What is the management plan for an adult patient with acute ischemic stroke, possibly with a history of hypertension, diabetes, or hyperlipidemia?

Acute Ischemic Stroke Management

Immediate Assessment and Stabilization

For acute ischemic stroke, immediately assess eligibility for IV thrombolysis (rtPA) within 3 hours of symptom onset, maintain airway patency with NPO status until swallow assessment is complete, and avoid supplemental oxygen unless SpO2 falls below 94%. 1, 2, 3

Airway and Breathing

• Maintain patent airway and monitor for deterioration, especially in patients with decreased GCS or aphasia who are at high aspiration risk 2
• Keep patient NPO until formal swallow evaluation by speech therapy is completed to prevent aspiration pneumonia 2
• Provide supplemental oxygen only if oxygen saturation drops below 94%—non-hypoxic patients do not benefit from routine oxygen therapy 1, 2

Neurological Monitoring

• Perform baseline NIHSS score and repeat at least hourly for the first 24 hours to detect early deterioration, hemorrhagic transformation, or cerebral edema 2
• Monitor for signs of increased intracranial pressure or stroke progression 2

Blood Pressure Management: The Critical Decision Point

For Patients RECEIVING IV Thrombolysis (rtPA)

Blood pressure must be lowered to <185/110 mmHg before initiating rtPA and maintained <180/105 mmHg for at least 24 hours afterward to prevent hemorrhagic transformation. 1, 4, 5

Pre-thrombolysis BP Control

• Target: SBP <185 mmHg AND DBP <110 mmHg before rtPA administration 1, 4
• First-line agent: Labetalol 10-20 mg IV over 1-2 minutes, may repeat every 10-20 minutes (maximum 300 mg) 1, 4
• Alternative: Nicardipine infusion 5 mg/h IV, titrate by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h) 1, 4
• Avoid: Sublingual nifedipine (causes precipitous uncontrollable drops) and sodium nitroprusside (worsens cerebral autoregulation) 1, 4

Post-thrombolysis BP Monitoring

• Target: Maintain SBP <180 mmHg AND DBP <105 mmHg for 24 hours 1, 4, 5
• Monitoring frequency: Every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1, 4, 2
• High BP during the first 24 hours post-thrombolysis significantly increases symptomatic intracranial hemorrhage risk 4, 5

For Patients NOT RECEIVING Reperfusion Therapy

Practice permissive hypertension for 48-72 hours—do not treat BP unless it exceeds 220/120 mmHg, as aggressive lowering compromises cerebral perfusion to the ischemic penumbra and worsens outcomes. 1, 4, 5

The Rationale for Permissive Hypertension

• Cerebral autoregulation is grossly impaired in the ischemic penumbra, making blood flow pressure-dependent 1, 4, 5
• Systemic perfusion pressure is needed for oxygen delivery to potentially salvageable brain tissue 1, 4, 5
• Studies show a U-shaped relationship with optimal admission SBP of 121-200 mmHg and DBP of 81-110 mmHg 1, 4
• Rapid BP reduction can extend infarct size by converting salvageable penumbra into irreversibly damaged tissue 4

When to Treat (Non-reperfusion Patients)

• Threshold: Only treat if SBP ≥220 mmHg OR DBP ≥120 mmHg during first 48-72 hours 1, 4, 5
• Target: If treatment required, reduce mean arterial pressure by only 15% over 24 hours—not more aggressively 1, 4, 5
• Agents: Labetalol 10 mg IV over 1-2 minutes (may repeat) or continuous infusion 2-8 mg/min; alternatively nicardipine 5 mg/h titrated by 2.5 mg/h 1, 4

Exceptions Requiring Immediate BP Control

Override permissive hypertension guidelines for: 4

• Hypertensive encephalopathy
• Aortic dissection
• Acute myocardial infarction
• Acute pulmonary edema
• Acute renal failure

Glucose Management

Target blood glucose 140-180 mg/dL (7.8-10 mmol/L) and treat hyperglycemia >140-185 mg/dL with insulin, as persistent hyperglycemia during the first 24 hours is associated with poor outcomes and increased infarct volume. 1, 2, 6

• Hyperglycemia >200 mg/dL increases infarct expansion and worsens neurological outcomes 2, 6
• Admission hyperglycemia occurs in 30-40% of acute stroke patients, even without known diabetes 6
• Monitor glucose closely to avoid hypoglycemia during insulin therapy 1
• Consider simultaneous glucose and potassium administration as needed 1

Thrombolytic Therapy Decision

Administer IV rtPA 0.9 mg/kg (maximum 90 mg) if treatment can be initiated within 3 hours of clearly defined symptom onset. 1, 3

Eligibility Criteria

• Symptom onset <3 hours with clearly defined time 1, 3
• BP successfully lowered to <185/110 mmHg 1
• No contraindications to thrombolysis 3

Time Windows

• 0-3 hours: Strong recommendation for IV rtPA (Grade 1A evidence) 3
• 3-4.5 hours: Suggest not using IV rtPA (Grade 2A evidence) 3
• >4.5 hours: Recommend against IV rtPA (Grade 1A evidence) 3

Antiplatelet Therapy

For patients NOT receiving thrombolysis, initiate aspirin therapy early (within 24-48 hours) to reduce recurrent stroke risk. 3

• Early aspirin reduces recurrent stroke and improves outcomes 3
• Delay antiplatelet therapy for 24 hours in patients who received rtPA to minimize hemorrhagic risk 2, 3

Venous Thromboembolism Prophylaxis

Implement intermittent pneumatic compression immediately for all patients with restricted mobility; avoid pharmacological anticoagulation for 24 hours post-thrombolysis. 2, 3

• Prophylactic low-dose subcutaneous heparin or LMWH is recommended for immobile patients not receiving thrombolysis 3
• Mechanical prophylaxis (pneumatic compression) is safer in the immediate post-thrombolysis period 2

Subacute Management (After 48-72 Hours)

Restart or initiate antihypertensive therapy in neurologically stable patients with BP ≥140/90 mmHg after 72 hours for long-term secondary prevention. 1, 5

• Typically begin antihypertensive therapy after 3 days once patient is stable 5
• Target BP <130/80 mmHg for secondary prevention reduces recurrent stroke risk by 25-30% 5
• Preferred regimen: ACE inhibitor + thiazide diuretic (reduces recurrent stroke by 43%) 5
• Alternative agents: ARBs or combination therapy 1

Critical Pitfalls to Avoid

• Never treat BP aggressively in non-reperfusion patients during first 48-72 hours—this extends infarct size and worsens outcomes 1, 4, 5
• Never use sublingual nifedipine—it causes uncontrollable precipitous BP drops that compromise cerebral perfusion 1, 4
• Never ignore hypotension—it is associated with poor outcomes and requires urgent evaluation and correction 4
• Never give supplemental oxygen to non-hypoxic patients—there is no benefit 1, 2
• Never delay swallow assessment—aspiration pneumonia significantly worsens stroke outcomes 2
• Never use the affected limb for BP measurement—this underestimates true systemic pressure and could lead to inappropriate thrombolytic administration 4