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

Immediate Management of Acute Ischemic Stroke

Activate the stroke team immediately, obtain non-contrast head CT within 25 minutes of arrival to exclude hemorrhage, and administer intravenous alteplase 0.9 mg/kg (maximum 90 mg) within 3-4.5 hours of symptom onset if the patient meets eligibility criteria—this is the single most critical intervention that reduces mortality and improves functional independence. 1, 2

Time-Critical Initial Actions (First 60 Minutes)

The goal is door-to-needle time under 60 minutes, as every 15-minute delay increases in-hospital mortality by 5%. 1

Immediate Assessment (First 10 Minutes)

• Stabilize airway, breathing, and circulation while simultaneously beginning stroke evaluation—do not delay assessment for stabilization unless airway is compromised 3, 2
• Determine exact time of last known well (not when symptoms were discovered)—this is time zero for all treatment decisions 2
• Obtain fingerstick glucose immediately to exclude hypoglycemia as a stroke mimic 3, 1
• Calculate NIHSS score to quantify stroke severity and guide treatment intensity 3, 1

Essential Laboratory Tests (Simultaneous with Imaging)

Order these tests immediately but do NOT delay thrombolysis while awaiting results unless there is clinical suspicion of bleeding abnormality, thrombocytopenia, or known anticoagulant use: 3

• Blood glucose 3
• Complete blood count with platelet count 3
• PT/INR and aPTT 3
• Serum electrolytes and renal function 3
• Cardiac biomarkers (troponin) 3
• ECG 3

Brain Imaging (Within 25 Minutes of Arrival)

Non-contrast head CT is the required initial imaging modality to exclude hemorrhage and identify early ischemic changes—interpretation must occur within 45 minutes for thrombolytic candidates. 3, 1, 2

• CT angiography should be added if considering endovascular thrombectomy to identify large vessel occlusion 1
• Do NOT delay emergency treatment to obtain multimodal imaging studies (CT perfusion, MRI) 3
• Vascular imaging must not delay treatment in patients presenting within 3 hours of symptom onset 3

Blood Pressure Management

For Thrombolysis Candidates

Blood pressure MUST be reduced to <185/110 mmHg BEFORE initiating alteplase, then maintained ≤180/105 mmHg during and for 24 hours after infusion. 3, 1

Use labetalol 10-20 mg IV over 1-2 minutes (may repeat), or nicardipine infusion 5 mg/hr titrated up by 2.5 mg/hr every 5-15 minutes to maximum 15 mg/hr. 3

For Non-Thrombolysis Patients

Practice permissive hypertension—do NOT treat blood pressure unless systolic ≥220 mmHg or diastolic ≥120 mmHg, as aggressive lowering jeopardizes penumbral perfusion. 3, 1

If treatment is required, lower blood pressure cautiously by only 15% during the first 24 hours. 3, 1

Intravenous Thrombolysis Protocol

Administer alteplase 0.9 mg/kg (maximum 90 mg) with 10% given as IV bolus over 1 minute and the remaining 90% infused over 60 minutes. 1, 2

Eligibility Criteria (3-4.5 Hour Window)

• Symptom onset <4.5 hours 3, 1
• Age ≥18 years 3
• No hemorrhage on CT 3
• Blood pressure <185/110 mmHg (after treatment if needed) 3, 1
• No recent surgery, trauma, or active bleeding 3
• Platelet count >100,000/mm³, INR <1.7 3

Treatment within 90 minutes of onset provides the highest probability of favorable outcomes—37% of patients recover to fully independent function when guidelines are followed. 3, 1

Endovascular Thrombectomy

Consider mechanical thrombectomy with stent retrievers for patients meeting ALL criteria: 1

• Large vessel occlusion confirmed on CT angiography 1
• Pre-stroke modified Rankin Scale 0-1 1
• NIHSS ≥6 1
• ASPECTS ≥6 on CT 1
• Groin puncture possible within 6 hours of symptom onset 1

Stent retrievers (Solitaire, Trevo) are superior to older coil retrievers based on multiple randomized trials. 1

Airway and Oxygenation Management

Monitor oxygen saturation with pulse oximetry and maintain target ≥92%—supplemental oxygen is NOT routinely needed for most patients but should be provided if hypoxia is present. 3

Place endotracheal tube if airway is threatened due to decreased consciousness or brainstem dysfunction with impaired protective reflexes. 3

Antiplatelet Therapy

Start aspirin 325 mg within 24-48 hours after stroke onset, but WAIT 24 hours after alteplase and obtain repeat head CT to exclude hemorrhage before starting aspirin. 1

Aspirin reduces early recurrent stroke but is NOT a substitute for IV alteplase in eligible patients and must NEVER be given within 24 hours of thrombolysis due to increased hemorrhage risk. 1

Clopidogrel alone or combined with aspirin is NOT recommended for acute ischemic stroke. 1

Anticoagulation

Do NOT use full-dose unfractionated heparin or low-molecular-weight heparin for acute ischemic stroke—they do not improve outcomes and increase hemorrhage risk. 1

Emergency anticoagulation does not lower the risk of early recurrent stroke, even with cardioembolic sources, and does not prevent early neurological worsening. 1

Hospital Admission and Monitoring

Admit to dedicated stroke unit with continuous monitoring for at least 24 hours—stroke unit care provides mortality and morbidity benefits comparable to IV thrombolysis itself. 1, 4

Monitoring Protocol

• NIHSS every 15 minutes during thrombolysis, then hourly for 6 hours, then every 2 hours for 18 hours 4
• Blood pressure every 15 minutes during and for 2 hours after thrombolysis, then every 30 minutes for 6 hours, then hourly for 16 hours 3
• Temperature every 4 hours—treat fever aggressively if >37.5°C (99.5°F) with acetaminophen, as hyperthermia worsens neurological damage 4

Early Supportive Care

• Keep patient NPO until formal swallowing assessment completed within 24 hours—aspiration pneumonia significantly worsens outcomes 4
• Begin intermittent pneumatic compression devices to both legs within 24 hours for VTE prophylaxis 1, 4
• Start early mobilization within 24 hours if patient stable 1, 4
• Repeat non-contrast head CT at 24 hours (or sooner if neurological deterioration) to assess for hemorrhagic transformation 4

Critical Pitfalls to Avoid

• Never aggressively lower blood pressure in acute stroke unless giving thrombolytics or BP >220/120 mmHg—permissive hypertension maintains penumbral perfusion 3, 1
• Never delay alteplase for "minor" symptoms—early treatment is critical even for seemingly mild deficits 1
• Never give aspirin as adjunctive therapy with alteplase or within 24 hours of thrombolysis 1
• Never delay emergency treatment to obtain multimodal imaging studies 3
• Never give oral medications, food, or water before swallowing assessment 4