What is the latest management approach for a patient presenting with ischemic stroke?

Latest Management of Acute Ischemic Stroke

For patients presenting with acute ischemic stroke, immediately administer IV alteplase 0.9 mg/kg (maximum 90 mg) if treatment can be initiated within 3 hours of clearly defined symptom onset, followed by mechanical thrombectomy with stent retrievers for large vessel occlusions if groin puncture can be performed within 6 hours. 1

Immediate Hyperacute Phase (Door-to-Needle <60 Minutes)

Pre-Treatment Blood Pressure Management

• Blood pressure must be reduced to <185/110 mmHg before alteplase administration using labetalol, nicardipine, or clevidipine 2
• After thrombolysis, maintain BP ≤180/105 mmHg for at least 24 hours 3, 1

IV Thrombolysis Protocol

• Administer IV alteplase 0.9 mg/kg (maximum 90 mg) within 3 hours of symptom onset with 10% given as bolus over 1 minute and remaining 90% infused over 60 minutes 3, 1
• For patients presenting between 3 to 4.5 hours, alteplase should be considered using ECASS III inclusion/exclusion criteria 3
• Target door-to-needle time of less than 60 minutes 1
• Do not delay IV alteplase even if endovascular treatment is being considered 1

Critical Pitfall: Every 30-minute delay in reperfusion reduces the probability of favorable outcome by approximately 10.6%, with treatment within 90 minutes of onset yielding the best results 1. The number needed to treat is 8.3 for achieving minimal or no disability 3.

Endovascular Thrombectomy Evaluation

Proceed with mechanical thrombectomy using stent retrievers if ALL criteria are met:

• Prestroke modified Rankin Scale (mRS) score 0-1 1
• Patient receiving or has received IV alteplase within 4.5 hours 1
• Causative occlusion of ICA or proximal MCA (M1) confirmed on CT angiography 3, 1
• Age ≥18 years 1
• NIHSS score ≥6 1
• ASPECTS ≥6 1
• Groin puncture can be initiated within 6 hours of symptom onset 3, 1

Technical Considerations

• Use stent retrievers (Solitaire FR, Trevo) in preference to coil retrievers (MERCI device) 3
• Use a proximal balloon guide catheter or large-bore distal-access catheter rather than cervical guide catheter alone 3
• Technical goal is TICI grade 2b/3 angiographic result 3
• Salvage intra-arterial fibrinolysis may be reasonable if completed within 6 hours 3

Post-Thrombolysis Monitoring Protocol

Neurological and Hemodynamic Surveillance

• Monitor every 15 minutes during and for 2 hours after alteplase infusion 1
• Then every 30 minutes for 6 hours 1
• Then hourly until 24 hours post-treatment 1
• Maintain BP ≤180/105 mmHg throughout this entire period 1, 2

Symptomatic Intracerebral Hemorrhage Risk

• The symptomatic ICH rate is approximately 5.6% when protocols are followed strictly 4
• Protocol violations increase symptomatic ICH rate to 15% 4
• Obtain 24-hour post-thrombolysis CT scan before initiating antiplatelet therapy 1

Physiological Parameter Management

Blood Glucose Control

• Monitor blood glucose regularly and treat hyperglycemia to achieve levels of 140-180 mg/dL 3, 2
• Treat hypoglycemia (blood glucose <60 mg/dL) immediately 3
• Close monitoring is essential to prevent hypoglycemia 2

Temperature Management

• Identify and treat sources of hyperthermia (temperature >38°C) 3, 2
• Administer antipyretic medications to lower temperature in hyperthermic patients 3, 2
• Check temperature every 4 hours for the first 48 hours 2

Blood Pressure Management (Non-Thrombolysis Candidates)

• For patients NOT receiving fibrinolysis with markedly elevated BP, withhold medications unless systolic BP >220 mmHg or diastolic BP >120 mmHg 3, 2
• Reasonable goal is to lower BP by 15% during first 24 hours 3

Airway and Oxygenation

• Provide supplemental oxygen to maintain oxygen saturation >94% 3
• Airway support and ventilatory assistance for patients with decreased consciousness or bulbar dysfunction 3

Antiplatelet and Anticoagulation Therapy

Timing of Antiplatelet Initiation

• Delay aspirin until after 24-hour post-thrombolysis CT scan has excluded intracranial hemorrhage 1
• Then initiate aspirin 325 mg daily 1
• Aspirin can be administered within first 48 hours for non-thrombolysis patients 3

Anticoagulation Considerations

• Do not use full-dose anticoagulation (IV or subcutaneous heparin) for acute stroke treatment as it does not improve outcomes and increases hemorrhage risk 1
• Urgent anticoagulation cannot be recommended routinely due to increased risk of brain hemorrhage 3

Stroke Unit Care and Early Mobilization

Specialized Unit Admission

• Admit all stroke patients to a geographically defined stroke unit with specialized nursing staff as soon as possible, ideally within 24 hours 1, 2
• Stroke unit care reduces mortality (OR 0.76) and dependency (OR 0.80) compared to general ward care 2

Early Rehabilitation

• Begin frequent brief mobilization within 24 hours if no contraindications 1, 2
• Initial assessment by rehabilitation professionals within 48 hours of admission 2
• Screen swallowing, nutritional, and hydration status on day of admission 2

Management of Complications

Cerebral Edema and Increased Intracranial Pressure

• Do not use corticosteroids for cerebral edema 2
• Use osmotherapy and hyperventilation for deteriorating patients 2
• For patients selected for decompressive hemicraniectomy, proceed urgently prior to significant decline in GCS or pupillary change, ideally within 48 hours from stroke onset 2

Seizure Management

• Treat new-onset seizures with short-acting medications (e.g., lorazepam IV) if not self-limiting 2
• Do not use prophylactic anticonvulsants 2

Secondary Prevention Workup

Cardiac Evaluation

• Obtain transthoracic echocardiography to assess for cardioembolic sources 1
• Consider transesophageal echocardiography if cardioembolic source is suspected but not identified on transthoracic study 1

Risk Factor Modification

• Identify stroke etiology to guide secondary prevention strategies 2
• Address modifiable risk factors including hypertension, diabetes, hyperlipidemia, and smoking 2, 5
• Consider carotid imaging for patients with carotid territory symptoms who might be candidates for revascularization 2

Special Populations

Elderly Patients (≥80 Years)

• No evidence supports withholding tPA treatment in appropriately selected patients aged ≥80 years 6
• Risk of symptomatic ICH (3%) and favorable outcomes (37% with mRS 0-1) are comparable to younger patients 6
• These patients are more likely to be discharged to nursing care facilities (17% vs 5%) 6

Common Pitfalls to Avoid

• Observing patients after IV tPA to assess clinical response before pursuing endovascular therapy is not required and is not recommended 3
• Inadequate blood pressure control before thrombolysis increases hemorrhagic risk 2
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) worsens outcomes 2
• Overly selective treatment criteria may exclude patients who could benefit from therapy 2
• Delays in recognition and treatment significantly worsen outcomes—every 30-minute delay in recanalization decreases the chance of good functional outcome by 8-14% 2