What are the primary recommendations for managing a patient with acute stroke, including those with ischemic and hemorrhagic stroke, with consideration of their eligibility for tissue plasminogen activator (tPA) and other interventions?

Acute Stroke Management

Immediate Assessment and Differentiation

For acute ischemic stroke presenting within 4.5 hours of symptom onset, immediately administer IV tPA at 0.9 mg/kg (maximum 90 mg total) after confirming eligibility, with 10% given as a bolus over 1 minute and the remaining 90% infused over 60 minutes. 1, 2

Critical Pre-Treatment Requirements

• Blood pressure must be reduced to <185/110 mmHg before initiating tPA—if this threshold cannot be achieved, tPA is absolutely contraindicated. 1, 2
• Use labetalol or nicardipine for blood pressure control. 1
• Obtain non-contrast CT immediately to exclude hemorrhagic stroke and assess for contraindications (hemorrhagic transformation, extensive early ischemic changes >1/3 MCA territory). 2
• Confirm the patient is not on direct oral anticoagulants (DOACs) like apixaban, as these patients should NOT receive tPA due to substantially elevated bleeding risk. 1, 2

Time-Based Treatment Algorithm for Ischemic Stroke

0-3 Hours from Symptom Onset

• Administer IV tPA (Grade 1A recommendation)—this is the strongest evidence-based intervention with the greatest absolute benefit (NNT=8 for minimal or no disability). 3, 2, 4
• Earlier treatment within 90 minutes provides the greatest benefit (odds ratio 2.11 vs 1.69 for 90-180 minutes). 1, 4

3-4.5 Hours from Symptom Onset

• Offer IV tPA using ECASS III criteria (Grade 2C recommendation)—the benefit is smaller (NNT=14) but still clinically meaningful. 3, 2, 4
• Apply more restrictive patient selection: exclude patients >80 years old, those with NIHSS >25, those taking oral anticoagulants, or those with both diabetes and prior stroke. 5

Beyond 4.5 Hours

• Do NOT administer IV tPA (Grade 1B recommendation against use). 3, 4
• For proximal cerebral artery occlusions in patients who don't meet IV tPA eligibility, consider intraarterial tPA within 6 hours (Grade 2C). 3, 4

Large Vessel Occlusions

• Add mechanical thrombectomy to IV tPA for large vessel occlusions—these are complementary therapies, not alternatives. 2
• Do not delay door-to-needle time for tPA while arranging thrombectomy. 2
• Consider thrombectomy for carefully selected patients presenting within 6-12 hours with favorable imaging. 2

Post-tPA Management Protocol

Blood Pressure Monitoring

• Monitor BP every 15 minutes during infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly for 16 hours. 1
• Maintain BP <180/105 mmHg during and after treatment. 1

Antiplatelet and Anticoagulation Timing

• Do NOT give anticoagulants or antiplatelet agents for 24 hours after tPA administration. 1, 4
• After 24-48 hours, initiate aspirin 160-325 mg for patients not receiving anticoagulation (Grade 1A). 3, 1, 2, 4
• For minor stroke or high-risk TIA, consider dual antiplatelet therapy (aspirin plus clopidogrel) for 21 days when initiated within 12-24 hours. 1, 2

Hemorrhage Surveillance

• Watch closely for symptomatic intracranial hemorrhage (ICH) in the first 36 hours—baseline risk is 6.4% with tPA vs 0.6% with placebo. 1, 2, 6
• Patients on prior antiplatelet therapy have a 3% absolute increased risk of symptomatic ICH but can still receive tPA at standard dosing. 1, 2

Special Populations and Common Pitfalls

Minor Strokes

• Do NOT exclude patients with minor strokes from tPA consideration—they may still benefit significantly. 1, 4
• Apply the same time windows and dosing protocols. 1

Patients on Antiplatelet Therapy

• Proceed with standard tPA dosing (0.9 mg/kg), accepting the 3% absolute increased ICH risk. 1, 2

Patients on Anticoagulation

• Never give tPA to patients on DOACs—this is an absolute contraindication. 1, 2
• For patients with atrial fibrillation and history of stroke/TIA, recommend oral anticoagulation over antiplatelet therapy for long-term secondary prevention (Grade 1B). 3

Hemorrhagic Stroke Management

For hemorrhagic stroke (identified on CT):

• Do NOT administer tPA or any thrombolytic therapy. 2
• Focus on blood pressure control, reversal of anticoagulation if applicable, and neurosurgical consultation for potential intervention.
• The guidelines provided focus primarily on ischemic stroke; hemorrhagic stroke requires entirely different management.

DVT Prophylaxis in Acute Stroke

For patients with acute ischemic stroke and restricted mobility:

• Use prophylactic-dose subcutaneous heparin or intermittent pneumatic compression devices (Grade 2B). 3
• Avoid elastic compression stockings (Grade 2B recommendation against). 3

Long-Term Secondary Prevention (Non-Cardioembolic)

After the acute phase, for noncardioembolic ischemic stroke or TIA:

• Recommend long-term antiplatelet therapy: aspirin 75-100 mg daily, clopidogrel 75 mg daily, aspirin/extended-release dipyridamole 25/200 mg twice daily, or cilostazol 100 mg twice daily (Grade 1A). 3
• Prefer clopidogrel or aspirin/extended-release dipyridamole over aspirin alone (Grade 2B). 3