6 hours, but endovascular thrombectomy with stent retrievers is preferred as first-line therapy 1

Blood Pressure Management

Critical Caveat for tPA Recipients

• Control blood pressure carefully in patients receiving thrombolytic therapy to reduce hemorrhage risk 2, 4, 6
• For non-thrombolysis candidates, lower elevated blood pressure cautiously as overly aggressive reduction can worsen ischemia 1

Early Antiplatelet Therapy

For Non-Thrombolysis Patients

• Administer aspirin 160-325 mg daily within the first 48 hours for patients not receiving thrombolysis 1, 5
• This provides reasonable safety with small but meaningful benefit 1
• Do not use full-dose anticoagulation (IV or subcutaneous heparin/heparinoids) acutely, as this increases hemorrhage risk without proven benefit 1, 5

Hospital Admission and Monitoring

Stroke Unit Care

• Admit to dedicated stroke unit with monitored beds for at least 24 hours 2, 4
• Monitor neurological status frequently to detect early deterioration 2, 4
• Treat fever aggressively as it worsens neurological damage 2

Venous Thromboembolism Prophylaxis

• Begin intermittent pneumatic compression devices within 24 hours for immobile patients 2, 4, 5
• Use low-dose subcutaneous heparin or low molecular weight heparin for prophylaxis in non-hemorrhagic patients with restricted mobility 5

Systems of Care

Transport Decisions

• Transport patients rapidly to the closest certified primary stroke center or comprehensive stroke center 1, 2
• In some instances, this may involve air medical transport and hospital bypass to reach appropriate facilities 1
• Facilities providing initial care should develop capability for emergency noninvasive intracranial vascular imaging to select patients for transfer and reduce time to endovascular treatment 1

Critical Pitfalls to Avoid

Time-Dependent Outcomes

• Every 15-minute reduction in door-to-needle time decreases in-hospital mortality by 5% 2
• Delays in imaging interpretation, team mobilization, or protocol execution directly worsen patient outcomes 1, 2

Contraindications to Thrombolysis

• Do not administer tPA to patients with extensive, clearly identifiable hypodensity on CT 5
• Never substitute streptokinase or other thrombolytic agents for tPA—streptokinase is contraindicated 1, 5
• Strict adherence to NINDS selection criteria is mandatory for safe tPA use 1

Resource Requirements

• Endovascular therapy requires experienced stroke centers with immediate access to cerebral angiography and qualified neurointerventionalists 1
• Track outcomes for all patients and credential individuals performing intra-arterial revascularization procedures 1