What is the immediate management for a patient presenting with ischemic stroke?

Immediate Management of Ischemic Stroke

Administer IV alteplase (0.9 mg/kg, maximum 90 mg) to eligible patients within 3 hours of symptom onset, with 10% as a bolus over 1 minute and 90% infused over 60 minutes, while simultaneously evaluating for endovascular thrombectomy in patients with large vessel occlusions. 1, 2

Time-Critical Initial Assessment

Perform non-contrast CT scan immediately upon arrival to rule out hemorrhage and identify early infarction signs, as this is the single most critical decision point for thrombolytic therapy. 2, 3 Complete CT angiography simultaneously to identify large vessel occlusions and their precise location, as this determines endovascular therapy eligibility. 2, 3

Document the exact time the patient was last known to be neurologically normal (last known well time), not when symptoms were discovered, as this determines all treatment eligibility windows. 2, 3

IV Alteplase Eligibility Criteria

Inclusion Requirements

• Clearly defined symptom onset within 3 hours (can be extended to 4.5 hours in selected patients). 1, 2
• Measurable neurologic deficit on NIHSS examination. 2, 3
• Age ≥18 years. 2, 3
• CT scan showing no hemorrhage. 2, 3

Critical Exclusion Criteria

• Blood pressure >185/110 mmHg (must be lowered first). 1, 3
• Platelet count <100,000. 3
• INR >1.7 or PT >15 seconds. 1, 3
• Glucose <50 or >400 mg/dL (may be reasonable after normalization). 1, 3
• Prior stroke or serious head injury within 3 months. 3
• Major surgery within 14 days. 1, 3
• History of intracranial hemorrhage. 3

Alteplase Administration Protocol

Dose: 0.9 mg/kg (maximum 90 mg total) with 10% given as IV bolus over 1 minute and the remaining 90% infused over 60 minutes. 1, 2, 3 This dosing regimen was validated in the ECASS III trial, which demonstrated improved clinical outcomes when administered between 3 and 4.5 hours after symptom onset. 4

Admit the patient to an intensive care or stroke unit for monitoring immediately after initiating treatment. 1

Blood Pressure Management Algorithm

Before alteplase: Blood pressure must be reduced to <185/110 mmHg using labetalol, nicardipine, or clevidipine. 2, 3 Do not administer alteplase until this target is achieved.

During and after alteplase: Maintain blood pressure ≤180/105 mmHg for at least 24 hours. 1, 2, 3

Monitoring frequency: Every 15 minutes during infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly until 24 hours. 1, 2, 3

Neurological Monitoring Protocol

Perform neurological assessments every 15 minutes during and for 2 hours after IV alteplase infusion, then every 30 minutes for 6 hours, then hourly until 24 hours after treatment. 1, 2, 3

If the patient develops severe headache, acute hypertension, nausea, vomiting, or worsening neurological examination: Discontinue the infusion immediately and obtain emergency head CT scan. 1, 3

Management of Symptomatic Intracranial Hemorrhage

If hemorrhage occurs within 24 hours of alteplase administration:

• Stop alteplase infusion immediately. 1
• Obtain CBC, PT (INR), aPTT, fibrinogen level, and type and cross-match. 1
• Perform emergent nonenhanced head CT. 1
• Administer cryoprecipitate 10 units infused over 10-30 minutes (includes factor VIII). 1
• Give tranexamic acid 1000 mg IV over 10 minutes OR ε-aminocaproic acid 4-5 g over 1 hour. 1
• Obtain immediate hematology and neurosurgery consultations. 1

Endovascular Thrombectomy Indications

Perform thrombectomy for proximal anterior circulation large vessel occlusion (internal carotid artery, M1 segment, proximal M2 segment) within 6 hours of symptom onset. 2, 3 This can be extended up to 24 hours in selected patients with favorable CT perfusion or MRI diffusion/perfusion mismatch. 2, 3

The optimal technique uses combined stent-retriever and aspiration (BADDASS approach), targeting reperfusion to modified TICI grade 2b/3. 2, 3 Every 30-minute delay in recanalization decreases good functional outcome by 8-14%. 2, 3

Post-Thrombolysis Care

Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if the patient can be safely managed without them. 1

Obtain follow-up CT or MRI scan at 24 hours after IV alteplase before starting anticoagulants or antiplatelet agents. 1, 2 Failure to obtain this imaging before starting antiplatelets or anticoagulants significantly increases hemorrhage risk. 2, 3

Early Antiplatelet Therapy

Start aspirin 160-325 mg within 24-48 hours after ruling out hemorrhage on follow-up imaging at 24 hours. 2, 3 This should be delayed for 24 hours if alteplase was administered. 3

Physiological Parameter Management

Temperature control: Monitor every 4 hours for the first 48 hours and treat fever >37.5°C with antipyretics. 2, 3

Oxygen management: Maintain oxygen saturation >94% with supplemental oxygen. 2

Cardiac monitoring: Initiate continuous cardiac monitoring for at least 24 hours to detect arrhythmias. 2

Glucose management: Monitor blood glucose regularly and treat hyperglycemia to maintain 140-180 mg/dL while avoiding hypoglycemia. 3

Stroke Unit Admission

Admit all stroke patients to a geographically defined stroke unit with specialized staff within 24 hours of arrival, as this reduces mortality and dependency. 2, 3 Begin rehabilitation assessment within 48 hours of admission. 3

Special Considerations for Extended Time Windows

For patients presenting between 3 and 4.5 hours, IV alteplase may be as effective as treatment in the 0- to 3-hour window and is reasonable. 1 However, additional exclusion criteria apply: age >80 years, NIHSS >25, history of both diabetes and prior stroke, and use of oral anticoagulants regardless of INR. 1

For patients with seizure at stroke onset, IV alteplase is reasonable if evidence suggests residual impairments are secondary to stroke and not a postictal phenomenon. 1

Critical Pitfalls to Avoid

Time is brain: Every 30-minute delay in recanalization decreases good functional outcome by 8-14%. 2, 3 Prioritize rapid door-to-needle time under 60 minutes. 2, 3

Blood pressure control: Inadequate blood pressure control before thrombolysis significantly increases symptomatic intracranial hemorrhage risk. 3 Never administer alteplase with BP >185/110 mmHg.

Imaging before antiplatelets: Failure to obtain follow-up imaging at 24 hours before starting antiplatelets or anticoagulants significantly increases hemorrhage risk. 2, 3