From the Guidelines
An embolic stroke should be treated with intravenous tissue plasminogen activator (tPA) if within 4.5 hours of symptom onset, at a dose of 0.9 mg/kg (maximum 90 mg) with 10% given as bolus and the remainder over 60 minutes, as recommended by the American Heart Association 1.
Key Considerations
- For patients presenting within 24 hours with large vessel occlusion, mechanical thrombectomy may be performed, as suggested by the Journal of the American College of Cardiology 1.
- After the acute phase, secondary prevention includes antiplatelet therapy (typically aspirin 81-325 mg daily, clopidogrel 75 mg daily, or combination therapy depending on risk factors) 1.
- For cardioembolic strokes, particularly with atrial fibrillation, anticoagulation with direct oral anticoagulants (DOACs) like apixaban 5 mg twice daily or warfarin with target INR 2-3 is recommended, as stated by the European Heart Journal 1.
Risk Factor Management
- Risk factor management is essential, including:
- Blood pressure control (target <130/80 mmHg)
- Statin therapy (high-intensity like atorvastatin 40-80 mg daily)
- Diabetes management
- Lifestyle modifications including smoking cessation, limited alcohol intake, regular exercise, and a Mediterranean-style diet
Prompt Recognition and Medical Attention
- Embolic strokes require prompt recognition of symptoms (facial drooping, arm weakness, speech difficulties) and immediate medical attention, as "time is brain" with approximately 1.9 million neurons lost each minute during an acute stroke 1.
From the Research
Embolic Stroke Treatment
- Intravenous thrombolysis with alteplase is recommended for patients with acute ischemic stroke within 4.5 hours of symptom onset 2, 3, 4
- The dose of alteplase is 0.9 mg/kg body weight, with a maximum dose of 90 mg, and is administered as a bolus followed by a 60-minute infusion 2
- Intravenous thrombolysis can be considered in patients with seizures at stroke onset, if the neurological deficit is related to acute cerebral ischemia 2
- Mechanical thrombectomy can be considered in patients with acute middle cerebral artery or carotid occlusions, and within a larger time window for patients with basilar artery occlusion 2
Patient Selection and Timing
- Patient selection and timely treatment are crucial for effective intravenous thrombolysis 4
- The benefit of thrombolysis decreases and the risks increase with progressing time after symptom onset 3
- Intravenous thrombolysis can be considered in patients with acute ischemic stroke on awakening from sleep, who were last seen well more than 4.5 hours earlier, and who have MRI DWI-FLAIR mismatch 4
Safety and Efficacy
- Intravenous thrombolysis with alteplase has been shown to improve functional outcome in patients with acute ischemic stroke 2, 3, 4
- The incidence of symptomatic intracranial hemorrhage is a significant safety concern, but the overall benefit of thrombolysis outweighs the risks in most cases 3, 5
- Alteplase administered 4.5 to 24 hours after stroke onset has been shown to result in a higher frequency of functional independence at 90 days compared to standard medical care in patients with mild posterior circulation stroke 5
Anticoagulation and Antiplatelet Therapy
- Antiplatelet agents, such as aspirin, are recommended for patients with acute ischemic stroke, but should be delayed for 24 hours after thrombolysis 2
- Urgent anticoagulation is not recommended for the treatment of acute ischemic stroke, but may be considered for secondary prevention in patients with a high risk of cardioembolism 2