What is the primary management approach for a patient with acute stroke, including ischemic and hemorrhagic types?

Acute Stroke Management

Ischemic Stroke: Immediate Hyperacute Management

For patients presenting within 3-4.5 hours of clearly defined symptom onset, administer IV alteplase 0.9 mg/kg (maximum 90 mg) with 10% given as bolus over 1 minute and remaining 90% infused over 60 minutes. 1, 2, 3

Pre-Thrombolysis Requirements

• Obtain non-contrast CT brain immediately to exclude hemorrhage before initiating thrombolysis 2
• Reduce blood pressure to <185/110 mmHg before alteplase administration 2, 4, 3
• Target door-to-needle time of less than 60 minutes, as every 30-minute delay reduces probability of favorable outcome by approximately 10.6% 2, 3
• Treatment within 3 hours yields the strongest benefit (Grade 1A recommendation), with the 3-4.5 hour window representing an acceptable extension based on ECASS-3 trial data 1, 2

Post-Thrombolysis Monitoring Protocol

• Monitor neurological status and vital signs every 15 minutes during and for 2 hours after alteplase infusion, then every 30 minutes for 6 hours, then hourly until 24 hours post-treatment 2, 3
• Maintain BP ≤180/105 mmHg throughout the 24-hour monitoring period 2, 4, 3
• Monitor for symptomatic intracranial hemorrhage, which occurs in approximately 6.4% of rtPA-treated patients 2, 5
• Delay aspirin initiation until after the 24-hour post-thrombolysis CT scan has excluded intracranial hemorrhage, then initiate aspirin 150-325 mg daily 2, 3

Endovascular Thrombectomy

Proceed with mechanical thrombectomy using stent retriever devices if ALL of the following criteria are met: 2, 3

• Prestroke modified Rankin Scale (mRS) score 0-1
• Causative large vessel occlusion (internal carotid, middle cerebral, or basilar artery) confirmed on CT angiography 2
• Age ≥18 years
• NIHSS score ≥6
• ASPECTS ≥6
• Groin puncture can be initiated within 6 hours of symptom onset

Do not delay IV alteplase even if endovascular treatment is being considered—both therapies are complementary. 2, 3

• Stent retrievers (Solitaire FR, Trevo) are preferred over coil retrievers (Merci) based on MR CLEAN, ESCAPE, SWIFT PRIME, EXTEND-IA, and REVASCAT trials 2, 3

Antiplatelet Therapy for Non-Thrombolyzed Patients

For patients NOT receiving thrombolysis, administer aspirin 160-325 mg within 24-48 hours after stroke onset. 1, 2, 4

• This represents a Grade 1A recommendation for early aspirin therapy 1
• Do not administer antiplatelet agents or anticoagulants for 24 hours after rtPA due to increased bleeding risk 2

Blood Pressure Management

For Ischemic Stroke NOT Receiving Thrombolysis

• Avoid lowering blood pressure unless systolic BP >220 mmHg or diastolic BP >120 mmHg, as aggressive reduction can worsen ischemic injury 4
• If treatment is required, lower blood pressure cautiously by approximately 15% during the first 24 hours using easily titratable parenteral agents such as labetalol or nicardipine 4

For Ischemic Stroke Receiving Thrombolysis

• Maintain BP <185/110 mmHg before alteplase and ≤180/105 mmHg during and for 24 hours after treatment 2, 4, 3

Hemorrhagic Stroke Management

For intracerebral hemorrhage (ICH) patients with history of hypertension, maintain mean arterial pressure below 130 mmHg. 2

Surgical Considerations

• Surgical evacuation may be undertaken for cerebellar hemisphere hematomas >3 cm diameter in selected patients 2
• Routine surgery is not recommended for supratentorial hematoma 2
• The use of recombinant factor VIIa (rFVIIa) is currently considered experimental and not recommended outside clinical trials 2

VTE Prophylaxis

For Ischemic Stroke with Restricted Mobility

• Initiate prophylactic-dose subcutaneous LMWH or intermittent pneumatic compression devices (Grade 2B recommendation) 1
• Prophylactic-dose LMWH is preferred over prophylactic-dose UFH 1

For Intracerebral Hemorrhage with Restricted Mobility

• Initiate prophylactic-dose subcutaneous heparin (UFH or LMWH) started between days 2 and 4, or use intermittent pneumatic compression devices 1
• Do not use elastic compression stockings (Grade 2B recommendation against) 1

Stroke Unit Care

Admit to a geographically defined stroke unit with specialized nursing staff and begin frequent brief mobilization within 24 hours if no contraindications. 2, 3

• Stroke unit care reduces mortality and disability across all stroke types, ages, and severities 2

Critical Pitfalls to Avoid

• Do not use full-dose anticoagulation (IV or subcutaneous heparin) for acute ischemic stroke treatment—it increases hemorrhage risk without improving outcomes (Grade 1A recommendation against) 1, 2, 3
• Do not delay thrombolysis for advanced imaging (perfusion/diffusion MRI) if patient is otherwise eligible based on non-contrast CT 2
• Do not use glycoprotein IIb/IIIa inhibitors, volume expansion, vasodilators, or induced hypertension strategies outside clinical trials 4
• Do not use corticosteroids for cerebral edema management following ischemic stroke 4
• Do not use neuroprotective agents—they lack demonstrated efficacy in improving outcomes 4

Secondary Prevention Workup

• Obtain transthoracic echocardiography to assess for cardioembolic sources; consider transesophageal echocardiography if cardioembolic source is suspected but not identified 2, 3
• Initiate high-intensity statin therapy regardless of baseline cholesterol levels 2, 4
• Evaluate for carotid stenosis with duplex ultrasound or CT angiography 4
• Perform urgent carotid revascularization within 2 weeks if ≥70% symptomatic stenosis is identified 4