What is the management plan for a patient with acute ischemic stroke?

Management of Acute Ischemic Stroke

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) to eligible patients within 3-4.5 hours of symptom onset with a door-to-needle time under 60 minutes, and perform endovascular thrombectomy for large vessel occlusions within 6-24 hours based on imaging selection. 1, 2

Immediate Assessment and Diagnosis

Time is brain—every 30-minute delay in recanalization decreases good functional outcome by 8-14%. 2 The management algorithm begins the moment stroke is suspected:

Pre-Hospital Phase

• EMS personnel must document the exact time the patient was last known to be neurologically normal (last known well time), not when symptoms were discovered, as this determines all treatment eligibility windows 2
• Use the FAST (Face, Arms, Speech, Time) screening tool immediately—a single abnormality carries 72% probability of stroke 2

Emergency Department Parallel Processing

• Perform non-contrast CT scan immediately upon arrival to rule out hemorrhage—this is the single most critical step and should not be delayed for any additional diagnostic studies 3, 1, 2
• Complete CT angiography from arch-to-vertex simultaneously to identify large vessel occlusions and their precise location 1, 2
• Obtain 12-lead ECG to assess for atrial fibrillation, but this should not delay thrombolysis assessment 1
• Target door-to-imaging time of less than 25 minutes and door-to-needle time of less than 60 minutes in 90% of treated patients 1

Intravenous Thrombolysis Protocol

Eligibility Criteria

Inclusion criteria: 2

• Clearly defined symptom onset within 3 hours (extended to 4.5 hours in selected patients) 1, 4
• Measurable neurologic deficit on NIHSS 2
• Age ≥18 years 2
• CT scan showing no hemorrhage 2

Recent evidence from the 2025 HOPE trial demonstrates that alteplase can be safely administered 4.5 to 24 hours after onset in patients with salvageable brain tissue identified by perfusion imaging, showing 40% functional independence versus 26% with standard treatment, though symptomatic ICH increased from 0.51% to 3.8%. 5 However, this extended window requires perfusion imaging selection and is not yet incorporated into standard guidelines.

Dosing and Administration

• Total dose: 0.9 mg/kg (maximum 90 mg total) 3, 1, 2
• 10% given as IV bolus over 1 minute 3, 2
• Remaining 90% infused over 60 minutes 3, 2

Blood Pressure Management Before and During Thrombolysis

Critical pitfall: Blood pressure must be aggressively controlled before initiating alteplase to prevent hemorrhagic transformation.

• Reduce BP to <185/110 mmHg before starting thrombolysis using labetalol, nicardipine, or clevidipine 2
• Maintain BP ≤180/105 mmHg for at least 24 hours after treatment 3, 2
• Measure BP every 15 minutes during and for 2 hours after infusion, then every 30 minutes for 6 hours, then hourly until 24 hours 3, 2
• If SBP >180 mmHg or DBP >105 mmHg, increase frequency of measurements and administer antihypertensive medications 3

Post-Thrombolysis Monitoring

• Admit to intensive care or stroke unit for close monitoring 3
• Monitor neurological status every 15 minutes during and for 2 hours after infusion, then every 30 minutes for 6 hours, then hourly until 24 hours 3, 2
• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if the patient can be safely managed without them 3
• Obtain follow-up CT or MRI scan at 24 hours after IV alteplase before starting anticoagulants or antiplatelet agents 3

Management of Symptomatic Intracranial Hemorrhage

If the patient develops severe headache, acute hypertension, nausea, vomiting, or worsening neurological examination: 3

• Stop alteplase infusion immediately 3
• Obtain CBC, PT (INR), aPTT, fibrinogen level, and type and cross-match 3
• Perform emergent non-enhanced head CT 3
• Administer cryoprecipitate 10 units infused over 10-30 minutes; give additional dose if fibrinogen <200 mg/dL 3
• Administer tranexamic acid 1000 mg IV over 10 minutes OR ε-aminocaproic acid 4-5 g over 1 hour, followed by 1 g IV until bleeding controlled 3
• Obtain hematology and neurosurgery consultations 3

Endovascular Thrombectomy

Indications and Time Windows

EVT with stent retrievers is first-line therapy for large vessel occlusions. 1

• Standard window: within 6 hours of symptom onset for proximal anterior circulation large vessel occlusion (internal carotid artery, M1 segment, proximal M2 segment) 1, 2
• Extended window: 6-24 hours based on advanced imaging selection showing salvageable brain tissue 1
• EVT should be delivered within a coordinated system with rapid neurovascular imaging access and specialized neurointerventional expertise 1

Technical Approach

• Use combined stent-retriever and aspiration technique (BADDASS approach) 2
• Target reperfusion to modified TICI grade 2b/3 2
• Do not delay IV alteplase to pursue EVT—both treatments are complementary, not mutually exclusive 3

Transport Strategies

The optimal transport strategy depends on geography and system capabilities: 3

• Mothership model: Direct transport to comprehensive stroke center capable of EVT
• Drip-and-ship model: Thrombolysis at primary stroke center, then transfer for EVT
• Mobile stroke unit: Pre-hospital thrombolysis with direct transport to EVT center
• Choice is context-specific and sensitive to transport times, treatment times, and accuracy in patient selection 3

Antiplatelet Therapy

• Start aspirin 160-325 mg within 24-48 hours after ruling out hemorrhage on follow-up imaging at 24 hours 1, 2
• Do not administer aspirin within 24 hours of rtPA administration 1, 2
• For patients not receiving thrombolysis, administer oral aspirin 325 mg within 24-48 hours after stroke onset 1

Blood Pressure Management in Non-Thrombolysis Patients

• Do not routinely treat blood pressure unless extremely elevated (SBP >220 mmHg or DBP >120 mmHg) in patients not receiving thrombolysis 1, 2
• Permissive hypertension allows for cerebral perfusion in the acute phase 1

Supportive Care and Physiological Management

Stroke Unit Care

• Admit all stroke patients to a geographically defined stroke unit with specialized staff within 24 hours of hospital arrival—this reduces mortality and dependency 1, 2
• Initiate continuous cardiac monitoring for at least 24 hours to detect arrhythmias 2

Airway and Oxygenation

• Provide airway support and ventilatory assistance for patients with decreased consciousness or bulbar dysfunction 1
• Maintain oxygen saturation >94% with supplemental oxygen 1, 2

Temperature Management

• Monitor temperature every 4 hours for the first 48 hours 2
• Treat fever >37.5°C with antipyretics 2

Management of Cerebral Edema and Increased Intracranial Pressure

Critical pitfall: Corticosteroids are contraindicated and harmful in ischemic stroke.

• Do not use corticosteroids for cerebral edema management following ischemic stroke 1, 2
• Use osmotherapy and hyperventilation for patients deteriorating due to increased intracranial pressure, including herniation syndromes 1, 2
• Perform surgical drainage of cerebrospinal fluid for hydrocephalus 1

Surgical Interventions

Emergency Carotid Endarterectomy

• Emergency CEA is generally not performed for acute ischemic stroke with large deficits due to high risk of hemorrhagic transformation and adverse events 3, 2
• May be considered for neurologically stable patients after nondisabling stroke or TIA with severe carotid stenosis 2

Decompressive Hemicraniectomy

• Consider for malignant MCA infarction with significant mass effect and deterioration despite medical management 1

Common Pitfalls to Avoid

• Failure to obtain follow-up imaging at 24 hours before starting antiplatelets or anticoagulants significantly increases hemorrhage risk 2
• Delaying thrombolysis to pursue additional diagnostic studies beyond non-contrast CT 3
• Administering aspirin within 24 hours of alteplase 1, 2
• Using corticosteroids for cerebral edema 1, 2
• Inadequate blood pressure control during and after thrombolysis 3, 2