What is the appropriate treatment for a patient presenting with acute stroke?

Acute Stroke Treatment

For patients presenting with acute ischemic stroke, immediately administer IV alteplase 0.9 mg/kg (maximum 90 mg) if they arrive within 3-4.5 hours of clearly defined symptom onset and have no contraindications, with a target door-to-needle time under 60 minutes. 1, 2

Immediate Assessment and Preparation

Rapid Diagnostic Workup

• Obtain non-contrast CT brain immediately to exclude hemorrhagic stroke before any thrombolytic therapy 2, 3
• Perform CT angiography simultaneously to identify large vessel occlusions (internal carotid, middle cerebral, or basilar artery) for potential endovascular therapy 2, 3
• Check blood glucose immediately and correct hypoglycemia with IV dextrose if present 3
• Ensure oxygen saturation >94% with supplemental oxygen 3

Blood Pressure Management Before Thrombolysis

• Blood pressure must be reduced to <185/110 mmHg before initiating alteplase and maintained ≤180/105 mmHg during and for 24 hours after treatment 1, 2, 3
• For systolic BP >185 mmHg or diastolic >110 mmHg: administer labetalol 10-20 mg IV over 1-2 minutes (may repeat once), or nicardipine drip 5 mg/h titrated up by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h), or nitropaste 1-2 inches 1
• If blood pressure cannot be reduced below 185/110 mmHg, do not administer alteplase 1

Thrombolytic Therapy Administration

Alteplase Dosing Protocol

• Administer alteplase 0.9 mg/kg (maximum 90 mg total) with 10% given as IV bolus over 1 minute and remaining 90% infused over 60 minutes 1, 2, 3
• This dosing differs from myocardial infarction protocols—verify the stroke-specific dose 1
• Before connecting the IV pump, draw the waste dose from the bottle and verify with another nurse to prevent accidental overdose 1
• Insert all necessary IV lines, Foley catheter, and indwelling tubes before starting alteplase, but do not delay treatment by more than a few minutes 1

Critical Time Targets

• Target door-to-needle time <60 minutes in 90% of patients, with median door-to-needle time of 30 minutes 1, 2
• Every 30-minute delay reduces probability of favorable outcome by approximately 10.6% 2, 3
• Treatment window extends to 4.5 hours based on ECASS-3 trial data, though earlier treatment yields better outcomes 2

Endovascular Thrombectomy

Patient Selection Criteria

• Proceed with mechanical thrombectomy if ALL criteria met: prestroke mRS 0-1, large vessel occlusion on CTA, age ≥18 years, NIHSS ≥6, ASPECTS ≥6, and groin puncture can be initiated within 6 hours of symptom onset 2
• Use stent retriever devices (Solitaire FR, Trevo) as they are superior to coil retrievers based on MR CLEAN, ESCAPE, SWIFT PRIME, EXTEND-IA, and REVASCAT trials 2
• Do not delay IV alteplase even if endovascular treatment is planned—both therapies are complementary and should be given together 2, 3

Post-Thrombolysis Monitoring

Neurological and Vital Sign Monitoring

• Monitor neurological status and vital signs every 15 minutes during and for 2 hours after alteplase infusion, then every 30 minutes for 6 hours, then hourly until 24 hours post-treatment 1, 3, 4
• Maintain BP ≤180/105 mmHg throughout the 24-hour monitoring period 1, 2, 3, 4
• If patient develops severe headache, acute hypertension, nausea, vomiting, or worsening neurological examination, discontinue alteplase immediately and obtain emergency CT scan 4

Blood Pressure Management During Monitoring

• For systolic 180-230 mmHg or diastolic 105-120 mmHg: labetalol 10 mg IV over 1-2 minutes, may repeat every 10-20 minutes (maximum 300 mg) or labetalol 10 mg IV followed by infusion at 2-8 mg/min 1
• For systolic >230 mmHg or diastolic 121-140 mmHg: labetalol 10 mg IV over 1-2 minutes, may repeat every 10-20 minutes (maximum 300 mg), or nicardipine 5 mg/h IV drip titrated up by 2.5 mg/h every 5 minutes to maximum 15 mg/h 1
• For diastolic >140 mmHg: sodium nitroprusside 0.5 μg/kg/min IV infusion as initial dose and titrate to desired blood pressure 1

Hemorrhagic Transformation Management

• Symptomatic intracranial hemorrhage occurs in approximately 3.3-6.4% of rtPA-treated patients 2, 4, 5
• If symptomatic hemorrhage suspected, immediately discontinue remaining alteplase infusion and obtain emergent non-contrast CT 4
• Consider cryoprecipitate to restore decreased fibrinogen levels 4
• There is insufficient evidence to support routine use of fresh frozen plasma, prothrombin complex concentrates, tranexamic acid, factor VIIa, or platelet transfusions for alteplase-associated bleeding—use should be decided case-by-case 1

Antiplatelet and Anticoagulant Therapy

Timing of Antiplatelet Initiation

• Do not administer antiplatelet agents or anticoagulants for 24 hours after alteplase due to increased bleeding risk 2, 3, 4
• Obtain follow-up CT scan at 24 hours to exclude intracranial hemorrhage before starting antiplatelet therapy 4
• After 24-hour CT excludes hemorrhage, initiate aspirin 160-325 mg daily 1, 2

Anticoagulation Considerations

• Urgent anticoagulation with IV heparin, subcutaneous heparin, or low molecular weight heparin is not recommended for acute ischemic stroke as it increases hemorrhage risk without improving outcomes 1, 2
• Subcutaneous unfractionated heparin or low molecular weight heparin may be considered solely for DVT prophylaxis in at-risk immobilized patients, recognizing non-pharmacologic options also exist 1
• Alteplase should not routinely be administered to patients on direct oral anticoagulants (DOACs)—consider endovascular therapy instead 1

Stroke Unit Care and Supportive Management

Admission and Monitoring Location

• Admit to geographically defined stroke unit or intensive care unit with specialized nursing staff for at least 24 hours 1, 2, 4
• Stroke unit care reduces mortality and disability across all stroke types, ages, and severities 1, 2
• Begin frequent brief mobilization within 24 hours if no contraindications 2

Supportive Care Measures

• Initiate continuous cardiac monitoring for at least 24 hours to detect arrhythmias 3
• Treat fever >38°C with antipyretics 3
• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters when possible 4
• Maintain normoglycemia—treat hyperglycemia to target range 3

Blood Pressure Management for Non-Thrombolysis Candidates

Conservative Approach for Elevated BP

• For patients NOT receiving thrombolytic therapy with systolic <220 mmHg or diastolic <120 mmHg: observe unless there is end-organ involvement (aortic dissection, acute MI, pulmonary edema, hypertensive encephalopathy) 1
• Treat other stroke symptoms such as headache, pain, agitation, nausea, and vomiting rather than aggressively lowering blood pressure 1
• For systolic >220 mmHg or diastolic 121-140 mmHg: labetalol 10-20 mg IV over 1-2 minutes (may repeat every 10 minutes, maximum 300 mg) or nicardipine 5 mg/h IV infusion, titrate by 2.5 mg/h every 5 minutes to maximum 15 mg/h, aiming for 10-15% reduction 1

Critical Pitfalls to Avoid

• Do not delay thrombolysis for advanced imaging (perfusion/diffusion MRI) if patient is otherwise eligible based on non-contrast CT 2
• Do not assume behavioral symptoms (confusion, agitation) are contraindications to thrombolysis—they may reflect the stroke pathology itself 2
• Do not use full-dose anticoagulation in acute ischemic stroke as it increases hemorrhage risk without improving outcomes 1, 2
• Failure to maintain strict blood pressure control increases risk of hemorrhagic transformation 4
• Premature administration of anticoagulants or antiplatelet agents before 24-hour follow-up CT scan 4
• Do not substitute streptokinase or other thrombolytic agents for alteplase—they cannot be used safely 1

Special Populations and Uncertain Situations

• When uncertain whether to treat with alteplase, urgently consult with stroke specialist within institution or through telestroke services 1
• For pediatric stroke (newborn to age 18) and pregnant women, urgent consultation with stroke expert is recommended alongside clinical judgment and discussion with patient or substitute decision-maker 1
• Hospital inpatients who develop acute stroke should be rapidly evaluated by specialist team and provided access to thrombolysis and endovascular therapy 1