How should an elderly patient with acute ischemic stroke be managed acutely (including intravenous thrombolysis, mechanical thrombectomy, and contraindications) and subsequently for secondary prevention (antithrombotic therapy, blood pressure control, statin therapy, and rehabilitation)?

Acute Ischemic Stroke Management in the Elderly

Immediate Acute Management

Elderly patients with acute ischemic stroke should receive intravenous alteplase (0.9 mg/kg, maximum 90 mg) if they present within 4.5 hours of symptom onset and have no contraindications, followed by mechanical thrombectomy if large vessel occlusion is confirmed—age alone is not a contraindication to either therapy. 1, 2

Prehospital and Emergency Department Protocol

• Activate emergency medical services immediately upon stroke recognition, as EMS transport reduces time to treatment by approximately 8 minutes compared to private transportation 3
• Document the exact "last known well" time, as this determines eligibility for all time-sensitive interventions 3, 2
• Obtain non-contrast CT or MRI within 30 minutes of hospital arrival to exclude hemorrhage (absolute contraindication) and assess for early ischemic changes 1, 3
• Perform CT angiography or MR angiography from aortic arch to vertex to identify large vessel occlusions amenable to mechanical thrombectomy 1, 3
• Measure blood glucose immediately—only this test must precede alteplase administration 2

Intravenous Thrombolysis

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) with 10% as bolus over 1 minute, followed by 90% over 60 minutes, with door-to-needle time <60 minutes: 1, 2

• 0-3 hours from symptom onset: Strong recommendation for IV alteplase (Class I, Level A evidence) 1
• 3-4.5 hours from symptom onset: Recommended, but with additional exclusion criteria: age >80 years, oral anticoagulant use regardless of INR, NIHSS >25, or history of both stroke and diabetes 1, 2
• Beyond 4.5 hours: IV alteplase is NOT recommended 1

Critical contraindications to assess: 1, 2

• Blood pressure must be lowered below 185/110 mmHg before initiating thrombolysis 2
• Frank hypodensity involving more than one-third of the MCA territory on CT—withhold alteplase (Class III, Level A) 1
• Blood glucose >11.1 mmol/L increases symptomatic intracranial hemorrhage risk to 36% 2

Important caveat: Pooled data from the HERMES collaboration demonstrated that mechanical thrombectomy had favorable effect in patients ≥80 years old (common odds ratio 3.68; 95% CI 1.95-6.92), though benefit in patients ≥90 years is unclear due to small numbers 1

Mechanical Thrombectomy

Proceed with mechanical thrombectomy using stent retrievers for patients meeting ALL of the following criteria (Class I, Level A): 1, 2

• Prestroke modified Rankin Scale score 0-1
• Causative occlusion of internal carotid artery or MCA M1 segment
• Age ≥18 years (including elderly—age alone is NOT a contraindication)
• NIHSS score ≥6
• ASPECTS ≥6
• Treatment can be initiated (groin puncture) within 6 hours of symptom onset

Do NOT delay IV thrombolysis to evaluate for mechanical thrombectomy eligibility, and do NOT wait to assess IV thrombolysis response before proceeding with catheter angiography: 2

• Eligible patients should receive IV alteplase even if mechanical thrombectomy is planned 2
• Combined therapy achieves recanalization rates of 72-88% with modern stent retrievers 2
• Symptomatic intracranial hemorrhage rates are similar between thrombectomy (4.4%) and control (4.3%) groups 2

For M2/M3 occlusions, vertebral/basilar/posterior cerebral artery occlusions: Mechanical thrombectomy may be reasonable but evidence is less certain (Class IIb) 1

Intraarterial Thrombolysis

• Consider intraarterial alteplase as rescue therapy when early recanalization with IV thrombolysis is not achieved, particularly for large clot burden in proximal vessels 2
• Intraarterial thrombolysis initiated within 6 hours may be considered for patients with proximal cerebral artery occlusions who do not meet IV alteplase eligibility criteria 1

Acute In-Hospital Management

Stroke Unit Care

Admit ALL stroke patients to a geographically defined stroke unit with dedicated multidisciplinary team: 3

• Maintain nurse-to-patient ratio of 1:2 for the first 24 hours, as up to 30% of patients experience neurological deterioration during this period 3
• Monitor closely for cerebral edema, which peaks at 3-4 days but can occur within 24 hours with reperfusion 3
• Selected patients (18-60 years) with significant MCA infarction should be urgently referred to neurosurgery for consideration of hemicraniectomy within 48 hours of symptom onset 1

Early Antiplatelet Therapy

Administer aspirin 160-325 mg within 48 hours of stroke onset if CT/MRI excludes hemorrhage: 1

• In patients who received IV alteplase, postpone aspirin until MORE than 24 hours after thrombolysis to minimize intracranial hemorrhage risk 3
• Aspirin is superior to therapeutic parenteral anticoagulation in acute ischemic stroke 1

Do NOT use routine anticoagulation (unfractionated heparin or LMWH) in unselected patients following acute ischemic stroke—harms outweigh benefits: 1

Prevention of Acute Complications

Swallowing assessment: 3

• Perform swallowing screening before ANY oral intake to prevent aspiration pneumonia (compulsory quality indicator) 3
• For patients unable to swallow, place naso-enteric feeding tube within 24 hours 3
• Perform oral hygiene at least three times daily and immediately after meals 3

Venous thromboembolism prophylaxis for immobilized patients: 1, 3

• Administer subcutaneous LMWH over unfractionated heparin (5000 IU twice daily) 1, 3
• Add intermittent pneumatic compression devices for additional VTE reduction 3
• Do NOT use elastic compression stockings—they are not recommended 1

Early mobilization: 3

• Mobilize neurologically and hemodynamically stable patients within 24 hours of admission (ideally ≤52 hours) 3
• Early mobilization reduces medical complications 3

Fluid management: 3

• Maintain euvolemia with isotonic normal saline 3
• Administer supplemental oxygen only when peripheral oxygen saturation falls below 94% 3
• Avoid glucose-containing fluids unless patient is hypoglycemic 3

Other measures: 3

• Avoid routine indwelling urinary catheters due to infection risk 3
• Use high-specification foam mattresses for pressure-area care in high-risk patients 3

Secondary Prevention

Antithrombotic Therapy

For noncardioembolic ischemic stroke (long-term): 1

• Recommend clopidogrel 75 mg once daily OR aspirin/extended-release dipyridamole 25 mg/200 mg twice daily over aspirin alone 1
• These agents are superior to aspirin 75-100 mg once daily for secondary prevention 1

For atrial fibrillation: 1, 3

• Initiate oral anticoagulation at discharge (compulsory quality indicator) 1, 3
• Oral anticoagulants are superior to antiplatelet agents for cardioembolic stroke prevention 1

For minor stroke (NIHSS ≤3-5) or high-risk TIA (ABCD2 ≥4): 1

• Administer dual antiplatelet therapy (aspirin plus clopidogrel or ticagrelor) within 24 hours of symptom onset 1

Blood Pressure Control

Initiate antihypertensive medication regardless of baseline blood pressure: 1

• Target blood pressure control with diet, exercise, and antihypertensive medication 1
• Blood pressure assessment and treatment is a compulsory quality indicator 1

Lipid Management

Prescribe high-intensity statin therapy: 1

• Target LDL-cholesterol <1.8 mmol/L (70 mg/dL) 1
• Statin therapy is beneficial for all patients with ischemic stroke or TIA 1

Carotid Revascularization

For ≥50% symptomatic carotid stenosis by NASCET criteria: 3

• Perform carotid endarterectomy within 14 days after symptom onset for severe ipsilateral internal carotid artery stenosis 1

Lifestyle Modifications

Provide tailored interventions for: 1

• Smoking cessation counseling for active smokers 1
• Alcohol intake reduction counseling (>2 drinks/day for men, >1 drink/day for women) 1
• Low/moderate-intensity aerobic activity for 10 minutes, 4 days per week 1
• Dietary sodium intake <2000 mg daily 1

Rehabilitation and Discharge Planning

Rehabilitation Initiation

Begin rehabilitation planning within 24 hours involving caregivers: 3

• Conduct standardized screening evaluation during initial hospitalization to identify residual impairments 3
• 50-70% of patients regain functional independence, but 15-30% remain permanently disabled 3
• Patients with ongoing rehabilitation goals should have access to specialized stroke services after hospital discharge 1

Discharge Planning

Before discharge, establish: 1, 3

• Health and social care plan agreed with patient and family/caregiver 1
• Safe and enabling home environment 1
• Adequate caregiver support 1
• Structured patient and family education about stroke causes, risk factors, warning signs, secondary prevention strategies, and proper EMS activation 3

Follow-up Care

Arrange follow-up within 72 hours by specialist stroke rehabilitation team: 1

• Review health and social care needs at 6 months and annually thereafter 1
• This includes patients in care homes 1