What is the acute management of ischemic and hemorrhagic stroke?

Acute Management of Stroke

Ischemic Stroke

Immediate Hyperacute Management (Within Minutes)

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) if the patient presents within 3-4.5 hours of clearly defined symptom onset, with 10% given as bolus over 1 minute and remaining 90% infused over 60 minutes. 1, 2, 3

• Target door-to-needle time of less than 60 minutes is critical, as every 30-minute delay reduces probability of favorable outcome by approximately 10.6% 2, 3
• Blood pressure must be reduced to <185/110 mmHg before alteplase administration and maintained ≤180/105 mmHg during and for 24 hours after treatment 2, 4, 3
• Obtain non-contrast CT brain immediately to exclude hemorrhage before initiating thrombolysis 4, 3
• Check blood glucose immediately and correct hypoglycemia with IV dextrose 3
• The 3-4.5 hour window represents an expansion from the original 3-hour window based on ECASS-3 trial data 1

Endovascular Thrombectomy Evaluation

Proceed with mechanical thrombectomy using stent retriever devices if ALL criteria are met: prestroke mRS 0-1, causative large vessel occlusion on CT angiography, age ≥18 years, NIHSS ≥6, ASPECTS ≥6, and groin puncture can be initiated within 6 hours of symptom onset. 2, 3

• Obtain CT angiography immediately to identify large vessel occlusion (internal carotid, middle cerebral, or basilar artery) 2, 4, 3
• Stent retrievers (Solitaire FR, Trevo) are preferred over coil retrievers (Merci) based on MR CLEAN, ESCAPE, SWIFT PRIME, EXTEND-IA, and REVASCAT trials 2
• Do not delay IV alteplase even if endovascular treatment is being considered - both therapies are complementary 2, 3
• Technical goal is reperfusion to modified TICI grade 2b/3 3

Post-Thrombolysis Monitoring Protocol

Monitor neurological status and vital signs every 15 minutes during and for 2 hours after alteplase infusion, then every 30 minutes for 6 hours, then hourly until 24 hours post-treatment. 2, 4, 3

• Maintain BP ≤180/105 mmHg throughout the 24-hour monitoring period 2, 4, 3
• Monitor for symptomatic intracranial hemorrhage, which occurs in approximately 6.4% of rtPA-treated patients 3, 5
• Maintain oxygen saturation >94% with supplemental oxygen 3
• Treat fever >38°C with antipyretics 3
• Initiate continuous cardiac monitoring for at least 24-48 hours to detect arrhythmias, particularly atrial fibrillation 4, 3

Antiplatelet Therapy Timing

Delay initiation of aspirin until after the 24-hour post-thrombolysis CT scan has excluded intracranial hemorrhage, then initiate aspirin 150-325 mg daily. 1, 2

• Do not administer antiplatelet agents or anticoagulants for 24 hours after rtPA due to increased bleeding risk 1, 2, 3
• For patients not receiving thrombolysis, aspirin 150-300 mg should be given as soon as possible after CT excludes hemorrhage (within 48 hours) 1
• Urgent anticoagulation is not recommended for acute ischemic stroke as it does not prevent early recurrent stroke or improve outcomes and increases hemorrhage risk 1, 2

Stroke Unit Care

Admit to a geographically defined stroke unit with specialized nursing staff and begin frequent brief mobilization within 24 hours if no contraindications. 1, 2, 4

• Stroke unit care reduces mortality and disability across all stroke types, ages, and severities 1
• Monitor closely for neurological deterioration over 24-72 hours, particularly with large MCA infarcts that can develop life-threatening edema 4
• Consider decompressive hemicraniectomy urgently (within 48 hours) for patients 18-60 years with significant middle cerebral artery infarction showing signs of malignant edema 1, 4

Secondary Prevention Workup

Obtain transthoracic echocardiography to assess for cardioembolic sources and consider transesophageal echocardiography if cardioembolic source is suspected but not identified. 2, 4

• Continuous cardiac monitoring for 24-48 hours to detect paroxysmal atrial fibrillation 4
• Initiate statin therapy for lipid lowering regardless of baseline levels 1
• Begin antihypertensive therapy for long-term blood pressure control before discharge 1

Blood Pressure Management (Non-Thrombolysis Candidates)

If blood pressure is extremely high (>220/120 mmHg), cautiously reduce by no more than 10-20% and observe for neurological deterioration. 1

• Preexisting antihypertensive therapy may be continued orally or via nasogastric tube if no symptomatic hypotension 1
• Avoid aggressive blood pressure lowering in acute phase as it may worsen cerebral perfusion 1

Hemorrhagic Stroke (Intracerebral Hemorrhage)

Blood Pressure Management

In ICH patients with history of hypertension, maintain mean arterial pressure below 130 mmHg. 1

• Aggressive blood pressure lowering is more appropriate in hemorrhagic than ischemic stroke 1

Surgical Considerations

Surgical evacuation may be undertaken for cerebellar hemisphere hematomas >3 cm diameter in selected patients. 1

• Routine surgery is not recommended for supratentorial hematoma 1
• Consider stereotactic surgery for deep ICH 1
• Consider craniotomy for superficial hematomas (<1 cm from surface) 1

Hemostatic Therapy

The use of recombinant factor VIIa (rFVIIa) is currently considered experimental and not recommended outside clinical trials. 1

Critical Pitfalls to Avoid

• Do not delay thrombolysis for advanced imaging (perfusion/diffusion MRI) if patient is otherwise eligible based on non-contrast CT 1
• Do not use full-dose anticoagulation (IV or subcutaneous heparin) in acute ischemic stroke as it increases hemorrhage risk without improving outcomes 1, 2
• Do not exclude patients from thrombolysis based on mild symptoms if they have disabling deficits, as this is a common reason for undertreatment 6
• Do not assume behavioral symptoms (confusion, agitation) are contraindications to thrombolysis - they may reflect the stroke pathology itself 4
• Only 15% of patients arrive within the treatment window, making public education about stroke symptoms and urgency critical 6