What is the management of acute ischemic stroke?

From the Guidelines

Acute stroke management requires immediate recognition and intervention to minimize brain damage, with the most recent guidelines from 2020 recommending intravenous recombinant tissue plasminogen activator (rtPA, alteplase) at 0.9 mg/kg (maximum 90 mg) with 10% given as bolus and remainder over 60 minutes for ischemic strokes presenting within 4.5 hours of symptom onset 1. For eligible patients presenting within 24 hours with large vessel occlusion, mechanical thrombectomy should be considered. The first step in acute stroke management is to determine if the stroke is ischemic or hemorrhagic through rapid neuroimaging, typically a non-contrast CT scan. Some key points to consider in acute stroke management include:

• Intravenous rtPA administration within 4.5 hours of symptom onset for eligible patients
• Mechanical thrombectomy for patients with large vessel occlusion within 24 hours of symptom onset
• Blood pressure control for hemorrhagic strokes, typically maintaining systolic BP <140-160 mmHg
• Reversal of anticoagulation if applicable for hemorrhagic strokes
• Neurosurgical evaluation for potential hematoma evacuation for hemorrhagic strokes
• Close monitoring of vital signs, neurological status, blood glucose (target 140-180 mg/dL), and swallowing function for all stroke patients
• Secondary prevention with antiplatelet therapy (aspirin, clopidogrel, or combination therapy), statins, antihypertensives, and lifestyle modifications
• Early rehabilitation to maximize functional recovery as soon as the patient is medically stable. The time-sensitive nature of stroke treatment is critical, with approximately 1.9 million neurons dying each minute during an untreated stroke, emphasizing the importance of rapid assessment and intervention 1.

From the Research

Acute Stroke Management Overview

• Acute ischemic stroke management involves various treatments, including intravenous thrombolysis and mechanical thrombectomy 2, 3.
• The primary therapy for acute ischemic stroke is intravenous thrombolysis with alteplase, which has been shown to improve functional outcomes when administered early 2.
• Mechanical thrombectomy is also used, particularly in patients with large-vessel occlusion, and intra-arterial alteplase may be used as an adjunct to mechanical thrombectomy 3.

Treatment Timing and Eligibility

• Early administration of intravenous thrombolysis improves functional outcomes, with the greatest benefit seen when treatment is initiated soon after symptom onset 2.
• The recommended time window for intravenous thrombolysis is up to 4.5 hours after symptom onset, although some studies suggest that treatment may be effective in extended time windows or in patients with unknown symptom onset 2, 4.
• Patient eligibility criteria for intravenous thrombolysis and mechanical thrombectomy are evolving, with advances in imaging techniques and automated interpretation allowing for more accurate identification of patients who may benefit from these treatments 4, 5.

Imaging and Diagnostic Techniques

• Advanced imaging techniques, such as MRI and CT perfusion, can guide evidence-based reperfusion treatment of acute stroke and help identify patients who may benefit from mechanical thrombectomy or intravenous thrombolysis 4.
• Imaging-based algorithms can be used to select patients for treatment, taking into account factors such as infarct core size, perfusion lesion size, and clinical deficit 4.

Intensive Care Management

• Intensive care management of acute ischemic stroke involves a range of interventions, including airway and ventilation management, hemodynamic and fluid optimization, and control of seizures 6.
• There is limited evidence to support specific management principles in the ICU setting, although guidelines recommend care on a stroke unit, intravenous tissue plasminogen activator, aspirin, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction 6.

Emerging Therapies and Future Research

• Emerging therapies, such as dual antiplatelet therapy, may be used to prevent recurrent stroke in the high-risk period immediately after stroke 5.
• Further research is needed to address questions such as the optimal timing and dosage of intra-arterial alteplase during mechanical thrombectomy, and the role of advanced imaging techniques in guiding treatment decisions 3, 5.