What to give a stroke patient?

Acute Stroke Management

For acute ischemic stroke patients presenting within 3 hours of symptom onset, administer intravenous alteplase (tPA) 0.9 mg/kg (maximum 90 mg) with 10% as a bolus over 1 minute and 90% infused over 60 minutes—this is the standard of care with the strongest evidence for improved functional outcomes. 1

Immediate Actions Upon Presentation

Time-Critical Assessment

• Establish the exact time of symptom onset or last known normal time immediately—this single determination dictates all treatment eligibility. 2
• Obtain urgent non-contrast CT or MRI to exclude hemorrhage and assess for contraindications to thrombolysis. 1, 2
• Calculate the NIHSS score to quantify stroke severity and guide treatment decisions. 2
• Target door-to-tPA time of ≤60 minutes for eligible patients. 2

Blood Pressure Management Before tPA

• If systolic BP >185 mmHg or diastolic >110 mmHg, administer labetalol 10-20 mg IV over 1-2 minutes (may repeat once) or nicardipine drip starting at 5 mg/h, titrating by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h). 1
• Do not administer tPA if BP cannot be reduced and maintained below 185/110 mmHg. 1

Thrombolytic Therapy Protocol

Within 0-3 Hours of Symptom Onset

• Administer IV alteplase 0.9 mg/kg (maximum 90 mg): 10% as bolus over 1 minute, remaining 90% infused over 60 minutes. 1, 2
• This produces a number needed to treat of 8 for achieving minimal or no disability (mRS 0-1). 1, 2
• Favorable outcomes occur in 31-50% of tPA-treated patients versus 20-38% with placebo. 2

Within 3-4.5 Hours of Symptom Onset

• Administer the same tPA dosing regimen (0.9 mg/kg, maximum 90 mg) using identical administration protocol. 1
• Number needed to treat is 14 in this time window. 1
• The benefit decreases with time: odds ratio for favorable outcome is 2.81 within 90 minutes, declining to 1.40 at 3-4.5 hours. 2, 3

Critical Contraindications to Verify

• Do not give tPA to patients on direct oral anticoagulants (DOACs) until commercially available validated assessment tools for DOAC levels exist. 1
• **Verify INR <1.7 for patients on warfarin**, aPTT within normal limits, and platelet count >100,000. 1
• Exclude intracranial hemorrhage on imaging before any tPA administration. 1

Post-tPA Monitoring Protocol

Neurological and Vital Sign Monitoring

• Check BP and perform neurological assessments every 15 minutes during and for 2 hours after tPA infusion, then every 30 minutes for 6 hours, then hourly until 24 hours. 1, 2
• Maintain systolic BP ≤180 mmHg and diastolic ≤105 mmHg after tPA administration. 1
• If systolic BP 180-230 mmHg or diastolic 105-120 mmHg post-tPA: give labetalol 10 mg IV over 1-2 minutes, may repeat every 10-20 minutes (maximum 300 mg). 1

Management of Symptomatic Intracranial Hemorrhage

• If severe headache, acute hypertension, nausea, vomiting, or neurological worsening occurs: stop tPA infusion immediately, obtain emergency head CT, and administer cryoprecipitate 10 units over 10-30 minutes plus tranexamic acid 1000 mg IV over 10 minutes. 1

Delayed Antiplatelet Therapy

• Do not administer aspirin, heparin, or other antithrombotics within 24 hours of tPA. 1, 2, 3
• Obtain follow-up CT or MRI at 24 hours to exclude hemorrhage before starting any antiplatelet or anticoagulant therapy. 1
• After 24-hour scan excludes hemorrhage, start aspirin 81-325 mg daily indefinitely. 1

For Patients NOT Receiving tPA

Immediate Aspirin Administration

• Give aspirin 160-325 mg immediately after CT excludes hemorrhage and dysphagia screening is passed. 1, 2, 3
• Aspirin must be given within 48 hours of symptom onset to reduce risk of early recurrent ischemic stroke. 1
• In dysphagic patients, administer aspirin 80 mg via enteral tube or 325 mg rectal suppository. 1

Anticoagulation NOT Recommended

• Do not routinely use anticoagulation (unfractionated heparin, LMWH) in unselected acute ischemic stroke patients—this increases hemorrhage risk without proven benefit. 1, 2, 4

Mechanical Thrombectomy Consideration

Endovascular Therapy Criteria

• Consider mechanical thrombectomy with stent retrievers for patients with: age ≥18 years, pre-stroke mRS 0-1, internal carotid artery or proximal MCA (M1) occlusion, NIHSS ≥6, and ASPECTS ≥6 on CT. 2
• Thrombectomy produces 43.7% good outcomes (mRS 0-2) versus 28.2% with medical therapy alone (adjusted OR 2.1). 2
• Endovascular therapy may be considered for patients on DOACs who cannot receive tPA. 1

Blood Pressure Management for Non-tPA Candidates

Conservative Approach

• If systolic BP <220 mmHg or diastolic <120 mmHg: observe without antihypertensive treatment unless other end-organ damage exists (aortic dissection, acute MI, pulmonary edema). 1
• If systolic BP >220 mmHg or diastolic 121-140 mmHg: give labetalol 10-20 mg IV over 1-2 minutes (may repeat every 10 minutes, maximum 300 mg) or nicardipine 5 mg/h IV, titrating by 2.5 mg/h every 5 minutes (maximum 15 mg/h). 1
• Target a 10-15% reduction in BP, not normalization. 1

Critical Pitfalls to Avoid

• Never delay tPA administration for insertion of Foley catheters or other lines—insert these rapidly before tPA or defer until after infusion. 1
• Never use unproven neuroprotective agents like Cerebrolysin—no neuroprotective medication has demonstrated benefit in acute ischemic stroke. 3
• Never extend tPA treatment beyond 4.5 hours—the ATLANTIS trial showed no benefit and increased symptomatic ICH (7.0% vs 1.1%) and fatal ICH (3.0% vs 0.3%) when tPA was given 3-5 hours after onset. 5
• Never give prophylactic anticonvulsants in acute stroke—these are not indicated. 2