What are the interventions and management for acute stroke?

Acute Stroke Management for IM Residents

Immediate Emergency Management (First 60 Minutes)

Intravenous alteplase 0.9 mg/kg (maximum 90 mg) is the single most critical intervention for acute ischemic stroke and must be administered within 3-4.5 hours of symptom onset if the patient meets eligibility criteria. 1, 2

Initial Stabilization and Assessment

• Stabilize ABCs while simultaneously beginning stroke evaluation—do not delay assessment for stabilization unless airway is compromised 1, 3
• Determine exact time of last known well (not when symptoms were discovered, but when patient was last at baseline)—this is the zero-hour for all treatment decisions 1, 3
• Obtain fingerstick glucose immediately to rule out hypoglycemia as a stroke mimic 3, 4
• Calculate NIHSS score to quantify stroke severity and guide treatment intensity 1, 3, 4

Diagnostic Imaging Protocol (Target: <25 Minutes to CT)

• Non-contrast head CT within 25 minutes of arrival to exclude hemorrhage and identify early ischemic changes 1, 3
• CT interpretation within 45 minutes for thrombolytic candidates (door-to-interpretation time) 1, 3
• Add CT angiography if considering endovascular thrombectomy to identify large vessel occlusion 1
• CT perfusion can be added in selected cases to assess penumbra and guide extended window treatment 1

Essential Laboratory Tests

• Blood glucose, electrolytes, renal function, PT/INR, aPTT before thrombolysis 1, 3
• 12-lead ECG due to high incidence of cardiac disease in stroke patients 1, 3
• Do not delay treatment waiting for troponin or other non-essential labs 1

Thrombolytic Therapy (Target: Door-to-Needle <60 Minutes)

IV Alteplase Administration

Dose: 0.9 mg/kg (maximum 90 mg)—10% as bolus over 1 minute, remaining 90% infused over 60 minutes 1, 2, 5

The American Heart Association confirms this is the only proven beneficial intervention for emergency stroke treatment, with 37% of patients recovering to fully independent function when guidelines are followed 6, 5

Critical Blood Pressure Management

• Reduce BP to <185/110 mmHg BEFORE starting alteplase 2
• Maintain BP ≤180/105 mmHg during and for 24 hours after treatment 2
• Use labetalol or nicardipine for BP control—avoid nitroprusside due to increased intracranial pressure risk 2

Post-Thrombolysis Monitoring Protocol

• Every 15 minutes during and for 2 hours after infusion 2
• Every 30 minutes for next 6 hours 2
• Hourly until 24 hours post-treatment 2
• Watch for neurological deterioration, bleeding complications, and BP excursions 2

Endovascular Thrombectomy Evaluation

Consider mechanical thrombectomy with stent retrievers if ALL criteria met: 2

• Prestroke mRS 0-1 (functionally independent)
• Large vessel occlusion confirmed on CTA
• Age ≥18 years
• NIHSS ≥6
• ASPECTS ≥6 (limited early ischemic changes)
• Groin puncture possible within 6 hours of symptom onset

Do not delay IV alteplase while arranging thrombectomy—give alteplase first, then proceed to angiography suite 2

The American Stroke Association notes that stent retrievers (Solitaire, Trevo) are superior to older coil retrievers based on multiple randomized trials (MR CLEAN, ESCAPE, SWIFT PRIME) 2

Antiplatelet Therapy Timing

• Aspirin 325 mg should be started within 24-48 hours for most patients 6
• Wait 24 hours after alteplase and obtain repeat head CT to exclude hemorrhage before starting aspirin 6, 2
• Never give aspirin within 24 hours of thrombolysis—this increases hemorrhage risk 6
• Aspirin is not a substitute for acute interventions and should never delay alteplase 6

Hospital Admission and Stroke Unit Care

Immediate Admission Requirements

• Admit to dedicated stroke unit with monitored beds for at least 24 hours 6, 1, 3
• Stroke unit care reduces mortality and morbidity comparably to the effects of alteplase itself 6
• The American Heart Association emphasizes that 25% of patients deteriorate in first 24-48 hours, making monitoring essential 6

Early Mobilization and Supportive Care

• Begin frequent brief mobilization within 24 hours if no contraindications 2, 3
• Assess swallowing before any oral intake to prevent aspiration 3
• Start intermittent pneumatic compression devices within 24 hours for VTE prophylaxis in immobile patients 1, 3
• Treat fever aggressively—hyperthermia worsens neurological damage 1, 3

Critical Time-Dependent Outcomes

Every 15-minute reduction in door-to-needle time decreases in-hospital mortality by 5% 1

Every 30-minute delay in reperfusion reduces probability of favorable outcome by 10.6% 2

The American College of Cardiology notes that treatment within 90 minutes of onset is most likely to result in favorable outcomes 2

Common Pitfalls to Avoid

Blood Pressure Management Errors

• Never aggressively lower BP in acute stroke unless giving thrombolytics or BP >220/120 mmHg—permissive hypertension maintains penumbral perfusion 6
• The exception is pre-thrombolysis, where strict BP control is mandatory 2

Anticoagulation Mistakes

• Do not use full-dose heparin or LMWH for acute stroke treatment—it does not improve outcomes and increases hemorrhage risk 2
• Clopidogrel efficacy in acute stroke is not established—stick with aspirin 6

Timing Errors

• Do not give aspirin as adjunctive therapy with alteplase—wait 24 hours 6
• Do not delay alteplase for "minor" symptoms—early treatment is critical even for seemingly mild deficits 1

System Delays

• Transport to certified stroke center, not nearest hospital—specialized care improves outcomes 1
• Barriers include lack of guideline awareness, stressful conditions, and resource limitations—advocate for system improvements 1