What is the recommended acute management for an adult presenting with symptoms of acute ischemic stroke?

Acute Ischemic Stroke Management

For adults presenting with acute ischemic stroke symptoms, immediately stabilize the airway and circulation, obtain non-contrast CT within 25 minutes to exclude hemorrhage, and administer IV alteplase (0.9 mg/kg, max 90 mg) within 3 hours (or up to 4.5 hours in select patients) if no contraindications exist, followed by admission to a specialized stroke unit with continuous monitoring. 1, 2

Immediate Assessment and Stabilization (First 10 Minutes)

ABCs and Vital Signs

• Ensure airway patency, adequate ventilation, and circulatory support immediately upon arrival 1, 2
• Administer supplemental oxygen only if oxygen saturation <94% (not routinely for all patients) 1
• Establish IV access and obtain blood samples for complete blood count, coagulation studies (PT/INR, aPTT), comprehensive metabolic panel, blood glucose, and cardiac biomarkers 1, 2
• Perform 12-lead ECG to identify atrial fibrillation or acute myocardial infarction as potential stroke etiology 1, 2

Neurological Assessment

• Determine the exact time the patient was last known to be at baseline (not when symptoms were discovered)—this is the "time zero" for treatment decisions 1, 2
• Perform National Institutes of Health Stroke Scale (NIHSS) assessment to quantify stroke severity 1, 2
• Identify and immediately treat hypoglycemia if blood glucose <50 mg/dL (2.7 mmol/L), as this is a stroke mimic and exclusion criterion for thrombolysis 1

Emergency Neuroimaging (Within 25 Minutes)

Non-Contrast CT Brain

• Complete CT scan within 25 minutes of ED arrival and interpret within 45 minutes 1, 2
• The primary purpose is to exclude intracranial hemorrhage—if hemorrhage is present, the patient is absolutely not a candidate for thrombolysis 1
• Early ischemic changes (hypodensity affecting >1/3 of cerebral hemisphere) on baseline CT do not preclude rtPA treatment within 3 hours 1

Advanced Imaging Considerations

• CT angiography, CT perfusion, or multimodal MRI may be obtained but must not delay IV rtPA administration in eligible patients presenting within the treatment window 1, 2
• Vascular imaging is necessary before intra-arterial thrombolysis or mechanical thrombectomy but should not delay IV rtPA 1

Blood Pressure Management

For Thrombolysis Candidates

• Blood pressure must be <185/110 mmHg before administering rtPA 1
• If BP is 185-230 systolic or 105-120 diastolic, treat with: 1
  • Labetalol 10-20 mg IV over 1-2 minutes (may repeat once), OR
  • Nicardipine IV 5 mg/hr, titrate by 2.5 mg/hr every 5-15 minutes to max 15 mg/hr
• If BP cannot be lowered to <185/110 mmHg, do not administer rtPA 1

During and After rtPA Administration

• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1
• Maintain BP <180/105 mmHg for at least 24 hours post-thrombolysis 3
• If BP rises to 180-230 systolic or 105-120 diastolic during/after rtPA, use labetalol or nicardipine as above 1

For Non-Thrombolysis Candidates

• Only lower BP if systolic >220 mmHg or diastolic >120 mmHg 1, 3
• Reduce BP by 15-25% within the first 24 hours if treatment is indicated 1
• Permissive hypertension is the standard approach—aggressive BP lowering reduces cerebral perfusion to the ischemic penumbra 3

Intravenous Thrombolysis with Alteplase

Inclusion Criteria for 0-3 Hour Window 1

• Diagnosis of ischemic stroke causing measurable neurologic deficit
• Symptom onset <3 hours before treatment initiation
• Age ≥18 years

Inclusion Criteria for 3-4.5 Hour Window 1

• Same as above, but symptom onset 3-4.5 hours before treatment
• Additional exclusions for this extended window:
  • Age >80 years
  • NIHSS >25 (severe stroke)
  • Taking oral anticoagulants regardless of INR
  • History of both diabetes AND prior ischemic stroke

Absolute Exclusion Criteria 1

• Head trauma or prior stroke in previous 3 months
• Symptoms suggesting subarachnoid hemorrhage
• History of intracranial hemorrhage
• Intracranial or spinal surgery within 3 months
• Arterial puncture at non-compressible site in previous 7 days
• Systolic BP >185 mmHg or diastolic >110 mmHg (that cannot be controlled)
• Evidence of active bleeding
• Platelet count <100,000/mm³
• INR >1.7 or PT >15 seconds
• Heparin within 48 hours with elevated aPTT
• Blood glucose <50 mg/dL
• CT showing multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Dosing and Administration

• Alteplase 0.9 mg/kg (maximum 90 mg total dose) 4
• Give 10% as IV bolus over 1 minute, then remaining 90% as continuous infusion over 60 minutes 4

Special Consideration: Rapidly Improving Symptoms

• If neurologic signs are spontaneously clearing and function is rapidly improving to near baseline, thrombolysis may not be required 1
• This requires clinical judgment—the patient should be approaching normal function, not just showing mild improvement

Mechanical Thrombectomy

Patient Selection

• Patients with large vessel occlusion (internal carotid artery, M1 or proximal M2 middle cerebral artery segments) should receive mechanical thrombectomy at experienced centers 4, 5
• Thrombectomy can be performed up to 24 hours from symptom onset in carefully selected patients with favorable imaging profiles 5
• Do not delay IV rtPA to arrange thrombectomy—give rtPA first if within the time window, then proceed to thrombectomy 4

Institutional Requirements

• Facilities must have immediate access to cerebral angiography and credentialed interventionalists 4
• Hospitals performing <5 thrombectomies per year have increased mortality risk 4

Admission and Monitoring

Stroke Unit Care

• All patients must be admitted to a specialized stroke unit—this intervention provides mortality and morbidity benefits comparable to thrombolysis itself 3
• Continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation and life-threatening arrhythmias 1
• Neurological assessments using NIHSS every 15 minutes during thrombolysis, then hourly for 6 hours, then every 2 hours for 18 hours 3

NPO Status and Aspiration Prevention

• Keep patient NPO until formal swallowing assessment is completed 3
• Perform bedside swallowing screen (water swallow test) within 24 hours before allowing any oral intake 3
• Patients with brainstem infarctions, depressed consciousness, dysphonia, or cranial nerve palsies are at highest aspiration risk 3
• Aspiration pneumonia significantly worsens outcomes—this is a critical pitfall to avoid 3

Temperature Management

• Monitor temperature every 4 hours for first 48 hours 3
• Treat fever aggressively if temperature exceeds 37.5°C (99.5°F) with acetaminophen and cooling measures, as hyperthermia worsens neurological damage 3

Glucose Management

• Check fingerstick glucose every 6 hours for first 24 hours 3
• Maintain glucose 140-180 mg/dL; treat if >180 mg/dL with sliding scale insulin 3

Antiplatelet Therapy

Timing Based on Thrombolysis Status

• If rtPA was given: Delay aspirin for 24 hours and obtain repeat head CT to exclude hemorrhagic transformation before starting 3, 4
• If rtPA was NOT given: Start aspirin 160-325 mg within 24-48 hours of symptom onset 3, 4

Venous Thromboembolism Prophylaxis

• Apply intermittent pneumatic compression devices to both legs within 24 hours 3
• Consider subcutaneous heparin 5000 units every 8-12 hours or enoxaparin 40 mg daily after 24 hours if no hemorrhagic transformation on repeat imaging 3
• Do not use subcutaneous heparin in first 24 hours after thrombolysis due to bleeding risk 3

Early Mobilization and Rehabilitation

• Begin early mobilization within 24 hours if patient is stable 3
• Initial bed rest with head of bed flat or at 30 degrees (avoid extreme head elevation which may reduce cerebral perfusion) 3
• Physical therapy, occupational therapy, and speech therapy consultations within 24 hours 3
• Prolonged immobility beyond 24 hours increases complications including pneumonia, DVT, pulmonary embolism, and pressure sores 3

Repeat Imaging

• Obtain repeat non-contrast head CT at 24 hours (or sooner if neurological deterioration) to assess for hemorrhagic transformation, especially if thrombolysis was given 3

Critical Pitfalls to Avoid

• Do not delay thrombolysis to obtain advanced imaging (CT angiography, MRI perfusion) in patients presenting within 3-4.5 hours 1
• Do not aggressively lower blood pressure in acute stroke unless specific criteria are met—permissive hypertension maintains cerebral perfusion 3
• Do not give oral medications, food, or water before swallowing assessment—aspiration pneumonia is a leading cause of post-stroke death 3
• Do not withhold thrombolysis based solely on high NIHSS scores (severe symptoms)—even patients with NIHSS ≥25 may benefit within 4.5 hours 1
• Protocol violations during thrombolysis administration significantly increase symptomatic intracranial hemorrhage risk and mortality 4