What is the treatment for a patient with acute ischemic stroke?

Treatment of Acute Ischemic Stroke

Intravenous alteplase (0.9 mg/kg, maximum 90 mg) administered within 4.5 hours of symptom onset is the primary pharmacological treatment, combined with endovascular thrombectomy for large vessel occlusions within 6-24 hours. 1, 2

Immediate Emergency Response and Time-Critical Actions

Every 30-minute delay in recanalization decreases the probability of good functional outcome by 8-14%, making rapid assessment and treatment the highest priority. 3, 1, 2

Pre-Hospital Phase

• Emergency Medical Services must immediately determine the last known well time—this single factor determines all treatment eligibility. 3
• Transport directly to stroke-capable centers (Primary Stroke Centers or Comprehensive Stroke Centers) rather than nearest hospitals, as this reduces 30-day mortality. 4
• Stabilize airway, breathing, and circulation; provide supplemental oxygen only if saturation <94%. 3, 2
• Check blood glucose immediately with finger stick and correct hypoglycemia, as it mimics stroke and causes brain injury. 3

Emergency Department Evaluation (Door-to-Needle Goal: <60 Minutes)

Obtain non-contrast CT scan immediately upon arrival—this is the single most important test to exclude hemorrhage and determine treatment eligibility. 3, 1

The three critical questions imaging must answer: 3

1. Is intracranial hemorrhage present?
2. Where is the vessel occlusion located?
3. What is the risk/benefit ratio for treatment?

Reperfusion Therapy: The Primary Treatment

Intravenous Alteplase (rtPA)

Administer 0.9 mg/kg (maximum 90 mg) as 10% bolus over 1 minute, then 90% infusion over 60 minutes. 3, 1, 2

Eligibility criteria within 3 hours: 3

• Ischemic stroke with measurable neurological deficit
• Symptom onset <3 hours from treatment start
• No intracranial hemorrhage on CT
• Blood pressure <185/110 mmHg (can be lowered with labetalol or nicardipine to meet this threshold) 3, 1

Extended window (3-4.5 hours) has additional exclusions: 2

• Age >80 years
• NIHSS >25
• Combination of prior stroke and diabetes
• Any anticoagulant use

Critical safety point: Patients with NIHSS >22 have very poor prognosis but still derive some benefit from treatment—do not withhold based on severity alone. 3

Blood Pressure Management for Thrombolysis

Before alteplase administration: 3, 1

• Must achieve BP <185/110 mmHg
• Use labetalol 10-20 mg IV over 1-2 minutes (may repeat once) or nicardipine infusion 5 mg/hour, titrate up by 2.5 mg/hour every 5-15 minutes to maximum 15 mg/hour

During and 24 hours after alteplase: 1, 2

• Maintain BP <180/105 mmHg to prevent hemorrhagic transformation
• Monitor blood pressure every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours

Endovascular Thrombectomy

For large vessel occlusions (internal carotid artery, M1/M2 middle cerebral artery segments), perform mechanical thrombectomy within 6-24 hours using combined stent-retriever and aspiration techniques. 3, 1

This applies even in extended time windows (up to 24 hours) when advanced imaging demonstrates salvageable brain tissue. 3

Blood Pressure Management in Patients NOT Receiving Thrombolysis

Do not treat elevated blood pressure unless systolic >220 mmHg or diastolic >120 mmHg. 3, 1, 2

Lowering blood pressure in acute stroke can worsen outcomes by reducing cerebral perfusion to ischemic penumbra. 3

Exceptions requiring immediate BP treatment regardless of level: 3

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

When treatment is necessary: 3

• Use labetalol (short-acting, minimal cerebral vasodilation)
• Avoid sublingual nifedipine—causes precipitous drops
• Lower pressure cautiously by 10-15% maximum

Antiplatelet Therapy

Administer aspirin 160-325 mg within 48 hours of stroke onset for all patients not receiving thrombolysis. 3, 1, 2

Critical timing restriction: Do not give aspirin or other antiplatelets within 24 hours of alteplase administration, as this increases hemorrhagic complications. 3

Physiological Parameter Management

Temperature Control

Treat all sources of fever aggressively with antipyretics—elevated temperature worsens ischemic injury. 3, 2

Glucose Management

Monitor glucose every 4-6 hours and treat hyperglycemia to maintain levels <300 mg/dL (<16.63 mmol/L). 2

Hyperglycemia increases tissue acidosis and blood-brain barrier permeability, though the optimal target remains uncertain. 3

Oxygenation

Provide supplemental oxygen only if saturation <94%—routine oxygen in non-hypoxic patients provides no benefit. 3, 2

Cardiac Monitoring

Continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation and life-threatening arrhythmias. 3

Complication Management

Cerebral Edema and Increased Intracranial Pressure

Do NOT use corticosteroids—they are ineffective and potentially harmful. 1, 2, 4

For patients with neurological deterioration: 2

• Administer osmotic therapy: mannitol 0.25-0.5 g/kg IV every 6 hours OR hypertonic saline 3% bolus
• Consider hyperventilation to PaCO2 30-35 mmHg as temporary measure
• Surgical decompressive craniectomy for large cerebellar infarcts causing brainstem compression

Seizure Management

Do NOT give prophylactic anticonvulsants to patients without seizures. 3

If seizures occur, treat with short-acting agents like lorazepam 2-4 mg IV. 2

Venous Thromboembolism Prophylaxis

Initiate prophylactic-dose low molecular weight heparin (preferred over unfractionated heparin) or intermittent pneumatic compression devices within 24 hours for immobilized patients. 2

Do not use elastic compression stockings alone—they are ineffective. 2

Stroke Unit Care

Admit all stroke patients to dedicated stroke units with geographically defined beds and interdisciplinary teams—this reduces death by 24%, death or institutionalization by 24%, and death or dependency by 20% compared to general medical wards. 3, 4

The stroke unit team must include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with stroke expertise. 4

Early Rehabilitation

Begin rehabilitation assessment within 48 hours and initiate therapy as soon as medically stable. 2

Start frequent, brief out-of-bed activities (sitting, standing, walking) within 24 hours if no contraindications exist. 2

Critical Pitfalls to Avoid

Time delays are devastating—avoid time-consuming imaging protocols and overly restrictive selection criteria that exclude patients who could benefit. 3, 2

Do not use combination clopidogrel plus aspirin in acute phase—this increases bleeding without proven benefit. 2

Avoid precipitous blood pressure lowering with sublingual nifedipine—this can cause neurological worsening. 3

Do not perform routine anticoagulation in acute ischemic stroke—this increases hemorrhagic transformation without reducing early recurrent stroke. 3