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

Ischemic Stroke Management

Immediate Recognition and Pre-Hospital Care

All suspected stroke patients require immediate EMS activation using FAST (Face, Arms, Speech, Time) screening, with pre-notification of the receiving hospital to activate stroke protocols before arrival. 1, 2

• Document the exact time the patient was last known to be normal (last known well time), not when symptoms were discovered, as this determines treatment eligibility 1
• Transport directly to comprehensive stroke centers capable of endovascular therapy when large vessel occlusion is suspected ("mothership" approach) rather than routing through primary stroke centers 1
• EMS should minimize on-scene time and implement "recognize and mobilize" protocols 2

Emergency Department Assessment and Imaging

Perform immediate non-contrast CT scan within minutes of arrival to rule out hemorrhage, followed immediately by CT angiography to identify large vessel occlusions. 1, 3

• Complete these imaging studies during parallel processing while assessing NIHSS score 1
• Obtain vital signs, complete blood count, electrolytes, renal function, glucose, coagulation studies (PT/INR, aPTT), and platelet count 2, 3
• Perform 12-lead ECG to identify atrial fibrillation, but do not delay thrombolysis assessment 3
• Target door-to-imaging time under 20 minutes and door-to-needle time under 60 minutes 1, 3

Intravenous Alteplase Administration (0-3 Hours)

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) to all eligible patients within 3 hours of symptom onset—this is a Level A recommendation with the strongest evidence for improving functional outcomes. 4, 1

Inclusion Criteria:

• Clearly defined symptom onset within 3 hours 1, 3
• Measurable neurologic deficit on NIHSS 1
• Age ≥18 years 1
• CT scan showing no hemorrhage 1, 3

Critical Exclusion Criteria:

• Blood pressure >185/110 mmHg (must lower first) 4, 1, 3
• Platelet count <100,000 1
• INR >1.6 or PT >15 seconds 1
• Glucose <50 or >400 mg/dL 4, 1
• Prior stroke or serious head injury within 3 months 1
• Major surgery within 14 days 1
• History of intracranial hemorrhage 4, 1
• Infective endocarditis 4
• Aortic arch dissection 4
• Intra-axial intracranial neoplasm 4
• Taking direct thrombin inhibitors or direct factor Xa inhibitors unless appropriate laboratory tests are normal or patient has not received a dose for >48 hours with normal renal function 4

Dosing Protocol:

• 10% of total dose (0.9 mg/kg) given as IV bolus over 1 minute 4, 1, 3
• Remaining 90% infused over 60 minutes 4, 1, 3
• Maximum total dose is 90 mg 4, 1, 3

Extended Window Alteplase (3-4.5 Hours)

Consider IV alteplase for patients presenting between 3 to 4.5 hours who meet ECASS III criteria—this is a Level B recommendation. 4, 1

• Additional exclusions for the 3-4.5 hour window: age >80 years, NIHSS >25, history of both diabetes and prior stroke, or any oral anticoagulant use 4
• Patients >80 years presenting in the 3-4.5 hour window can still be treated safely and effectively 4
• For mild stroke symptoms in the 3-4.5 hour window, treatment may be reasonable after weighing risks versus benefits 4

Blood Pressure Management

Before alteplase administration, blood pressure must be lowered to <185/110 mmHg using labetalol, nicardipine, or clevidipine. 4, 1, 3

Pre-Alteplase BP Lowering:

• Labetalol 10-20 mg IV over 1-2 minutes, may repeat once 4, 1
• Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h 4, 1
• Do not administer alteplase if BP cannot be maintained at or below 185/110 mmHg 4

During and After Alteplase:

• Maintain BP ≤180/105 mmHg 4, 1, 3
• Monitor BP every 15 minutes during infusion and for 2 hours after 4, 1
• Then every 30 minutes for 6 hours 4, 1
• Then hourly until 24 hours 4, 1

For Patients NOT Receiving Alteplase:

• Do not routinely treat blood pressure unless SBP >220 mmHg or DBP >120 mmHg 4, 2, 3

Endovascular Thrombectomy

Perform endovascular thrombectomy with stent retrievers for proximal anterior circulation large vessel occlusions (ICA, M1, proximal M2) within 6 hours of symptom onset. 1, 3

• Standard window: within 6 hours of symptom onset 1, 3
• Extended window: up to 24 hours in selected patients with favorable CT perfusion or MRI diffusion/perfusion mismatch showing salvageable tissue 1
• Optimal technique: combined stent-retriever and aspiration technique (BADDASS approach) with dual aspiration through balloon guide catheter and distal access catheter 1
• Endovascular thrombectomy should be performed in addition to, not instead of, IV alteplase when both are indicated 3

Post-Alteplase Monitoring

Monitor neurological status every 15 minutes during and for 2 hours after infusion, every 30 minutes for the next 6 hours, then hourly until 24 hours. 4, 1

• Immediately stop alteplase infusion and obtain emergency head CT if patient develops: 4, 1

  • Severe headache
  • Acute hypertension
  • Nausea or vomiting
  • Neurological worsening

• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if patient can be safely managed without them 4

• Obtain follow-up CT or MRI at 24 hours before starting anticoagulants or antiplatelet agents 4

Management of Symptomatic Intracranial Hemorrhage

If symptomatic intracranial hemorrhage occurs, immediately stop alteplase, obtain emergent non-contrast head CT, and administer reversal agents. 4, 1

• Stop alteplase infusion immediately 4, 1
• Obtain CBC, PT/INR, aPTT, fibrinogen level, type and cross-match 4, 1
• Emergent non-contrast head CT 4, 1
• Administer cryoprecipitate 10 units infused over 10-30 minutes; give additional dose if fibrinogen <200 mg/dL 4, 1
• Tranexamic acid 1000 mg IV over 10 minutes OR ε-aminocaproic acid 4-5 g over 1 hour, followed by 1 g IV until bleeding controlled 4, 1
• Obtain immediate hematology and neurosurgery consultations 4, 1

Antiplatelet Therapy

Administer aspirin 160-325 mg within 24-48 hours after ruling out hemorrhage on follow-up imaging. 1, 3

• Delay aspirin for 24 hours if alteplase was administered 1, 3
• For patients not receiving alteplase, aspirin 325 mg can be given within 24-48 hours 3
• Do not administer glycoprotein IIb/IIIa receptor inhibitors concurrently with IV alteplase 4

Physiological Parameter Management

Temperature Control:

• Monitor temperature every 4 hours for the first 48 hours 1, 2
• Treat fever >37.5°C with antipyretics 1, 2
• Identify and treat sources of hyperthermia 1, 2
• Avoid hypothermia except in clinical trial contexts 1, 2

Glucose Management:

• Monitor blood glucose regularly 1, 2
• Treat hyperglycemia to maintain 140-180 mg/dL 1, 2
• Avoid hypoglycemia with close monitoring 1, 2

Oxygen Management:

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

Stroke Unit Care

Admit all stroke patients to a geographically defined stroke unit with specialized staff within 24 hours of hospital arrival. 1, 2, 3

• Stroke unit care significantly reduces mortality (OR 0.76) and dependency (OR 0.80) compared to general ward care 2
• Begin rehabilitation assessment within 48 hours of admission 1, 2
• Start frequent, brief out-of-bed activity within 24 hours if no contraindications 1, 2
• Screen swallowing, nutrition, and hydration status on day of admission 1, 2

Management of Cerebral Edema and Increased ICP

Do not use corticosteroids for cerebral edema—they are ineffective and potentially harmful. 1, 2, 3

• Use osmotherapy and hyperventilation for deteriorating patients with increased ICP 1, 2, 3
• Perform surgical decompression for large cerebellar infarctions with brainstem compression 1, 2, 3
• Perform decompressive hemicraniectomy urgently for malignant MCA infarction before significant GCS decline or pupillary changes, ideally within 48 hours of onset 1, 2
• Surgical drainage of CSF for hydrocephalus 3

Seizure Management

Treat new-onset seizures with short-acting medications (e.g., lorazepam IV) if not self-limiting. 1, 2

• Do not use prophylactic anticonvulsants 1, 2

Critical Pitfalls to Avoid

Every 30-minute delay in recanalization decreases good functional outcome by 8-14%—speed is absolutely critical. 1, 2

• Failure to obtain follow-up imaging at 24 hours before starting antiplatelets or anticoagulants increases hemorrhage risk 1
• Inadequate blood pressure control before thrombolysis significantly increases symptomatic intracranial hemorrhage risk 1, 2
• Overly selective treatment criteria may exclude patients who could benefit from therapy 2
• Overlooking swallowing difficulties, infections, or venous thromboembolism prevention worsens outcomes 2
• Delaying rehabilitation assessment beyond 48 hours impairs recovery 2