What is the immediate treatment for a patient presenting with ischemic stroke, possibly with a history of atrial fibrillation, hypertension, diabetes, and hyperlipidemia?

Immediate Treatment for Ischemic Stroke

For patients presenting with acute ischemic stroke, IV recombinant tissue plasminogen activator (r-tPA) at 0.9 mg/kg (maximum 90 mg) is the priority treatment if initiated within 3 hours of symptom onset, followed by early aspirin therapy (160-325 mg) within 48 hours if thrombolysis is not given. 1

Time-Critical Thrombolytic Therapy

Within 3 Hours of Symptom Onset

• Administer IV r-tPA 0.9 mg/kg (maximum 90 mg) immediately if the patient meets eligibility criteria (Grade 1A) 1
• This represents the strongest evidence for improved functional outcomes and reduced disability 1
• Door-to-needle time should be ≤60 minutes 1

3 to 4.5 Hours from Symptom Onset

• IV r-tPA is still recommended but with slightly weaker evidence (Grade 2C) 1
• The benefit decreases with time, so treatment should still be expedited 1

Beyond 4.5 Hours

• IV r-tPA is contraindicated and should not be given (Grade 1B) 1
• Consider intra-arterial r-tPA for proximal cerebral artery occlusions if treatment can be initiated within 6 hours, though this is only suggested (Grade 2C) and requires specialized centers 1

Blood Pressure Management

Critical caveat: Blood pressure should be managed cautiously to avoid precipitous drops that can worsen neurological outcomes. 1

For Patients NOT Receiving Thrombolysis

• Only treat if systolic BP >220 mmHg or diastolic BP >120 mmHg 1
• Use short-acting agents with minimal cerebral vascular effects 1
• Avoid sublingual nifedipine due to risk of precipitous BP drops causing neurological worsening 1

For Patients Eligible for r-tPA

• Lower BP cautiously to systolic <185 mmHg and diastolic <110 mmHg before administering thrombolysis 1
• Sustained hypertension above these levels is a contraindication to IV r-tPA 1

Antiplatelet Therapy

Immediate Management (First 48 Hours)

• Administer aspirin 160-325 mg within 48 hours of symptom onset if thrombolysis is not given (Grade 1A) 1, 2
• Aspirin is preferred over therapeutic anticoagulation in the acute phase (Grade 1A) 1
• Do not give aspirin for 24 hours after r-tPA administration to minimize bleeding risk 1

For Minor Stroke or High-Risk TIA

• Initiate dual antiplatelet therapy (aspirin 81 mg + clopidogrel 75 mg daily) within 12-24 hours after excluding intracranial hemorrhage 2, 3
• Use loading doses: aspirin 160-325 mg plus clopidogrel 300-600 mg on day 1 3
• Continue for 21-30 days, then transition to single antiplatelet therapy 2, 3

Supportive Care

Airway, Breathing, and Circulation

• Protect airway and support breathing, especially in seriously ill or comatose patients 1
• Maintain adequate oxygenation and circulation 1

Temperature Management

• Treat fever aggressively with antipyretics (Grade B) 1
• Monitor for and control elevated temperatures 1

Cardiac Monitoring

• Initiate continuous cardiac monitoring to detect atrial fibrillation and life-threatening arrhythmias (Grade C) 1
• This is critical given the patient's history of atrial fibrillation 1

Glucose Management

• Control hypoglycemia or marked hyperglycemia 1
• Target glucose <300 mg/dL (<16.63 mmol/L) for markedly elevated levels (Grade C) 1
• Avoid glucose-containing IV solutions 1
• Monitor closely to prevent overly aggressive correction 1

VTE Prophylaxis for Immobilized Patients

• Use prophylactic-dose heparin or intermittent pneumatic compression devices (Grade 2B) 1
• Avoid elastic compression stockings (Grade 2B) 1

Long-Term Planning Based on Stroke Etiology

For Atrial Fibrillation (Cardioembolic Stroke)

• Oral anticoagulation is mandatory for secondary prevention, not antiplatelet therapy alone (Grade 1B) 1, 2, 4
• Initiate within 1-2 weeks after stroke onset 4
• Direct oral anticoagulants are preferred over warfarin for nonvalvular AF 4
• Warfarin (INR 2.0-3.0) is an alternative if DOACs are contraindicated 4, 5

For Noncardioembolic Stroke

• After the acute phase, transition to long-term single antiplatelet therapy 1, 2, 4
• Preferred options: clopidogrel 75 mg daily or aspirin 75-100 mg + extended-release dipyridamole 200 mg twice daily (Grade 2B) 1, 2, 4

Critical Pitfalls to Avoid

• Do not delay imaging: All patients require urgent CT or MRI to exclude hemorrhage before any treatment 1
• Do not use streptokinase or other thrombolytics: Only r-tPA is proven safe and effective 1
• Do not give urgent anticoagulation routinely: This increases hemorrhage risk without proven benefit for early recurrent stroke prevention 1
• Do not use mechanical thrombectomy routinely: This is only suggested for carefully selected patients (Grade 2C) 1
• Do not continue dual antiplatelet therapy beyond 21-30 days in noncardioembolic stroke, as bleeding risk outweighs benefit (Grade 1B) 2, 4, 3