What is the recommended management for an adult patient with acute ischemic stroke, history of stroke or stroke risk factors, and MRI findings of hyperintensity in T2 FLAIR?

Management of Acute Ischemic Stroke with T2 FLAIR Hyperintensity

For an adult patient with acute ischemic stroke showing T2 FLAIR hyperintensity on MRI, proceed immediately with standard acute stroke protocols without delay—the presence of FLAIR hyperintensity does not preclude thrombolytic therapy within the treatment window and should not delay emergency interventions. 1

Immediate Emergency Management

Do Not Delay Treatment for Advanced Imaging

• Emergency treatment of stroke must not be delayed to obtain multimodal imaging studies, including detailed MRI sequences. 1
• Vascular imaging should not delay treatment in patients whose symptoms started <3 hours ago. 1
• The American Heart Association explicitly states that no specific CT or MRI finding (except hemorrhage) should preclude rtPA treatment within 3 hours of stroke onset. 1

Airway and Oxygenation

• Assess airway, breathing, and circulation immediately upon arrival, monitoring oxygen saturation with pulse oximetry targeting ≥92%. 1, 2
• Place endotracheal tube if airway is threatened, particularly in patients with decreased consciousness or brain stem dysfunction. 1
• Administer supplemental oxygen only if saturation <94% to prevent hypoxemia-related secondary brain injury. 2

Blood Pressure Management Algorithm

Critical decision point: Is the patient a candidate for IV thrombolysis?

If YES (candidate for rtPA):

• Blood pressure must be reduced to <185/110 mmHg before thrombolytic administration. 1, 2
• Use labetalol 10-20 mg IV over 1-2 minutes (may repeat once), OR nitropaste 1-2 inches, OR nicardipine infusion starting at 5 mg/h. 1
• Monitor blood pressure every 15 minutes during treatment, then every 30 minutes for 6 hours, then hourly for 16 hours. 1

If NO (not a candidate for rtPA):

• Withhold antihypertensive agents unless diastolic BP ≥120 mmHg or systolic BP ≥220 mmHg. 1, 2
• When treatment is indicated, lower blood pressure cautiously by 15-25% within the first day to avoid neurological worsening. 1

Thrombolytic Therapy Decision

Within 3-4.5 Hour Window

• Administer IV alteplase 0.9 mg/kg (maximum 90 mg): give 10% as bolus, infuse remaining 90% over 60 minutes. 1, 3, 2
• The presence of T2 FLAIR hyperintensity alone does not contraindicate thrombolysis—only hemorrhage on imaging is an absolute contraindication. 1

Antiplatelet Therapy

• Do NOT administer aspirin within 24 hours of thrombolytic therapy. 1
• If patient is NOT receiving thrombolytic therapy, administer aspirin 325 mg orally within 24-48 hours after stroke onset. 1, 2
• Clopidogrel alone or in combination with aspirin is not recommended for acute ischemic stroke treatment. 1

Vascular Imaging for Endovascular Therapy

When to Obtain Vascular Imaging

• Vascular imaging (CTA, MRA, or conventional angiography) is strongly recommended during initial evaluation if endovascular therapy is being considered. 1
• This is necessary as a preliminary step for intra-arterial pharmacological agents or endovascular interventions. 1
• However, do not delay IV thrombolysis to obtain vascular imaging in patients within the 3-hour window. 1

Monitoring for Complications

Brain Edema and Increased Intracranial Pressure

• Patients with major hemispheric infarctions are at high risk for brain edema and increased intracranial pressure. 1
• Close monitoring for signs of neurological worsening during the first days after stroke is essential. 1
• Elevate head of bed 20-30 degrees to facilitate venous drainage. 3
• Consider mannitol 0.25-0.5 g/kg IV over 20 minutes every 6 hours (maximum 2 g/kg) or hypertonic saline (3% NaCl) if intracranial pressure increases. 3

Cerebellar Infarction Specific Management

• For acute hydrocephalus secondary to cerebellar infarction, place a ventricular drain. 1
• Decompressive surgical evacuation of space-occupying cerebellar infarction is potentially life-saving with good clinical recovery potential. 1, 3

Seizure Management

• Single self-limiting seizures at onset should not be treated with long-term anticonvulsants. 2
• Recurrent seizures after stroke should be treated with appropriate short-acting medications (lorazepam IV). 1, 2

Secondary Prevention Workup

Vascular Imaging for Etiology

• Perform CTA, MRA, or duplex ultrasound of cervical and intracranial arteries to identify stenosis/occlusion and determine appropriate secondary prevention. 1, 4
• Concordant results from at least two noninvasive imaging techniques can determine treatment eligibility for revascularization procedures. 1

Cardiac Evaluation

• Obtain echocardiography (transthoracic or transesophageal) within 24-48 hours if cardiac source suspected, particularly to evaluate for atrial fibrillation or valvular disease. 2, 4

Critical Pitfalls to Avoid

• Never delay thrombolytic therapy to obtain additional MRI sequences or vascular imaging in patients within the treatment window. 1
• Do not assume that FLAIR hyperintensity indicates tissue that is unsalvageable—this finding does not preclude treatment. 1
• Avoid aggressive blood pressure lowering in patients not receiving thrombolytics, as this may worsen ischemia by decreasing cerebral perfusion pressure. 1, 2
• Do not administer aspirin as adjunctive therapy within 24 hours of thrombolytic administration. 1