What are the current guidelines for managing a patient with acute ischemic stroke?

Acute Ischemic Stroke Management Guidelines

Immediate Emergency Department Actions

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) to all eligible patients presenting within 3 hours of clearly defined symptom onset, with treatment extending to 4.5 hours for selected patients, targeting a door-to-needle time under 60 minutes. 1, 2

Time-Critical Imaging and Assessment

• Obtain non-contrast CT brain immediately upon arrival to exclude hemorrhage before initiating thrombolysis 1, 2
• Perform CT angiography from arch-to-vertex for patients arriving within 6 hours who may be candidates for endovascular thrombectomy to identify large vessel occlusions 2
• Complete blood count, electrolytes, renal function, glucose, coagulation studies, and 12-lead ECG should be obtained but must not delay thrombolysis assessment 2

Intravenous Thrombolysis Protocol

Eligibility Criteria (3-Hour Window)

Inclusion requirements: 3

• Diagnosis of ischemic stroke causing measurable neurological deficit
• Symptom onset <3 hours before treatment initiation
• Age ≥18 years

Absolute exclusions: 3

• Significant head trauma or prior stroke in previous 3 months
• Symptoms suggesting subarachnoid hemorrhage
• History of intracranial hemorrhage
• Intracranial neoplasm, arteriovenous malformation, or aneurysm
• Arterial puncture at noncompressible site in previous 7 days

Extended Window (3-4.5 Hours)

For the 3-4.5 hour window, apply the same inclusion criteria as the 3-hour window with these additional exclusions: 3

• Age >80 years
• Taking oral anticoagulants regardless of INR
• Baseline NIHSS score >25
• Imaging evidence of ischemic injury involving more than one-third of MCA territory
• History of both stroke and diabetes mellitus

Relative Contraindications (Require Risk-Benefit Assessment)

Consider carefully before administering alteplase if any of these are present: 3

• Only minor or rapidly improving stroke symptoms
• Pregnancy
• Seizure at onset with postictal residual neurological impairments
• Major surgery or serious trauma within previous 14 days
• Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
• Recent acute myocardial infarction (within previous 3 months)

Blood Pressure Requirements

Before alteplase administration: Reduce BP to <185/110 mmHg 1, 2

During and for 24 hours after treatment: Maintain BP ≤180/105 mmHg 1, 2

Dosing and Administration

Infuse 0.9 mg/kg (maximum 90 mg) over 60 minutes: 3, 1

• Give 10% as IV bolus over 1 minute
• Infuse remaining 90% over 60 minutes

Post-Thrombolysis Monitoring Protocol

Neurological and vital sign monitoring schedule: 3, 1

• Every 15 minutes during and for 2 hours after alteplase infusion
• Every 30 minutes for the next 6 hours
• Hourly until 24 hours post-treatment

If severe headache, acute hypertension, nausea, vomiting, or worsening neurological examination develops: 3

• Discontinue the infusion immediately if still running
• Obtain emergent CT scan

Delay placement of: 3

• Nasogastric tubes
• Indwelling bladder catheters
• Intra-arterial pressure catheters (if patient can be safely managed without them)

Obtain follow-up CT or MRI at 24 hours after IV alteplase before starting anticoagulants or antiplatelet agents 3

Mechanical Thrombectomy

Proceed with mechanical thrombectomy using stent retriever devices if ALL criteria are met: 1, 4

• Prestroke modified Rankin Scale (mRS) 0-1
• Causative large vessel occlusion (internal carotid, middle cerebral, or basilar artery) on CT angiography
• Age ≥18 years
• NIHSS ≥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 1

Stent retrievers (Solitaire FR, Trevo) are preferred over coil retrievers (Merci) based on multiple randomized trials 1

Antiplatelet Therapy

For patients who received thrombolysis: 1, 2

• Do NOT administer aspirin or other antiplatelet agents for 24 hours after rtPA
• After 24-hour post-thrombolysis CT excludes hemorrhage, initiate aspirin 150-325 mg daily

For patients NOT receiving thrombolysis: 2, 4

• Administer oral aspirin 325 mg within 24-48 hours after stroke onset

Anticoagulation

Urgent routine anticoagulation is NOT recommended for acute ischemic stroke treatment: 3

• Parenteral anticoagulants (heparin, low-molecular-weight heparins, heparinoids) increase risk of serious bleeding complications including symptomatic hemorrhagic transformation
• Do not initiate anticoagulant therapy within 24 hours of IV rtPA administration
• More studies are needed to determine if certain subgroups (large-vessel atherothrombosis or high-risk embolic sources) may benefit

Blood Pressure Management (Non-Thrombolysis Patients)

Do not routinely treat blood pressure unless extremely elevated: 2, 4

• Systolic BP >220 mmHg OR
• Diastolic BP >120 mmHg

Permissive hypertension maintains cerebral perfusion through collaterals 4

Stroke Unit Care

Admit all stroke patients to a geographically defined stroke unit with specialized interdisciplinary nursing staff: 1, 2, 4

• Begin frequent brief mobilization within 24 hours if no contraindications
• Stroke unit care reduces mortality and disability across all stroke types, ages, and severities

Supportive Care

Airway and oxygenation: 2

• Provide airway support and ventilatory assistance for patients with decreased consciousness or bulbar dysfunction
• Maintain oxygen saturation >94% with supplemental oxygen

Management of increased intracranial pressure: 2

• Use osmotherapy and hyperventilation for patients deteriorating due to increased intracranial pressure, including herniation syndromes
• Perform surgical drainage of cerebrospinal fluid for hydrocephalus
• Do NOT use corticosteroids for cerebral edema management

Secondary Prevention Workup

Before discharge, initiate: 1, 4

• Transthoracic echocardiography to assess for cardioembolic sources (consider transesophageal if cardioembolic source suspected but not identified)
• Urgent carotid duplex ultrasound for all patients with carotid territory symptoms who are potential revascularization candidates
• Statin therapy for lipid lowering regardless of baseline levels
• Antihypertensive therapy for long-term blood pressure control

Critical Pitfalls to Avoid

Do NOT delay thrombolysis for advanced imaging (perfusion/diffusion MRI) if patient is otherwise eligible based on non-contrast CT 1

Do NOT use full-dose anticoagulation (IV or subcutaneous heparin) in acute ischemic stroke—it increases hemorrhage risk without improving outcomes 3, 1

Do NOT use volume expansion, vasodilators, or induced hypertension—these have been studied for decades without proven benefit 4

Do NOT use neuroprotective agents—none have demonstrated efficacy in improving outcomes 4

Do NOT assume behavioral symptoms (confusion, agitation) are contraindications to thrombolysis—they may reflect the stroke pathology itself 1

Every 30-minute delay in treatment reduces probability of favorable outcome by approximately 10.6%—time is brain 1, 4