What is the recommended acute management for an adult presenting with an acute thrombotic (ischemic) stroke?

Acute Thrombotic (Ischemic) Stroke Management

Immediate Reperfusion Therapy

Intravenous alteplase 0.9 mg/kg (maximum 90 mg) administered within 3-4.5 hours of symptom onset is the single most critical intervention for acute ischemic stroke and must be prioritized above all other treatments. 1

Alteplase Administration Protocol

• Dose: 0.9 mg/kg (maximum 90 mg)—give 10% as IV bolus over 1 minute, then infuse remaining 90% over 60 minutes 1
• Time window: Within 3 hours (Class I, Level A evidence) or 3-4.5 hours (weaker evidence but still beneficial) 1, 2
• Outcome: 37% of patients achieve fully independent function when guidelines are followed correctly 1
• Critical timing: Every 15-minute reduction in door-to-needle time decreases in-hospital mortality by 5%; every 30-minute delay reduces favorable outcome probability by 10.6% 1

Pre-Thrombolysis Requirements

• Blood pressure control: Reduce BP to <185/110 mmHg BEFORE starting alteplase 1, 3
• Maintain BP: Keep ≤180/105 mmHg during infusion and for 24 hours after treatment 1, 3
• Imaging: Non-contrast head CT within 25 minutes of arrival to exclude hemorrhage 1
• CT interpretation: Within 45 minutes for thrombolytic candidates 1
• Exclude hypoglycemia: Immediate fingerstick glucose to rule out stroke mimics 1

Endovascular Thrombectomy

Mechanical thrombectomy with stent retrievers (Solitaire, Trevo) should be performed for large vessel occlusions when all criteria are met, as this intervention is superior to older devices and provides additional benefit beyond IV thrombolysis alone. 1, 4

Thrombectomy Eligibility Criteria

• Prestroke modified Rankin Scale (mRS) 0-1 1
• Large vessel occlusion confirmed on CT angiography 1
• Age ≥18 years 1
• NIHSS ≥6 1
• ASPECTS ≥6 1
• Groin puncture possible within 6 hours of symptom onset (up to 24 hours in selected patients with perfusion imaging) 1, 4

Imaging for Thrombectomy Decisions

• Add CT angiography to identify large vessel occlusion 1
• CT perfusion can guide extended window treatment in selected cases 1
• Imaging parameters are prognostic but do not modify relative treatment benefit of thrombectomy versus medical care 4

Antiplatelet Therapy

Aspirin 325 mg should be started within 24-48 hours for most patients, but you must wait 24 hours after alteplase and obtain repeat head CT to exclude hemorrhage before initiating aspirin. 1, 5

Aspirin Administration Rules

• Timing: Start 24-48 hours after stroke onset (Class I, Level A evidence) 3, 5
• Dose: 325 mg initially, then 160-325 mg daily 1, 5
• Primary benefit: Reduces early recurrent stroke rather than limiting initial neurological damage 3, 5
• Never give aspirin within 24 hours of thrombolysis—this increases hemorrhage risk 1, 5
• Aspirin is NOT a substitute for IV alteplase in eligible patients 3, 5

Other Antiplatelet Agents

• Clopidogrel alone or combined with aspirin: Not recommended for acute ischemic stroke treatment (Class III, Level C evidence) 3, 5
• IV glycoprotein IIb/IIIa inhibitors: Not recommended outside clinical trials (Class III, Level B evidence) 3, 5

Anticoagulation in Acute Stroke

Do not use full-dose heparin or low-molecular-weight heparin for acute ischemic stroke treatment—these agents do not improve outcomes and increase hemorrhage risk. 1, 3

• Emergency anticoagulation does not lower risk of early recurrent stroke, even in cardioembolic stroke 3
• Anticoagulation does not prevent early neurological worsening 3
• Most trials have not demonstrated efficacy of anticoagulation in improving acute stroke outcomes 3
• The American College of Chest Physicians guidelines recommend against urgent therapeutic anticoagulation 3

Blood Pressure Management

Do not aggressively lower blood pressure in acute stroke unless administering thrombolytics or BP >220/120 mmHg—permissive hypertension maintains penumbral perfusion. 1, 3

BP Thresholds Without Thrombolysis

• BP <220/120 mmHg: Do NOT treat—initiating antihypertensive therapy within 48-72 hours is not effective to prevent death or dependency (Class III, Level A evidence) 3
• BP ≥220/120 mmHg: May lower by 15% during first 24 hours, but benefit is uncertain (Class IIb, Level C evidence) 3

BP Management With Thrombolysis

• Before alteplase: Lower to <185/110 mmHg (Class I, Level B-NR evidence) 3, 1
• During and after alteplase: Maintain <180/105 mmHg for at least 24 hours (Class I, Level B-NR evidence) 3, 1

Intra-Arterial Thrombolysis

Intra-arterial thrombolysis is an option for selected patients with major stroke <6 hours duration due to middle cerebral artery occlusion who are not candidates for IV alteplase, but this requires an experienced stroke center with immediate angiography access. 3

• Treatment requires qualified interventionalists and comprehensive stroke center resources (Class I, Level C evidence) 3
• Reasonable for patients with contraindications to IV thrombolysis, such as recent surgery (Class IIa, Level C evidence) 3
• The availability of intra-arterial therapy should NOT preclude IV alteplase in eligible patients (Class III, Level C evidence) 3

Hospital Care and Stroke Unit Admission

Admit all acute stroke patients to a dedicated stroke unit with monitored beds for at least 24 hours—stroke unit care reduces mortality and morbidity comparably to the effects of alteplase itself. 1

Essential Stroke Unit Interventions

• Early mobilization: Begin frequent brief mobilization within 24 hours if no contraindications 1
• Swallowing assessment: Evaluate before any oral intake to prevent aspiration 1
• VTE prophylaxis: Start intermittent pneumatic compression devices within 24 hours for immobile patients 1
• Temperature control: Treat fever aggressively as hyperthermia worsens neurological damage 1

Critical Pitfalls to Avoid

• Never delay alteplase for "minor" symptoms—early treatment is critical even for seemingly mild deficits 1
• Never use aspirin as adjunctive therapy with alteplase—wait 24 hours and obtain repeat CT first 1, 5
• Never substitute experimental neuroprotective agents (like cerebroprotin) for proven reperfusion therapies 2
• Never use vasodilatory agents in acute ischemic stroke (Class III, Level A evidence) 2
• Avoid aggressive BP lowering unless giving thrombolytics or BP >220/120 mmHg 1, 3

Time-Dependent Treatment Algorithm

1. 0-10 minutes: Stabilize ABCs, determine last known well time, fingerstick glucose, calculate NIHSS 1
2. 0-25 minutes: Non-contrast head CT to exclude hemorrhage 1
3. 0-45 minutes: CT interpretation completed 1
4. Add CTA: If considering thrombectomy for large vessel occlusion 1
5. Within 3-4.5 hours: Administer IV alteplase if eligible 1
6. Within 6-24 hours: Perform mechanical thrombectomy if large vessel occlusion and eligible 1, 4
7. 24-48 hours: Start aspirin 325 mg (after repeat CT if thrombolysis given) 1, 5