What is the treatment for embolic stroke?

Treatment of Embolic Stroke

For acute embolic stroke presenting within 3 hours of symptom onset, administer IV alteplase (0.9 mg/kg, maximum 90 mg) immediately after excluding intracranial hemorrhage on CT imaging, followed by aspirin 160-325 mg within 24-48 hours. 1, 2, 3

Acute Phase Treatment Algorithm

Time-Dependent Thrombolysis

Within 0-3 hours of symptom onset:

• Administer IV recombinant tissue plasminogen activator (r-tPA/alteplase) 0.9 mg/kg (maximum 90 mg), with 10% given as bolus and remainder infused over 60 minutes (Grade 1A recommendation). 1, 2, 3
• This represents the strongest evidence-based intervention with proven mortality and morbidity benefit. 1

Within 3-4.5 hours of symptom onset:

• Consider IV r-tPA after careful risk-benefit assessment (Grade 2C recommendation—weaker evidence but still beneficial). 1, 2, 3
• The evidence is less robust in this window, but treatment can still improve functional outcomes. 2

Beyond 4.5 hours:

• Do NOT administer IV r-tPA (Grade 1B recommendation against use). 1, 2
• Instead, obtain CT angiography immediately to identify large vessel occlusions amenable to mechanical thrombectomy. 2

Alternative Reperfusion Strategies

For patients ineligible for IV thrombolysis with large vessel occlusion:

• Consider intraarterial r-tPA within 6 hours of symptom onset (Grade 2C recommendation). 1
• Mechanical thrombectomy may be considered in carefully selected patients, though evidence in 2012 guidelines suggested against routine use (Grade 2C). 1
• Note: More recent data (post-2015) has strengthened the role of mechanical thrombectomy, but the provided guidelines reflect 2012-2013 recommendations. 1

Early Antiplatelet Therapy

Aspirin administration:

• Give aspirin 160-325 mg within 24-48 hours after stroke onset (Grade 1A recommendation). 1, 3
• Critical timing caveat: If thrombolysis was administered, wait at least 24 hours before starting aspirin to minimize hemorrhagic risk. 3
• Aspirin is superior to therapeutic anticoagulation in the acute phase. 3, 4

Venous Thromboembolism Prophylaxis

For patients with restricted mobility:

• Use prophylactic-dose subcutaneous heparin (preferably low-molecular-weight heparin) OR intermittent pneumatic compression devices (Grade 2B recommendation). 1, 3
• Do NOT use elastic compression stockings (Grade 2B recommendation against). 1, 3
• Apply pneumatic compression within first 24 hours of admission. 3

Critical Contraindications and Pitfalls

Absolute contraindications to thrombolysis:

• Intracranial hemorrhage on CT or MRI imaging. 3
• Active therapeutic anticoagulation (elevated aPTT or INR). 4
• Recent major surgery or trauma. 1

Common pitfall: Therapeutic heparin use is incompatible with thrombolysis and dramatically increases hemorrhagic transformation risk. 4 If patient is on therapeutic heparin, verify aPTT has normalized before considering r-tPA. 4

Blood pressure management: While specific thresholds aren't detailed in these guidelines, uncontrolled severe hypertension increases bleeding risk with thrombolysis. 3

Secondary Prevention Based on Stroke Mechanism

For Cardioembolic Stroke (Atrial Fibrillation)

Long-term anticoagulation is mandatory:

• Oral anticoagulation is recommended over aspirin, no therapy, or dual antiplatelet therapy (Grade 1B recommendation). 1, 3
• Dabigatran 150 mg twice daily may be preferred over warfarin (Grade 2B recommendation). 3
• This represents the most critical intervention to prevent recurrent embolic events. 1

For Non-Cardioembolic Embolic Stroke

Long-term antiplatelet monotherapy:

• Choose ONE of the following (Grade 1A recommendation): 1, 3
  • Clopidogrel 75 mg once daily (preferred)
  • Aspirin/extended-release dipyridamole 25 mg/200 mg twice daily (preferred)
  • Aspirin 75-100 mg once daily
  • Cilostazol 100 mg twice daily

Hierarchy of preference:

• Clopidogrel or aspirin/extended-release dipyridamole are preferred over aspirin alone (Grade 2B recommendation). 1, 3
• Cilostazol is less preferred (Grade 2C recommendation). 1, 3

What NOT to use:

• Do NOT use oral anticoagulants for non-cardioembolic stroke (Grade 1B recommendation against). 1, 3
• Do NOT use combination clopidogrel plus aspirin long-term (Grade 1B recommendation against). 1, 3

Special Considerations for Embolic Stroke of Undetermined Source

For patients with embolic-appearing strokes without identified cardioembolic source or large artery atherosclerosis, recent trial evidence (NAVIGATE ESUS, RE-SPECT ESUS, ARCADIA) found no benefit of anticoagulation over aspirin. 5 Therefore, treat with antiplatelet therapy as outlined above rather than empiric anticoagulation. 5

Timing and Logistics

Critical time benchmarks:

• CT imaging must be completed within 45 minutes of emergency department arrival. 3
• Door-to-needle time for thrombolysis should be minimized. 1
• Document exact time of symptom onset or last known well time. 2

Post-thrombolysis monitoring:

• Monitor for symptomatic intracerebral hemorrhage, which occurs in approximately 2.1% of patients receiving standard-dose alteplase. 6
• Fatal hemorrhagic events occur in approximately 1.5% within 7 days. 6