What is the initial treatment for a patient who has suffered an ischemic stroke?

Initial Treatment for Acute Ischemic Stroke

Intravenous rtPA (0.9 mg/kg; maximum 90 mg) is the cornerstone of acute ischemic stroke treatment and must be administered within 3 hours of symptom onset in carefully selected patients, with possible extension to 4.5 hours in eligible cases. 1, 2

Immediate Stabilization (First Priority)

Airway, Breathing, and Circulation (ABCs) must be secured immediately, particularly in seriously ill or comatose patients. 1, 2, 3

• Administer supplemental oxygen to maintain oxygen saturation >94% 4
• Protect the airway in patients with reduced consciousness 3
• Avoid treating hypoxemia unless oxygen saturation falls below 92% 5

Urgent Diagnostic Evaluation (Within 60 Minutes)

Non-contrast CT scan of the brain is mandatory to exclude hemorrhage before any reperfusion therapy. 1, 2, 4

Essential laboratory tests include: 1

• Complete blood count
• Serum glucose (critical—treat if <50 mg/dL or >400 mg/dL) 1, 4
• Electrolytes and renal function
• Cardiac biomarkers and troponin 1
• Coagulation studies (PT/INR, aPTT) 1
• 12-lead ECG 1

Establish the exact time of symptom onset—defined as when the patient was last known to be at baseline or symptom-free. This single piece of information determines eligibility for thrombolysis. 1, 2

Blood Pressure Management

Do NOT lower blood pressure unless systolic BP >220 mmHg or diastolic >120 mmHg in patients NOT receiving thrombolysis. 4, 6

• Elevated blood pressure is a physiologic response to maintain cerebral perfusion in ischemic tissue 1
• Aggressive blood pressure reduction can worsen outcomes by reducing perfusion to the penumbra 5
• If reduction is necessary, use short-acting agents and lower cautiously 1, 4

Thrombolytic Therapy (Time-Critical)

Administer IV rtPA 0.9 mg/kg (maximum 90 mg) with 10% as bolus and 90% as infusion over 60 minutes within 3 hours of symptom onset. 1, 2

The therapeutic window may extend to 4.5 hours in selected patients. 2

Absolute contraindications include: 1

• Intracranial hemorrhage on CT
• Recent major surgery or serious head trauma
• Uncontrolled hypertension (>185/110 mmHg)
• Active bleeding or coagulopathy
• Prior intracranial hemorrhage

Critical safety requirement: Strict adherence to NINDS selection criteria is mandatory—deviation increases hemorrhagic transformation risk. 1

Antiplatelet Therapy

Aspirin 325 mg should be administered within 24-48 hours of stroke onset in patients who do NOT receive thrombolysis, as it provides modest benefit with reasonable safety. 1, 3

• Do NOT give aspirin within 24 hours of rtPA administration 1
• Aspirin reduces early recurrent stroke risk by a small but meaningful margin 1

Temperature and Glucose Control

Treat fever aggressively—hyperthermia (>37.5°C) worsens neurological outcomes and increases infarct size. 2, 5

Normalize glucose levels: 2, 4

• Treat hypoglycemia (<50 mg/dL) immediately—it mimics stroke and causes brain injury 4
• Lower markedly elevated glucose (>400 mg/dL or >300 mg/dL per some protocols) 2, 4
• Avoid overly aggressive correction that causes fluid shifts 4

Cardiac Monitoring

Continuous cardiac monitoring for at least 24 hours is essential to detect atrial fibrillation and other arrhythmias that may have caused the stroke or occur as a complication. 1, 2

Stroke Unit Admission

All stroke patients should be admitted to a geographically defined stroke unit with specialized interdisciplinary staff—this intervention alone improves mortality and functional outcomes. 1, 4

Prevention of Early Complications

Swallowing assessment before any oral intake is mandatory to prevent aspiration pneumonia, a leading cause of post-stroke mortality. 3, 4

DVT prophylaxis: 3, 4

• Use intermittent external compression stockings in immobilized patients 3, 4
• Subcutaneous anticoagulants may be considered after excluding hemorrhage 4

Do NOT administer prophylactic anticonvulsants—seizure prophylaxis in patients without seizures is not recommended. 1

Therapies NOT Recommended

Urgent anticoagulation (heparin, LMWH) is NOT recommended for acute ischemic stroke—it increases hemorrhagic transformation risk without reducing early recurrent stroke or improving outcomes. 1

Neuroprotective agents have no proven benefit in acute ischemic stroke. 1

Emergency carotid endarterectomy is NOT recommended outside research settings due to high procedural risks and lack of efficacy data. 1

Common Pitfalls to Avoid

• Missing the thrombolysis window due to delays in CT scanning or prolonged evaluation—organize a stroke protocol to complete evaluation within 60 minutes 1
• Treating elevated blood pressure too aggressively—this reduces perfusion to salvageable brain tissue 1, 5
• Allowing oral intake before swallowing assessment—aspiration pneumonia significantly worsens outcomes 3, 4
• Administering aspirin within 24 hours of rtPA—this increases bleeding risk 1