What is the recommended acute assessment and management for a patient presenting with an acute stroke, including imaging, intravenous tissue plasminogen activator (tPA) administration, endovascular thrombectomy, blood‑pressure control, anticoagulation reversal, and secondary‑prevention strategies?

Acute Stroke Assessment and Management

Immediate Imaging

All patients with suspected acute stroke must undergo immediate non-contrast CT (NCCT) of the brain to exclude hemorrhage, with imaging completed and interpreted within 45 minutes of emergency department arrival. 1, 2, 3

• CT angiography (CTA) from aortic arch-to-vertex should be performed simultaneously with NCCT to identify large vessel occlusion and guide treatment decisions, particularly for patients potentially eligible for endovascular therapy. 1, 3
• MRI with diffusion-weighted imaging (DWI) is superior to CT for detecting acute ischemia (77% vs 16% sensitivity in first 3 hours), but should only be used if it does not delay treatment initiation. 1, 2
• Frank hypodensity on CT involving more than one-third of the middle cerebral artery territory is a contraindication to thrombolysis due to hemorrhagic transformation risk. 1, 2

Intravenous tPA Administration

For patients presenting within 3 hours of symptom onset, administer IV alteplase (0.9 mg/kg, maximum 90 mg) immediately after excluding hemorrhage on imaging. 1

Time-Based Treatment Algorithm:

• 0-3 hours: IV tPA is strongly recommended (Grade 1A evidence). 1 Patients are at least 30% more likely to have minimal or no disability at 3 months. 4

• 3-4.5 hours: IV tPA is recommended (Grade 2C evidence). 1, 5 The ECASS-III trial demonstrated improved outcomes (52.4% vs 45.2% favorable outcome) despite increased symptomatic intracranial hemorrhage (2.4% vs 0.2%). 5

• Beyond 4.5 hours: Do NOT administer IV tPA in routine practice. 1, 6 The ATLANTIS trial showed no benefit and increased hemorrhagic complications when treating between 3-5 hours without advanced imaging selection. 7 However, the 2025 HOPE trial demonstrated that in highly selected patients with salvageable tissue on perfusion imaging treated 4.5-24 hours after onset, alteplase improved functional independence (40% vs 26%), though this requires perfusion imaging capabilities and careful patient selection. 8

Blood Pressure Management for tPA:

• Blood pressure must be reduced to <185/110 mmHg before tPA administration and maintained <180/105 mmHg for 24 hours post-treatment to avoid hemorrhagic complications. 1

Endovascular Thrombectomy

For patients with large vessel occlusion on CTA who present within 6 hours, endovascular thrombectomy should be strongly considered, even if they receive IV tPA. 1

• Vascular imaging (CTA, MRA, or conventional angiography) is mandatory during initial evaluation for patients being considered for endovascular therapy. 1
• Patients with proximal cerebral artery occlusions who are ineligible for IV tPA may receive intraarterial thrombolysis within 6 hours of symptom onset (Grade 2C recommendation). 1, 6
• The 2012 ACCP guidelines suggested against routine mechanical thrombectomy (Grade 2C), but this predates modern stent-retriever trials; current practice strongly favors thrombectomy for large vessel occlusion within 6-24 hours when advanced imaging shows salvageable tissue. 1

Antiplatelet Therapy

For patients NOT receiving thrombolysis, initiate aspirin 160-325 mg within 48 hours of stroke onset. 1, 6

• Do not give aspirin within 24 hours of tPA administration. 1
• Aspirin is preferred over therapeutic anticoagulation in acute ischemic stroke (Grade 1A evidence). 1

Anticoagulation Reversal

For patients on anticoagulation presenting with acute stroke, immediate reversal is required before considering thrombolysis:

• Check INR, aPTT, and coagulation status as part of initial blood work, but do not delay imaging or treatment decisions. 1
• Elevated INR is a contraindication to tPA and requires reversal with prothrombin complex concentrate or fresh frozen plasma before thrombolysis can be considered. 1

Venous Thromboembolism Prophylaxis

For patients with restricted mobility, initiate prophylactic-dose subcutaneous low-molecular-weight heparin (LMWH) or intermittent pneumatic compression devices. 1, 6

• LMWH is preferred over unfractionated heparin (Grade 2B evidence). 1
• Do not use therapeutic anticoagulation acutely unless specific indication (e.g., arterial dissection). 1

Secondary Prevention Strategies

Vascular Imaging for Stroke Mechanism:

All stroke patients require vascular imaging of head and neck vessels to determine stroke etiology and guide secondary prevention. 1

• CTA or MRA of extracranial and intracranial vessels should be performed to identify carotid stenosis, vertebral artery disease, or intracranial atherosclerosis. 1, 3
• For patients outside acute treatment windows (>4.5 hours), emphasis shifts to secondary prevention with comprehensive vascular imaging. 1

Cardiac Evaluation:

Perform ECG on all patients; reserve echocardiography for specific scenarios suggesting cardioembolic source. 3

• Echocardiography is indicated when: infectious endocarditis is suspected, young patients (<50 years) present with stroke, or no other stroke mechanism is identified. 3
• Consider prolonged cardiac monitoring (up to 30 days) when cardioembolic mechanism is suspected despite normal initial ECG. 3

Long-Term Antiplatelet Therapy:

For secondary prevention after non-cardioembolic stroke, prescribe clopidogrel 75 mg daily OR aspirin/extended-release dipyridamole 25/200 mg twice daily (preferred over aspirin alone). 1

• For patients with atrial fibrillation, oral anticoagulation is strongly recommended over antiplatelet therapy (Grade 1B evidence). 1
• Dual antiplatelet therapy (aspirin plus clopidogrel) is NOT recommended for long-term secondary prevention due to increased bleeding risk without additional benefit. 1

Critical Pitfalls to Avoid

• Never delay tPA while waiting for advanced imaging if the patient is within 4.5 hours and NCCT shows no hemorrhage or contraindications. 2
• Do not administer tPA beyond 4.5 hours without perfusion imaging demonstrating salvageable tissue, as routine use increases hemorrhage risk without benefit. 6, 7
• Do not give aspirin within 24 hours of tPA administration due to increased bleeding risk. 1
• Do not use prophylactic anticonvulsants in acute stroke, as they may impair neural recovery. 1
• Do not treat single self-limited seizures at stroke onset with long-term anticonvulsants; only treat recurrent seizures. 1