What are the management and therapeutic options for ischemic and hemorrhagic stroke?

Stroke Management and Therapeutics

Acute Ischemic Stroke: Reperfusion Therapy

For patients with acute ischemic stroke presenting within 3 hours of symptom onset, administer intravenous alteplase (0.9 mg/kg, maximum 90 mg) immediately after excluding hemorrhage on CT scan. 1, 2

Time-Based Treatment Algorithm

• 0-3 hours from onset: IV alteplase is strongly recommended (Grade 1A) 1
• 3-4.5 hours from onset: IV alteplase is suggested but with weaker evidence (Grade 2C) 1; clinical trial data demonstrates significant improvement in functional outcomes (52.4% vs 45.2% favorable outcomes) despite increased symptomatic hemorrhage risk (2.4% vs 0.2%) 3
• >4.5 hours from onset: IV alteplase is NOT recommended (Grade 1B) 1
• Up to 6 hours for proximal vessel occlusions: Consider intra-arterial alteplase if IV therapy is contraindicated (Grade 2C) 1

Pre-Treatment Requirements

• Blood pressure must be <185/110 mmHg before administering alteplase 2
• Non-contrast CT scan must exclude intracranial hemorrhage 2
• Use validated stroke severity scale (NIHSS) to document baseline deficit 2

Endovascular Therapy

For large vessel occlusions (LVO), combined stent-retriever and aspiration techniques should be used to achieve fast first-pass complete reperfusion. 1 Every 30-minute delay in recanalization decreases the probability of good functional outcome by 8-14% 1, 2. The current approach should prioritize asking "which patients should NOT be treated?" rather than limiting treatment to narrow guideline criteria 1.

Acute Ischemic Stroke: Antiplatelet Therapy

Initiate aspirin 160-325 mg within 48 hours of symptom onset for all patients not receiving thrombolysis. 1, 4

• Aspirin is strongly preferred over therapeutic anticoagulation in the acute phase (Grade 1A) 1
• For patients who received thrombolysis, delay aspirin for 24 hours and confirm no hemorrhagic transformation on follow-up imaging 4, 5

Venous Thromboembolism Prophylaxis

For patients with restricted mobility after ischemic stroke, initiate prophylactic-dose LMWH (preferred over UFH) or apply intermittent pneumatic compression devices within 24 hours. 1, 4

Timing After Thrombolysis

• Wait 24 hours after IV alteplase before starting pharmacologic VTE prophylaxis 4, 5
• Confirm absence of hemorrhagic transformation on imaging before initiating anticoagulation 4, 5
• Apply pneumatic compression devices immediately (within 24 hours of admission) as they carry no bleeding risk 4, 5

Contraindications to Prophylactic Anticoagulation

• Active intracranial hemorrhage (absolute contraindication) 4
• Severe hemorrhagic transformation (HI2, PH1, PH2 classification) - delay 7-10 days 4, 5
• Minor hemorrhagic transformation (HI1) - may initiate after 24-48 hours if no progression 4, 5
• Large ischemic strokes - delay 5-7 days until hemorrhagic transformation risk decreases 4

Do NOT use elastic compression stockings alone for VTE prophylaxis (Grade 2B) 1, 5

Blood Pressure Management

For patients NOT receiving thrombolysis, avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg. 2

• Exception: Treat hypertension emergently if concurrent acute MI, aortic dissection, acute renal failure, acute pulmonary edema, or preeclampsia/eclampsia 2
• For thrombolysis candidates, BP must be reduced to <185/110 mmHg before treatment 2

Hemorrhagic Stroke Management

For primary intracerebral hemorrhage with restricted mobility, delay prophylactic anticoagulation until days 2-4 and only after follow-up imaging confirms no hemorrhage expansion. 1, 4

• Prefer LMWH over UFH when initiating prophylaxis (Grade 2B) 1
• Intermittent pneumatic compression devices are the safer alternative to avoid rebleeding risk 1, 4
• Do NOT use elastic compression stockings (Grade 2B) 1

Physiological Management

Glucose Control

• Monitor blood glucose regularly and treat hyperglycemia to maintain levels <300 mg/dL (<16.63 mmol/L) 2

Temperature Management

• Identify and treat sources of fever; use antipyretics for elevated temperatures 2

Oxygenation

• Provide supplemental oxygen to maintain saturation ≥94% 2
• Intubate if airway compromised or inadequate ventilation 2

Cerebral Edema and Increased Intracranial Pressure

Do NOT use corticosteroids for cerebral edema in stroke patients. 2

• Use osmotic therapy and hyperventilation for patients who deteriorate neurologically 2
• Surgical decompression is necessary for large cerebellar infarcts causing brainstem compression and hydrocephalus 2

Long-Term Secondary Prevention (Non-Cardioembolic Stroke)

For long-term prevention after non-cardioembolic ischemic stroke, prescribe clopidogrel 75 mg daily OR aspirin/extended-release dipyridamole 25/200 mg twice daily as first-line agents. 1

• These agents are preferred over aspirin alone (Grade 2B) 1
• Do NOT use combination clopidogrel plus aspirin long-term (Grade 1B) 1
• Aspirin alone (75-100 mg daily) is acceptable but less preferred 1

Long-Term Prevention (Cardioembolic Stroke with Atrial Fibrillation)

For patients with ischemic stroke/TIA and atrial fibrillation, prescribe oral anticoagulation over antiplatelet therapy. 1

• Oral anticoagulation is strongly preferred over aspirin (Grade 1B) 1
• Oral anticoagulation is preferred over aspirin plus clopidogrel combination (Grade 1B) 1

Rehabilitation

• Initial assessment by rehabilitation professionals within 48 hours of admission 2
• Begin rehabilitation therapy as soon as medically stable 2
• Initiate frequent, brief out-of-bed activity (sitting, standing, walking) within 24 hours if no contraindications 2
• Avoid very early mobilization (within first 24 hours) as it may worsen outcomes 5

Critical Pitfalls to Avoid

• Time delays are devastating: Every 30-minute delay reduces good outcomes by 8-14%; streamline imaging and avoid time-consuming protocols 1, 2
• Overly restrictive selection criteria: Current evidence supports broader treatment inclusion; focus on who should NOT be treated rather than narrow eligibility 1
• Inadequate BP control before thrombolysis: Failure to reduce BP <185/110 mmHg significantly increases hemorrhage risk 2
• Premature anticoagulation after thrombolysis: Wait 24 hours and confirm no hemorrhagic transformation before starting VTE prophylaxis 4, 5
• Using elastic stockings alone: These are ineffective for VTE prophylaxis in stroke patients 1, 5
• Ignoring swallowing assessment: Failure to screen for dysphagia leads to aspiration pneumonia 2