What is the management plan for a patient with ischemic stroke?

Management of Ischemic Stroke

Ischemic stroke requires immediate emergency treatment with IV alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) if the patient presents within 3 hours of clearly defined symptom onset, following strict blood pressure control and exclusion of hemorrhage. 1

Immediate Prehospital Response

• Activate 911/EMS immediately when stroke symptoms are recognized — EMS use is strongly associated with faster hospital arrival and treatment within the critical 3-hour window 1
• Bystanders account for 62-95% of emergency activations and are critical to rapid response 1

Emergency Department Evaluation (Door-to-Imaging Goal: <25 minutes)

• Obtain non-contrast head CT or MRI immediately upon arrival to exclude hemorrhage and determine eligibility for thrombolysis 1
• Perform complete blood count, electrolytes, renal function, glucose, coagulation studies, and ECG 1, 2
• Use a standardized stroke severity evaluation (NIHSS score) to assess prognosis 2
• Establish written hospital protocols defining processes and responsibilities 2

Acute Reperfusion Therapy (Door-to-Needle Goal: <60 minutes)

IV Thrombolysis

• Administer IV alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) if ALL criteria are met: 3, 1

  • Symptom onset within 3 hours (can extend to 4.5 hours in selected patients) 3, 4
  • No hemorrhage on CT/MRI 1
  • Blood pressure <185/110 mmHg before treatment 1
  • No contraindications per NINDS criteria 3

• Blood pressure management for thrombolysis: 1

  • Must reduce BP to <185/110 mmHg BEFORE alteplase administration
  • Maintain BP ≤180/105 mmHg during and for 24 hours after treatment
  • Avoid sublingual nifedipine and agents causing precipitous BP drops 2

Mechanical Thrombectomy

• Proceed with mechanical thrombectomy using stent retriever devices if ALL criteria are met: 1

  • Prestroke mRS 0-1
  • Large vessel occlusion on CTA
  • Age ≥18 years
  • NIHSS ≥6
  • ASPECTS ≥6
  • Groin puncture can be initiated within 6 hours

• Every 30-minute delay reduces probability of favorable outcome by approximately 10.6% — do not delay for any reason 1

Intra-Arterial Thrombolysis

• Intra-arterial thrombolysis may be considered for patients beyond the 3-hour window, but patient selection criteria and effectiveness have not been fully established 3
• This therapy should not preclude IV tPA when feasible and is typically only available at tertiary care centers 4

Antiplatelet Therapy

• Administer aspirin 325 mg orally within 24-48 hours after stroke onset for patients NOT receiving thrombolysis 3, 1
• Do NOT give aspirin or other antiplatelet agents within 24 hours of IV thrombolysis 1

Blood Pressure Management (Non-Thrombolysis Patients)

• Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg in patients not receiving reperfusion therapy 1, 2
• Permissive hypertension allows maintenance of cerebral perfusion through collaterals 1
• This represents a critical pitfall: overly aggressive BP lowering can worsen outcomes by reducing cerebral perfusion 2

Anticoagulation

• Urgent anticoagulation is NOT recommended — it has not been shown to lessen early recurrent stroke risk and increases brain hemorrhage risk, especially in moderately severe strokes 3, 2
• Routine use of urgent anticoagulation cannot be recommended 3

Stroke Unit Admission

• Admit ALL stroke patients to a geographically defined stroke unit with specialized interdisciplinary staff 1, 2
• The multidisciplinary team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 2
• Continuous cardiac monitoring for at least 24 hours to detect arrhythmias 5

Management of Increased Intracranial Pressure

Medical Management

• Osmotherapy and hyperventilation are recommended for patients deteriorating secondary to increased intracranial pressure, including those with herniation syndromes 3, 5
• Corticosteroids are NOT recommended — they provide no benefit and may cause harm 5

Surgical Interventions

• Surgical decompression and evacuation of large cerebellar infarctions leading to brain stem compression and hydrocephalus is recommended 3
• Ventriculostomy for treatment of symptomatic obstructive hydrocephalus after cerebellar infarction 5
• Decompressive hemicraniectomy within 48 hours substantially reduces death and disability in selected patients (18-60 years old) with extensive hemispheric infarcts 2, 5
• Surgical decompression of large cerebral hemisphere infarctions can be life-saving but survivors have severe residual neurological impairments 3

Prevention and Management of Complications

Airway and Respiratory

• Immediately intubate patients who develop neurological deterioration with respiratory insufficiency to protect the airway and maintain adequate oxygenation 5
• Maintain oxygen saturation ≥94% 5

Swallowing and Nutrition

• Perform swallowing assessment before allowing oral intake to prevent aspiration pneumonia 2
• Insert nasogastric or nasoduodenal tubes when necessary for feedings and medication administration 2
• Percutaneous endoscopic gastric tube placement is superior to nasogastric tube feeding if prolonged feeding support is anticipated 2

Deep Vein Thrombosis Prevention

• Administer subcutaneous anticoagulants or intermittent external compression stockings for immobilized patients 2

Seizure Management

• Treat recurrent seizures as with any other acute neurological condition 3
• Prophylactic administration of anticonvulsants to patients who have not had seizures is NOT recommended 3

Other Complications

• Avoid indwelling bladder catheters when possible due to infection risk 2
• Monitor and treat fever, investigating and treating sources of infection 5
• Actively prevent pressure ulcers, falls, and pain 2

Glucose Management

• Promptly measure and correct hypoglycemia — hypoglycemia can mimic stroke symptoms 2
• Monitor glucose levels closely as both hypoglycemia and hyperglycemia can worsen outcomes 1

Secondary Prevention Workup

• Perform transthoracic echocardiography to assess for cardioembolic sources 1
• Urgent carotid duplex ultrasound for all patients with carotid territory symptoms who are potential revascularization candidates 1, 2
• Obtain fasting lipids, erythrocyte sedimentation rate and/or C-reactive protein 2
• Continue statin therapy during the acute period for patients already taking statins at stroke onset 2

Early Rehabilitation

• Early mobilization is strongly recommended to prevent complications 2
• Speech and language pathologists should evaluate and treat all stroke patients for residual communication difficulties 2
• Assess and manage mobility, activities of daily living, incontinence, and mood early after stroke 2

Critical Pitfalls to Avoid

• Do NOT use volume expansion, vasodilators, or induced hypertension — these have been studied for decades without proven benefit 1
• Do NOT use neuroprotective agents — none have demonstrated efficacy in improving outcomes 3, 1, 2
• Do NOT delay transfer to comprehensive stroke center if patient requires neurosurgical evaluation — the 48-hour window for surgical intervention is critical 1, 5
• Do NOT substitute intravenous streptokinase or other thrombolytic agents for rtPA — they cannot be safely substituted 3
• Do NOT use corticosteroids for cerebral edema management — this is ineffective and potentially harmful 5