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

Acute Ischemic Stroke Management

Immediate Diagnostic Evaluation

All patients with suspected acute ischemic stroke must undergo emergency non-contrast CT (NCCT) immediately upon arrival to exclude hemorrhage and determine thrombolysis eligibility. 1 This imaging must be interpreted within 45 minutes of ED arrival by a physician with expertise in reading brain CT studies. 2

• For patients arriving within 6 hours who are potential endovascular thrombectomy candidates, perform CT angiography (CTA) from arch-to-vertex immediately after NCCT to identify large vessel occlusions—but this must not delay IV thrombolysis if indicated. 2, 1
• Obtain a 12-lead ECG to assess cardiac rhythm and identify atrial fibrillation, though this should not delay thrombolysis assessment. 1, 3

Reperfusion Therapy: The Primary Treatment Goal

Intravenous Thrombolysis (First-Line for Eligible Patients)

Administer intravenous alteplase (0.9 mg/kg, maximum 90 mg) as soon as possible for eligible patients within 3 hours of symptom onset, with treatment extending to 4.5 hours for selected patients. 1, 3 The target door-to-needle time is less than 60 minutes in at least 80% of treated patients. 2, 3

Dosing protocol: Give 10% as an IV bolus over 1 minute, then infuse the remaining 90% over 60 minutes. 3

Critical blood pressure requirements:

• Before alteplase: Lower BP to <185/110 mmHg 1, 3
• During and after alteplase: Maintain BP <180/105 mmHg for at least 24 hours 1, 3

Eligibility criteria include: 1

• Age ≥18 years
• All stroke severities (though minor/rapidly improving symptoms remain controversial—approximately one-third of untreated patients with mild symptoms have poor outcomes) 2
• Patients on antiplatelet monotherapy or dual antiplatelet therapy
• End-stage renal disease patients on hemodialysis with normal aPTT

Key contraindications:

• Frank hypodensity involving more than one-third of the MCA territory on NCCT (Class III recommendation—do not give alteplase) 2
• Patients taking direct thrombin inhibitors (dabigatran) or direct factor Xa inhibitors (rivaroxaban, apixaban) without reliable rapid reversal testing 2

Monitoring after alteplase: Perform neurological assessments and BP checks every 15 minutes during and for 2 hours after infusion. 1 If symptomatic hemorrhage occurs, stop alteplase immediately and obtain emergent NCCT. 1

Endovascular Thrombectomy (For Large Vessel Occlusions)

Stent retrievers (Solitaire FR and Trevo) are the preferred mechanical thrombectomy devices over coil retrievers (Merci) for patients with large vessel occlusions. 2 EVT should be performed within 6 hours of symptom onset for anterior circulation occlusions. 2, 1

Key principles:

• Patients eligible for IV alteplase should receive it even if EVT is being considered—do not delay IV thrombolysis. 2
• EVT is indicated for patients with large vessel occlusions who received IV alteplase AND those ineligible for IV alteplase. 2, 1
• Time to reperfusion is directly correlated with outcomes—minimize all delays. 2
• EVT requires specialized stroke centers with rapid access to cerebral angiography and credentialed interventionalists. 2

The combination of IV thrombolysis followed by mechanical thrombectomy achieves the highest recanalization rates without increased hemorrhage risk. 2 Mechanical thrombectomy has a number needed to treat of less than 3 for improved functional outcome—unmatched efficacy in stroke medicine. 4

Antiplatelet Therapy (For Patients NOT Receiving Thrombolysis)

Administer oral aspirin 160-325 mg within 24-48 hours after stroke onset for patients who did not receive thrombolysis. 1, 3 For patients treated with IV alteplase, delay aspirin until 24 hours after treatment. 1

• Dual antiplatelet therapy (aspirin plus clopidogrel) for 21 days begun within 24 hours can be beneficial for early secondary prevention in minor stroke patients. 1
• Urgent anticoagulation is NOT recommended for acute ischemic stroke due to increased bleeding risk. 5

Blood Pressure Management

For Patients Receiving Thrombolysis

Strict BP control is mandatory: Lower to <185/110 mmHg before alteplase and maintain <180/105 mmHg for 24 hours after. 1, 3 This is an absolute requirement for safe thrombolysis.

For Patients NOT Receiving Thrombolysis

Do not routinely treat elevated BP unless extremely elevated (SBP >220 mmHg or DBP >120 mmHg). 1, 3 When treatment is necessary, reduce BP by approximately 15% (not more than 25%) over the first 24 hours. 1

The rationale: Elevated BP in acute stroke may represent a compensatory mechanism to maintain cerebral perfusion to the ischemic penumbra. Aggressive BP lowering can worsen outcomes. 2

Supportive Care and Complication Prevention

Admit all stroke patients to a geographically defined stroke unit with specialized staff as soon as possible, ideally within 24 hours. 1 Stroke unit care provides benefits comparable to IV thrombolysis itself. 2 Approximately 25% of patients deteriorate in the first 24-48 hours, requiring close monitoring. 2

Critical supportive measures:

• Oxygenation: Maintain oxygen saturation >94% with supplemental oxygen. 1, 3
• Temperature: Treat hyperthermia >38°C with antipyretics (sources should be identified and treated). 1, 3
• Glucose management:
  • Correct hypoglycemia (<60 mg/dL) immediately to achieve normoglycemia. 1, 3
  • Treat hyperglycemia to achieve blood glucose 140-180 mg/dL. 1, 3
• Hydration: Correct hypovolemia with IV normal saline. 3
• Swallowing assessment: Screen for dysphagia before allowing oral intake to reduce pneumonia risk. 1, 5
• Early mobilization: Begin frequent, brief, out-of-bed activity within 24 hours if no contraindications. 1, 5
• DVT prophylaxis: Start intermittent pneumatic compression on day of admission. 5

Cerebral Edema Management (Life-Threatening Complication)

Cerebral edema peaks 3-4 days after stroke but can occur within 24 hours after reperfusion of large infarcts (malignant edema). 2

Medical management:

• Restrict free water to avoid hypo-osmolar fluids 2
• Minimize hypoxemia, hypercarbia, and hyperthermia 2
• Osmotherapy and hyperventilation for patients deteriorating from increased intracranial pressure 2, 5
• Corticosteroids are NOT recommended for cerebral edema management 3

Surgical intervention:

• Decompressive surgery and evacuation are recommended for large cerebellar infarctions causing brainstem compression and hydrocephalus. 3, 5

Cardiovascular Monitoring

Continue cardiac monitoring for at least the first 24 hours after stroke to detect intermittent atrial fibrillation and potentially lethal arrhythmias, particularly in patients with large deficits and right hemispheric strokes. 2 Longer monitoring with 24-hour Holter or event-loop recording may be needed to detect occult arrhythmias. 2

Interventions NOT Recommended

The following strategies lack evidence and carry risks: 2

• Hemodilution by volume expansion (Class III) 2
• Vasodilatory agents such as pentoxifylline (Class III) 2
• Drug-induced hypertension outside clinical trials (Class IIb) 2
• Emergent carotid endarterectomy (limited data, high perceived risks) 2
• Extracranial-intracranial bypass (failed to improve outcomes, high hemorrhage risk) 2