What is the management of acute ischemic stroke?

Management of Acute Ischemic Stroke

Immediate Prehospital Response

Activate 911/EMS immediately when stroke symptoms are recognized, as EMS use is strongly associated with faster hospital arrival and treatment within the critical 3-hour window. 1, 2

• Bystanders (family members, coworkers) account for 62-95% of emergency activations and are critical to rapid response 1
• EMS personnel should use validated stroke screening tools during transport 2
• Paramedics must provide prenotification to receiving hospitals, which significantly reduces door-to-needle times 2, 3
• Target door-to-needle time is less than 60 minutes 4

Emergency Department Evaluation (First 15-30 Minutes)

Obtain non-contrast head CT or MRI immediately upon arrival to exclude hemorrhage and determine eligibility for thrombolysis. 2

Essential Initial Workup

• Complete blood count, electrolytes, renal function, glucose, coagulation studies, ECG 2
• Standardized stroke severity assessment using NIHSS score 2
• Blood pressure monitoring every 15 minutes initially 1
• Fasting lipids, ESR/CRP 2

Imaging Requirements

• Brain CT or MRI must be completed within 24 hours of symptom onset, but ideally within minutes 2
• CT angiography to identify large vessel occlusion if mechanical thrombectomy is being considered 4
• MRI is more sensitive than CT for detecting acute ischemia within the first 24 hours 5

Acute Reperfusion Therapy (Within 3-4.5 Hours)

Administer IV alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) if the patient presents within 3 hours of clearly defined symptom onset—this is the single most beneficial proven intervention for acute ischemic stroke. 1, 2, 4

Alteplase Administration Protocol

• Give 10% as IV bolus over 1 minute, then remaining 90% infused over 60 minutes 4
• Do not delay IV alteplase even if endovascular treatment is being considered 4
• Extended window up to 4.5 hours may be appropriate for carefully selected patients 6

Blood Pressure Management for Thrombolysis Candidates

Blood pressure must be reduced to <185/110 mmHg before alteplase and maintained ≤180/105 mmHg during and for 24 hours after treatment. 1, 4

Pre-Thrombolysis BP Reduction (if >185/110 mmHg)

• Labetalol 10-20 mg IV over 1-2 minutes, may repeat once 1
• OR Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes to maximum 15 mg/h 1
• If BP cannot be controlled below 185/110 mmHg, do NOT administer rtPA 1

During and Post-Thrombolysis BP Management

• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1, 4
• If systolic BP 180-230 mmHg or diastolic BP 105-120 mmHg: use labetalol 10 mg IV followed by continuous infusion 2-8 mg/min, OR nicardipine 5 mg/h IV titrated to effect 1
• Avoid sublingual nifedipine and agents causing precipitous BP drops 2

Mechanical Thrombectomy (Within 6 Hours)

Proceed with mechanical thrombectomy using stent retriever devices if ALL criteria are met: prestroke mRS 0-1, causative large vessel occlusion on CTA, age ≥18 years, NIHSS ≥6, ASPECTS ≥6, and groin puncture can be initiated within 6 hours. 4

• Stent retrievers (Solitaire FR, Trevo) are preferred over coil retrievers 4
• Every 30-minute delay reduces probability of favorable outcome by approximately 10.6% 4
• Do not delay IV alteplase while arranging thrombectomy 4

Antiplatelet Therapy

Administer aspirin 325 mg orally within 24-48 hours after stroke onset for patients NOT receiving thrombolysis. 1, 2

Critical Timing Restrictions

• Do NOT give aspirin or other antiplatelet agents within 24 hours of IV thrombolysis 1, 4
• Delay aspirin initiation until after 24-hour post-thrombolysis CT excludes intracranial hemorrhage 4
• Aspirin is not a substitute for acute reperfusion interventions 1
• Clopidogrel alone for acute stroke treatment has uncertain benefit 1
• IV glycoprotein IIb/IIIa inhibitors (abciximab, eptifibatide) are NOT recommended outside clinical trials 1

Blood Pressure Management for Non-Thrombolysis Candidates

Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg in patients not receiving reperfusion therapy. 2

• Permissive hypertension allows maintenance of cerebral perfusion through collaterals 1
• Monitor BP frequently during the first 24 hours to identify extreme fluctuations 1
• Temporarily discontinue or reduce premorbid antihypertensive medications acutely 1

Stroke Unit Admission

Admit all stroke patients to a geographically defined stroke unit with specialized interdisciplinary staff—this reduces mortality and improves functional outcomes. 2, 4

Stroke Unit Components

• Specialized nursing staff with stroke expertise 2
• Interdisciplinary team: physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, pharmacists 2
• Continuous cardiac monitoring for at least 24 hours 7
• Written protocols defining processes and responsibilities 2

Early Mobilization and Rehabilitation

Begin frequent brief mobilization within 24 hours if no contraindications exist. 2, 4

• Early screening for swallowing difficulties before allowing oral intake 2
• Assessment of mobility, activities of daily living, incontinence, and mood 2
• Speech-language pathology evaluation for communication and swallowing deficits 2

Prevention of Acute Complications

Aspiration Pneumonia Prevention

• Perform swallowing assessment before any oral intake 2
• Nasogastric or nasoduodenal tube feeding if swallowing is impaired 2
• Percutaneous endoscopic gastrostomy if prolonged feeding support anticipated 2

Deep Venous Thrombosis Prophylaxis

• Subcutaneous anticoagulants or intermittent external compression stockings for immobilized patients 2
• Full-dose anticoagulation (IV or subcutaneous heparin) is NOT recommended for acute stroke treatment due to increased hemorrhage risk without outcome benefit 4

Other Complications

• Avoid indwelling bladder catheters when possible 2
• Monitor and treat fever, investigating infection sources 7
• Prevent pressure ulcers, falls, and manage pain 2

Management of Malignant Cerebral Edema

For patients with massive hemispheric infarction and deteriorating neurological condition, decompressive hemicraniectomy within 48 hours substantially reduces death and disability, particularly in patients <60 years old. 2, 7

Medical Management of Increased ICP

• Osmotherapy and hyperventilation for patients with herniation syndromes 2, 7
• Corticosteroids are NOT recommended—they provide no benefit and may cause harm 7
• Serial neurological examinations and repeat head CT when condition deteriorates 7
• Intubate patients with respiratory insufficiency to protect airway 7

Cerebellar Infarction with Mass Effect

• Ventriculostomy for symptomatic obstructive hydrocephalus 7
• Decompressive suboccipital craniectomy if brainstem compression present 7
• Transfer to neurosurgical center immediately—delaying transfer worsens outcomes 7

Glucose Management

Measure serum glucose immediately, as hypoglycemia can mimic stroke symptoms and requires prompt correction. 2

• Maintain normoglycemia during acute phase 8
• Hyperglycemia management protocols should be in place 8

Secondary Prevention Workup

Cardiac Evaluation

• Transthoracic echocardiography to assess for cardioembolic sources 4
• Consider transesophageal echocardiography if cardioembolic source suspected but not identified on transthoracic study 4
• Prolonged cardiac monitoring to detect paroxysmal atrial fibrillation 9

Vascular Imaging

• Urgent carotid duplex ultrasound for all patients with carotid territory symptoms who are potential revascularization candidates 2

Risk Factor Management

• Continue statin therapy during acute period if already taking statins at stroke onset 2
• Address all modifiable risk factors: hypertension, diabetes, hypercholesterolemia, smoking 9
• Appropriate antithrombotic therapy based on stroke etiology 2

Critical Pitfalls to Avoid

• Do NOT use volume expansion, vasodilators, or induced hypertension—these have been studied for decades without proven benefit 1
• Do NOT use neuroprotective agents—none have demonstrated efficacy in improving outcomes 2
• Do NOT delay transfer to comprehensive stroke center if patient requires neurosurgical evaluation 7
• Do NOT give antiplatelet agents within 24 hours of thrombolysis 1, 4
• Do NOT use corticosteroids for cerebral edema 7

Quality Metrics

Monitor and report the following to drive quality improvement 2:

• Door-to-needle times (target <60 minutes) 4
• Door-to-imaging times 2
• Thrombolysis treatment rates 2
• Mechanical thrombectomy rates for eligible patients 2
• Stroke unit admission rates 2
• 90-day functional outcomes 2