What are the steps for symptomatic management of ischemic stroke?

Symptomatic Management of Acute Ischemic Stroke: Step-by-Step Protocol

Treat ischemic stroke as a life-threatening emergency requiring immediate, organized intervention with priority given to airway protection, cautious blood pressure management, and rapid assessment for reperfusion therapy. 1

Step 1: Immediate Life Support and Stabilization

Protect airway, breathing, and circulation first, especially in seriously ill or comatose patients. 1

• Assess and secure the airway immediately in patients with decreased consciousness, severe dysphagia, or risk of aspiration 2
• Maintain oxygen saturation >94% with supplemental oxygen as needed 2
• Establish IV access and begin continuous cardiac monitoring 2
• Perform mandatory swallow screening before any oral intake; if failed, maintain NPO status and consider NG tube for medications 3

Step 2: Blood Pressure Management

Lower elevated blood pressure cautiously—aggressive reduction can worsen ischemic injury. 1

Before Thrombolysis:

• Blood pressure must be <185/110 mmHg before alteplase administration 2
• Use labetalol (10-20 mg IV over 1-2 minutes, may repeat), nicardipine (5 mg/hour IV, titrate up by 2.5 mg/hour every 5-15 minutes to maximum 15 mg/hour), or clevidipine 2

During and After Thrombolysis:

• Maintain blood pressure ≤180/105 mmHg 2
• Monitor every 15 minutes during infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly until 24 hours 3, 2

Without Thrombolysis:

• Permit permissive hypertension unless blood pressure exceeds 220/120 mmHg or there are other compelling indications for treatment 1
• Induced hypertension with phenylephrine may improve outcomes in select patients with identified blood pressure thresholds, particularly those with multiple stenotic/occluded arteries 1

Step 3: Temperature Control

Treat fever aggressively as hyperthermia worsens neurological outcomes. 2

• Monitor temperature every 4 hours for the first 48 hours 2
• Treat any temperature >37.5°C with acetaminophen or other antipyretics 2
• Identify and treat infection sources (pneumonia, urinary tract infection) 2
• Avoid hypothermia except in clinical trial contexts 2

Step 4: Glucose Management

Maintain glucose between 140-180 mg/dL—both hyperglycemia and hypoglycemia worsen outcomes. 2

• Check glucose on arrival and monitor regularly 2
• Treat hyperglycemia with insulin to maintain target range 2
• Avoid hypoglycemia with close monitoring and appropriate dextrose administration if needed 2

Step 5: Cerebral Edema and Increased Intracranial Pressure

Do not use corticosteroids for cerebral edema—they are ineffective and potentially harmful. 1, 2

For Deteriorating Patients:

• Use osmotherapy (mannitol 0.25-0.5 g/kg IV or hypertonic saline 23.4% 30 mL bolus) 1, 2
• Consider hyperventilation as a temporizing measure (target PaCO2 30-35 mmHg) 1
• Elevate head of bed to 30 degrees 2

Surgical Interventions:

• Perform urgent decompressive hemicraniectomy for malignant MCA infarction within 48 hours of onset, before significant GCS decline or pupillary changes 2
• Surgical decompression and evacuation of large cerebellar infarctions causing brainstem compression and hydrocephalus is life-saving 1, 2
• Drain cerebrospinal fluid for hydrocephalus 1

Step 6: Seizure Management

Treat recurrent seizures with standard anticonvulsants, but do not use prophylactic anticonvulsants. 1, 2

• Use short-acting medications (lorazepam 2-4 mg IV) for acute seizures 2
• Start maintenance anticonvulsant (levetiracetam 500-1000 mg IV twice daily preferred due to minimal drug interactions) only after witnessed seizure 2
• Prophylactic anticonvulsants are not recommended and may worsen outcomes 1, 2

Step 7: Antiplatelet Therapy Timing

Administer aspirin 160-325 mg within 24-48 hours after stroke onset, but delay 24 hours if thrombolysis was given. 1, 2

• Aspirin provides reasonable safety and small benefit when started early 1
• Do not give aspirin or other antiplatelet agents within 24 hours of alteplase administration 1, 2
• Obtain repeat CT head at 24 hours to exclude hemorrhage before starting antiplatelets 2
• Aspirin is not a substitute for acute interventions like IV rtPA 1
• Clopidogrel's usefulness for acute ischemic stroke is not well established 1

Step 8: Anticoagulation Considerations

Do not routinely use urgent anticoagulation—it increases hemorrhage risk without proven benefit for early recurrent stroke prevention. 1

• Urgent anticoagulation has not been associated with lessening early recurrent stroke risk or improving outcomes 1
• Anticoagulation increases brain hemorrhage risk, especially in moderately severe strokes 1
• Low-dose subcutaneous heparin or low-molecular-weight heparin for DVT prophylaxis is reasonable after 24 hours 1

Step 9: Neuroprotective Agents

No neuroprotective medication has proven useful for acute ischemic stroke treatment. 1

• Despite numerous experimental studies showing promise, clinical trials of neuroprotective agents (glutamate antagonists, calcium channel blockers, free radical scavengers) have been disappointing 1
• Some treated patients had poorer outcomes or unacceptably high adverse event rates 1

Step 10: Stroke Unit Care and Early Mobilization

Admit all stroke patients to a geographically defined stroke unit with specialized staff—this reduces mortality and dependency. 1, 3, 2

• Comprehensive stroke unit care can be given to a broad spectrum of patients 1
• Begin rehabilitation assessment within 48 hours of admission 2
• Start frequent, brief out-of-bed activity within 24 hours if no contraindications 2
• Screen swallowing, nutrition, and hydration status on admission day 2

Step 11: Prevention and Treatment of Complications

Actively prevent and treat medical and neurological complications throughout hospitalization. 1

Aspiration Pneumonia Prevention:

• Mandatory swallow screening before any oral intake 3, 2
• Maintain aspiration precautions 3
• Consider speech therapy evaluation for formal swallow study 2

Deep Venous Thrombosis Prophylaxis:

• Intermittent pneumatic compression devices for all patients 2
• Subcutaneous heparin 5000 units twice daily or enoxaparin 40 mg daily after 24 hours if no hemorrhage 1

Hemorrhagic Transformation Monitoring:

• Petechiae are less important than hematomas, which can cause neurological decline 1
• Obtain emergent CT head for any sudden neurological worsening 3, 2
• Management depends on amount of bleeding and symptoms 1

Critical Pitfalls to Avoid

Every 30-minute delay in treatment decreases good functional outcome by 8-14%—speed is paramount. 3, 2

• Do not delay thrombolysis for additional testing beyond essential CT head and basic labs 3
• Do not withhold treatment based on stroke severity alone; high NIHSS is not a contraindication to therapy 3
• Failure to obtain follow-up imaging at 24 hours before starting antiplatelets or anticoagulants significantly increases hemorrhage risk 2
• Inadequate blood pressure control before thrombolysis dramatically increases symptomatic hemorrhage risk 2
• Do not use streptokinase or other thrombolytic agents as substitutes for rtPA—they cannot be safely substituted 1