What are the guidelines for managing a patient with ischemic stroke, including treatment and medication options?

Guidelines for Ischemic Stroke Management

Immediate Assessment and Diagnosis

All patients with suspected acute ischemic stroke must undergo non-contrast CT immediately upon arrival to exclude hemorrhagic stroke and determine thrombolysis eligibility. 1

• Perform CT angiography (CTA) from arch-to-vertex for patients arriving within 6 hours who may be candidates for endovascular thrombectomy to identify large vessel occlusions 1, 2
• Obtain a 12-lead ECG to assess for atrial fibrillation and cardiac arrhythmias, but do not delay thrombolysis assessment 1, 3
• Initiate continuous cardiac monitoring for at least 24 hours to screen for paroxysmal atrial fibrillation 2

Intravenous Thrombolysis (rtPA/Alteplase)

Administer intravenous alteplase 0.9 mg/kg (maximum 90 mg) to eligible patients within 3 hours of symptom onset, with the strongest evidence supporting treatment as early as possible. 4, 1

Dosing Protocol

• Give 10% of the total dose as an intravenous bolus over 1 minute 4, 1, 3
• Infuse the remaining 90% over 60 minutes 4, 1, 3
• The door-to-needle time must be less than 60 minutes in 90% of treated patients 4, 1, 3

Extended Time Window (3-4.5 Hours)

• Alteplase may be administered to selected patients between 3 and 4.5 hours after symptom onset 4, 1
• Additional exclusion criteria for the 3-4.5 hour window include: patients >80 years old, those taking oral anticoagulants regardless of INR, baseline NIHSS score >25, imaging evidence of ischemic injury involving more than one-third of the MCA territory, or history of both stroke and diabetes mellitus 4

Inclusion and Exclusion Criteria

Absolute contraindications include: 4

• 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 non-compressible site in previous 7 days
• Blood glucose <50 mg/dL
• CT demonstrating multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Relative contraindications requiring careful risk-benefit assessment: 4

• 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 21 days)
• Recent acute myocardial infarction (within 3 months)

Blood Pressure Management

For Patients Receiving Thrombolysis

Blood pressure must be lowered and maintained below 185/110 mmHg before rtPA administration and below 180/105 mmHg for at least 24 hours after treatment. 4, 1, 3

• Increase frequency of blood pressure measurements if systolic BP >180 mmHg or diastolic BP >105 mmHg 4
• Administer antihypertensive medications to maintain blood pressure at or below these levels 4

For Patients NOT Receiving Thrombolysis

Do not routinely lower blood pressure unless systolic BP >220 mmHg or diastolic BP >120 mmHg. 4, 3, 2

• When treatment is indicated, lower blood pressure by 15% during the first 24 hours 4, 3, 2
• Critical pitfall: Avoid aggressive blood pressure lowering in watershed or hemodynamic strokes, as these result from hypoperfusion and require adequate perfusion pressure 2

Endovascular Thrombectomy (EVT)

Perform EVT with stent retrievers as first-line therapy for patients with large vessel occlusions within 6 hours of symptom onset. 1

• EVT is indicated for patients who have received intravenous alteplase and those who are not eligible for intravenous alteplase 3
• EVT should be delivered within a coordinated system with rapid neurovascular imaging access and specialized neurointerventional expertise 1, 3

Antiplatelet Therapy

Administer oral aspirin 160-325 mg within 24-48 hours after stroke onset for patients not receiving thrombolysis. 1, 3, 2, 5

• Do not give aspirin within 24 hours of rtPA administration 1, 3
• Consider dual antiplatelet therapy (aspirin plus clopidogrel) only for minor non-cardioembolic strokes and high-risk transient ischemic attacks, converting to single antiplatelet therapy after 21-90 days 2
• Avoid routine therapeutic anticoagulation in acute non-cardioembolic stroke, as it increases hemorrhagic risk without proven benefit 2

Glucose Management

Treat hypoglycemia (blood glucose <60 mg/dL) immediately to achieve normoglycemia. 4, 3, 2

• Treat persistent hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL, as persistent in-hospital hyperglycemia during the first 24 hours is associated with worse outcomes 4, 3, 2
• Closely monitor to prevent hypoglycemia 4

Post-Thrombolysis Monitoring

Admit all patients receiving rtPA to an intensive care or stroke unit for close monitoring. 4

• Measure blood pressure and perform neurological assessments every 15 minutes during and after IV rtPA infusion for 2 hours 4
• Then every 30 minutes for 6 hours, then hourly until 24 hours after IV rtPA treatment 4
• If the patient develops severe headache, acute hypertension, nausea, vomiting, or worsening neurological examination, discontinue the infusion and obtain emergent CT scan 4
• Obtain a follow-up CT or MRI scan at 24 hours after IV rtPA before starting anticoagulants or antiplatelet agents 4

Stroke Unit Care and Supportive Management

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

• Provide airway support and ventilatory assistance for patients with decreased consciousness or bulbar dysfunction 1, 3, 2
• Maintain oxygen saturation >94% with supplemental oxygen 1, 3
• Correct hypovolemia with intravenous normal saline 4, 3
• Identify and treat sources of hyperthermia (temperature >38°C) 3
• Initiate early mobilization when the patient is neurologically stable 2

Management of Neurological Complications

Monitor patients with major hemispheric or cerebellar infarctions closely for signs of brain edema and neurological worsening. 2

• Use osmotherapy and hyperventilation for patients deteriorating due to increased intracranial pressure or herniation syndromes 1, 3, 2
• Do not use corticosteroids for managing cerebral edema and increased intracranial pressure following ischemic stroke 1, 3
• Perform surgical drainage of cerebrospinal fluid for hydrocephalus 1
• Consider surgical decompression and evacuation for large cerebellar infarctions causing brain stem compression and hydrocephalus 3

Prevention of Complications

Use intermittent pneumatic compression devices for patients who cannot receive anticoagulation. 2

• For acute ischemic stroke patients with restricted mobility, administer prophylactic low-dose subcutaneous heparin or low-molecular-weight heparins 5
• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if the patient can be safely managed without them 4

Secondary Prevention Strategies

Complete a comprehensive diagnostic workup to define ischemic stroke etiology and identify targets for treatment to reduce recurrent stroke risk. 2

• Initiate high-intensity statin therapy regardless of baseline cholesterol levels 2
• Evaluate for carotid stenosis and perform urgent carotid revascularization (endarterectomy or stenting) within 2 weeks if ≥70% symptomatic stenosis is identified 2
• For patients with atrial fibrillation and recent stroke or TIA, prescribe long-term oral anticoagulation with target INR 2.5 (range 2.0-3.0) 5

Critical Pitfalls to Avoid

• Do not use hyperbaric oxygen therapy (except for air embolization), as it may be harmful 2
• Do not use induced hypothermia, as insufficient evidence exists to recommend it for acute stroke treatment 2
• Do not give concomitant anticoagulants or antiplatelet agents during the first 24 hours after rtPA treatment 4