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

Administer IV r-tPA 0.9 mg/kg (maximum 90 mg) immediately if the patient presents within 3 hours of symptom onset and meets eligibility criteria, as this provides the strongest evidence for improved functional outcomes and reduced disability. 1

Time-Critical Assessment and Imaging

• Obtain urgent CT or MRI brain imaging immediately upon arrival to exclude hemorrhage before any treatment 1
• Target door-to-needle time ≤60 minutes for r-tPA administration, as this is associated with lower mortality (adjusted OR 0.78) and reduced symptomatic intracranial hemorrhage (4.7% vs 5.6%) compared to longer door-to-needle times 2
• Document exact time of symptom onset, as this determines eligibility for thrombolysis 1, 3

Thrombolytic Therapy Decision Algorithm

Within 3 hours of symptom onset:

• IV r-tPA 0.9 mg/kg (maximum 90 mg) is strongly recommended (Grade 1A) 1, 4
• This represents the strongest evidence window for benefit 1

Between 3-4.5 hours of symptom onset:

• IV r-tPA is recommended but with lower quality evidence (Grade 2C) 4
• Benefits decrease with time, so treat as rapidly as possible 3

Beyond 4.5 hours:

• IV r-tPA is not indicated 4, 3
• Consider mechanical thrombectomy only in carefully selected patients (Grade 2C) 1

Blood Pressure Management Before Thrombolysis

For patients eligible for r-tPA:

• Lower BP cautiously to systolic <185 mmHg and diastolic <110 mmHg before administering thrombolysis 1
• 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

Antiplatelet Therapy Timing

If r-tPA is administered:

• Do NOT give aspirin for 24 hours after r-tPA to minimize bleeding risk 1

If r-tPA is NOT given:

• Administer aspirin 160-325 mg within 48 hours of symptom onset (Grade 1A) 1, 4
• Aspirin is preferred over therapeutic anticoagulation in the acute phase (Grade 1A) 1, 4

Acute Supportive Care

• Protect airway and support breathing, especially in seriously ill or comatose patients 1
• Maintain adequate oxygenation and circulation 1
• Treat fever aggressively with antipyretics (Grade B) 1
• Initiate continuous cardiac monitoring to detect atrial fibrillation and life-threatening arrhythmias (Grade C), which is particularly important given the patient's history of atrial fibrillation 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

Planning for Secondary Prevention Based on Atrial Fibrillation

Given the patient's history of atrial fibrillation, this is critical:

• Oral anticoagulation is mandatory for secondary prevention, NOT antiplatelet therapy alone (Grade 1B) 1, 5
• Anticoagulation should generally be initiated within 1-2 weeks after stroke onset 5
• Direct oral anticoagulants are preferred over warfarin for nonvalvular atrial fibrillation 5
• Oral anticoagulation is superior to aspirin alone or combination aspirin plus clopidogrel (Grade 1B) 5

Critical Pitfalls to Avoid

• Do NOT use streptokinase or other thrombolytics: only r-tPA is proven safe and effective 1
• Do NOT give urgent anticoagulation routinely in the acute phase: this increases hemorrhage risk without proven benefit for early recurrent stroke prevention 1
• Do NOT delay imaging: all patients require urgent CT or MRI to exclude hemorrhage before any treatment 1
• Do NOT use mechanical thrombectomy routinely: this is only suggested for carefully selected patients (Grade 2C) 1
• The most common reason patients miss the thrombolysis window is presenting >3 hours after symptom onset 6, 7