What is the management approach for an adult patient with acute ischemic stroke, without contraindications such as active bleeding or recent surgery?

Acute Ischemic Stroke Management

Immediate Thrombolytic Therapy is the Priority

Intravenous alteplase 0.9 mg/kg (maximum 90 mg) is the single most critical intervention for acute ischemic stroke and must be administered within 3-4.5 hours of symptom onset if the patient meets eligibility criteria. 1, 2 This is the only FDA-approved therapy proven to improve clinical outcomes, with 37% of patients recovering to fully independent function when guidelines are followed. 2

Time-Critical Initial Assessment

• Determine the exact time of last known well immediately—this is the zero-hour for all treatment decisions. 2, 3 If the patient woke up with symptoms, use the time they were last seen normal (typically bedtime). 2

• Obtain fingerstick glucose within minutes of arrival to rule out hypoglycemia as a stroke mimic. 1

• Calculate NIHSS score to quantify stroke severity and guide treatment intensity. 1, 3

• Stabilize airway, breathing, and circulation simultaneously with stroke evaluation—do not delay assessment for stabilization unless the airway is compromised. 2, 3

Diagnostic Imaging Protocol

• Non-contrast head CT must be completed within 25 minutes of arrival to exclude hemorrhage and identify early ischemic changes. 1, 2, 3

• CT interpretation within 45 minutes for thrombolytic candidates (door-to-interpretation time). 1, 2

• Add CT angiography if considering endovascular thrombectomy to identify large vessel occlusion. 2, 3

• Advanced imaging (CT perfusion, multimodal MRI) can be obtained in selected cases but should never delay IV alteplase in eligible patients. 1, 3

Alteplase Administration Protocol

Eligibility Criteria (Within 3 Hours)

Inclusion criteria: 1

• Measurable neurological deficit on examination
• Age ≥18 years
• Symptom onset <3 hours before treatment initiation

Exclusion criteria: 1

• Head trauma or prior stroke in previous 3 months
• History of intracranial hemorrhage
• Blood pressure >185/110 mmHg (must be reduced first)
• INR >1.7 or PT >15 seconds
• Platelet count <100,000/mm³
• Blood glucose <50 mg/dL
• CT showing multilobar infarction (hypodensity >1/3 cerebral hemisphere)
• Active bleeding or acute bleeding diathesis
• Recent major surgery (within 14 days) or arterial puncture at noncompressible site (within 7 days)

Extended Window Criteria (3-4.5 Hours)

Additional exclusions for the 3-4.5 hour window: 1

• Age >80 years
• NIHSS >25
• Taking oral anticoagulants regardless of INR
• History of both diabetes AND prior ischemic stroke

Dosing and Administration

Dose: 0.9 mg/kg (maximum 90 mg)—give 10% as bolus over 1 minute, then infuse remaining 90% over 60 minutes. 1, 2

Blood Pressure Management

For Thrombolytic Candidates

• Blood pressure MUST be reduced to <185/110 mmHg BEFORE starting alteplase. 1, 2

• Maintain BP ≤180/105 mmHg during and for 24 hours after treatment. 1, 2

• Use labetalol 10-20 mg IV over 1-2 minutes (may repeat), or nicardipine infusion 5 mg/h titrated up by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h). 1

For Non-Thrombolytic Candidates

• Permissive hypertension is the standard approach—do not aggressively lower BP unless systolic >220 mmHg or diastolic >120 mmHg. 1, 2 Lowering BP can worsen outcomes by reducing penumbral perfusion. 1, 2

• If treatment is indicated, lower BP cautiously by only 15-25% within the first day. 1

Post-Thrombolysis Monitoring

Admit to dedicated stroke unit with monitored beds for at least 24 hours. 1, 2, 4

Monitoring protocol: 1

• Neurological assessments every 15 minutes during infusion
• Every 30 minutes for next 6 hours
• Hourly until 24 hours after treatment
• Blood pressure every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly

If severe headache, acute hypertension, nausea, or vomiting develop: 1

• Discontinue alteplase immediately if still infusing
• Obtain emergency CT scan
• Suspect symptomatic intracranial hemorrhage (occurs in 6.4% of treated patients) 5

Endovascular Thrombectomy

Consider mechanical thrombectomy with stent retrievers if: 2, 4

• Large vessel occlusion confirmed on CTA
• Prestroke modified Rankin Scale 0-1
• NIHSS ≥6
• ASPECTS ≥6
• Age ≥18 years
• Groin puncture possible within 6 hours of symptom onset

Thrombectomy should be performed at experienced stroke centers with immediate access to cerebral angiography and credentialed interventionalists. 4 Hospitals treating fewer than 5 thrombectomy patients per year have increased mortality risk. 4

Do not delay IV alteplase to arrange thrombectomy—give alteplase first if eligible, then proceed to thrombectomy. 4, 6

Antiplatelet Therapy

• Aspirin 325 mg should be started within 24-48 hours for most patients. 2, 4

• Wait 24 hours after alteplase and obtain repeat head CT to exclude hemorrhage before starting aspirin. 2, 4

• Never give aspirin within 24 hours of thrombolysis—this increases hemorrhage risk. 1, 2

• Do not give aspirin as adjunctive therapy with alteplase. 2

Anticoagulation

• Do not use full-dose heparin or LMWH for acute stroke treatment—it does not improve outcomes and increases hemorrhage risk. 2

• Delay anticoagulants and antiplatelet agents for 24 hours after alteplase. 1

Supportive Care in Stroke Unit

• Begin frequent brief mobilization within 24 hours if no contraindications. 2

• Assess swallowing before any oral intake to prevent aspiration. 2

• Start intermittent pneumatic compression devices within 24 hours for VTE prophylaxis in immobile patients. 2, 3

• Treat fever aggressively—hyperthermia worsens neurological damage. 2, 3

• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters during the first 24 hours after thrombolysis. 1

Time-Dependent Outcomes

• Every 15-minute reduction in door-to-needle time decreases in-hospital mortality by 5%. 2, 3

• Every 30-minute delay in reperfusion reduces the probability of favorable outcome by 10.6%. 2

• Treatment within 90 minutes of onset is most likely to result in favorable outcomes compared to 90-180 minute window. 1

• The goal door-to-needle time is 60 minutes. 6

Critical Pitfalls to Avoid

• Do not delay alteplase for "minor" symptoms—early treatment is critical even for seemingly mild deficits. 2 Symptoms may worsen, and the treatment window is narrow.

• Do not withhold alteplase based solely on age ≥80 years within the 3-hour window—elderly patients have comparable hemorrhage rates and favorable outcomes when appropriately selected. 7 The age >80 exclusion applies only to the 3-4.5 hour extended window. 1

• Avoid protocol violations during thrombolysis administration—they significantly increase symptomatic intracranial hemorrhage risk and mortality. 4

• Do not use streptokinase—it is contraindicated due to unacceptably high hemorrhage rates. 1

• Be aware of angioedema as a potential side effect that may cause partial airway obstruction. 1