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

Immediate Treatment for Acute Ischemic Stroke

Administer intravenous alteplase (0.9 mg/kg, maximum 90 mg) immediately if the patient presents within 4.5 hours of symptom onset or last known well, following rapid CT scan to exclude hemorrhage and confirm eligibility. 1

Time-Critical Assessment and Imaging

• Perform non-contrast head CT immediately to exclude intracranial hemorrhage and identify early ischemic changes—this is the only imaging required before initiating thrombolysis. 1
• Do not delay treatment to pursue additional diagnostic studies beyond essential CT and basic laboratory tests (glucose, complete blood count, coagulation studies). 1
• Each 30-minute delay in recanalization decreases favorable functional outcomes by 8-14%. 2
• Determine the exact time of symptom onset; if uncertain, use the time the patient was last known to be neurologically normal. 1

Alteplase Administration Protocol (0-4.5 Hour Window)

For patients within 3 hours of onset:

• Alteplase 0.9 mg/kg (maximum 90 mg) is strongly recommended with Class I, Level B-R evidence. 1
• Administer 10% as IV bolus over 1 minute, then infuse remaining 90% over 60 minutes. 1, 2

For patients between 3-4.5 hours of onset:

• Alteplase is recommended for selected patients meeting specific criteria (Class I, Level B-R). 1
• Additional exclusion criteria for this window include: age >80 years, NIHSS >25, history of both diabetes and prior stroke, or oral anticoagulant use regardless of INR. 1
• However, these exclusions may not be justified in practice based on subsequent data analysis. 1

Critical Exclusion Criteria

Absolute contraindications include: 2

• Prior intracranial hemorrhage
• Blood pressure >185/110 mmHg unresponsive to treatment
• Glucose <50 mg/dL or >400 mg/dL
• INR >1.7, aPTT >15 seconds above normal, or platelets <100,000
• Recent major surgery or trauma
• Active bleeding or known bleeding diathesis

Blood Pressure Management During Thrombolysis

• Maintain BP ≤180/105 mmHg throughout treatment. 1, 2
• Monitor BP every 15 minutes during and for 2 hours after infusion, then every 30 minutes for 6 hours, then hourly until 24 hours. 1, 2
• If BP exceeds 180/105 mmHg, increase monitoring frequency and administer antihypertensive medications immediately. 1

Post-Thrombolysis Monitoring and Care

Neurological monitoring: 1, 2

• Perform neurological assessments every 15 minutes during and for 2 hours after infusion
• Continue every 30 minutes for 6 hours, then hourly until 24 hours
• Immediately stop alteplase infusion if patient develops severe headache, acute hypertension, nausea/vomiting, or neurological deterioration

Admit to intensive care or stroke unit for specialized monitoring and care. 1

Management of Symptomatic Intracranial Hemorrhage

If hemorrhage occurs within 24 hours: 1

• Stop alteplase infusion immediately
• Obtain emergent non-contrast head CT
• Send CBC, PT/INR, aPTT, fibrinogen level, type and cross-match
• Administer cryoprecipitate 10 units over 10-30 minutes
• Consider tranexamic acid 1000 mg IV over 10 minutes
• Obtain immediate hematology and neurosurgery consultations

Endovascular Thrombectomy Consideration

• Perform urgent CT angiography (aortic arch to vertex) immediately to identify large vessel occlusion, even while alteplase is being administered. 2
• Endovascular thrombectomy is indicated for internal carotid artery, M1, or proximal M2 occlusions and can be performed in conjunction with IV alteplase (bridge therapy). 2
• This is particularly important for severe strokes (high NIHSS scores) where large vessel occlusion is likely. 2

Antiplatelet and Anticoagulant Management

• Do not administer aspirin or other antiplatelet agents for 24 hours after alteplase administration. 2
• Obtain follow-up CT or MRI at 24 hours before starting any anticoagulants or antiplatelet agents. 1
• After 24 hours and hemorrhage exclusion, initiate aspirin 160-325 mg daily. 2
• Never administer glycoprotein IIb/IIIa inhibitors concurrently with alteplase (Class III: Harm). 2

Ancillary Care Measures

• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters unless absolutely necessary. 1
• Stabilize airway, breathing, and circulation, especially in seriously ill or comatose patients. 1
• Maintain normoglycemia and normothermia. 3
• Monitor for cardiac arrhythmias, particularly atrial fibrillation. 3

Common Pitfalls to Avoid

• Do not withhold treatment based solely on stroke severity—even NIHSS scores of 18-20 are appropriate for thrombolysis. 2
• Do not delay treatment for additional imaging beyond non-contrast CT unless considering endovascular therapy. 1
• Do not substitute streptokinase or other thrombolytic agents for alteplase—they are not safe alternatives. 1
• For mild strokes (low NIHSS) presenting in the 3-4.5 hour window, treatment may be reasonable after weighing risks versus benefits (Class IIb). 1