Current Best-Practice Guidelines for Acute Stroke Management
All patients with suspected acute stroke require immediate non-contrast CT imaging to exclude hemorrhage and determine eligibility for reperfusion therapy, with CT angiography added for those presenting within 6 hours to identify large vessel occlusions amenable to endovascular thrombectomy. 1
Immediate Assessment and Imaging
Initial Evaluation
- Stabilize airway, breathing, and circulation while simultaneously beginning stroke evaluation 2
- Determine exact time of last known normal (when patient was last symptom-free), as this defines treatment eligibility 2
- Assess stroke severity using the National Institutes of Health Stroke Scale (NIHSS) to guide treatment decisions 2
- Complete non-contrast CT within 25 minutes of arrival and interpret within 45 minutes 1, 2
Imaging Protocol
- For patients presenting within 6 hours: Perform both non-contrast CT and CT angiography (arch-to-vertex) immediately to identify large vessel occlusions eligible for endovascular thrombectomy 1
- For patients presenting beyond 6 hours: Non-contrast CT alone is sufficient unless advanced imaging is needed for patient selection 1
- Advanced imaging (CT perfusion, multiphase CTA) may be considered to aid patient selection but must not delay thrombolysis or thrombectomy decisions 1
- MRI with diffusion-weighted imaging is more sensitive than CT for detecting acute ischemia but should only be used if it does not delay treatment 3, 4, 5
Essential Laboratory Tests
- Blood glucose (must exclude hypoglycemia <50 mg/dL before thrombolysis) 1
- Complete blood count with platelet count (must be >100,000/mm³ for thrombolysis) 1
- PT/INR and aPTT (INR must be ≤1.7 for thrombolysis) 1
- Electrolytes and renal function 2
- 12-lead ECG to identify atrial fibrillation or acute coronary syndrome 1, 6
Acute Ischemic Stroke Treatment
Intravenous Thrombolysis (Alteplase/rtPA)
Eligibility Criteria for 0-3 Hour Window: 1
- Measurable neurologic deficit on NIHSS
- Age ≥18 years
- No head trauma or prior stroke in previous 3 months
- No intracranial hemorrhage on CT
- Blood pressure <185/110 mmHg
- Platelet count ≥100,000/mm³
- INR ≤1.7
- Blood glucose ≥50 mg/dL
- No multilobar infarction (>1/3 cerebral hemisphere) on CT
Additional Exclusion Criteria for 3-4.5 Hour Window: 1
- Age >80 years
- NIHSS >25
- Taking oral anticoagulants (regardless of INR)
- History of both diabetes AND prior stroke
Administration Protocol: 6
- Dose: 0.9 mg/kg (maximum 90 mg total)
- Give 10% as IV bolus over 1 minute
- Give remaining 90% as IV infusion over 60 minutes
- Target door-to-needle time <60 minutes 6
Blood Pressure Management for Thrombolysis Candidates
Before and during thrombolysis: 1, 6
- Blood pressure must be lowered to <185/110 mmHg before starting alteplase
- Maintain blood pressure <180/105 mmHg for 24 hours after alteplase administration
- Use labetalol 10 mg IV or nicardipine IV infusion (5 mg/h, titrate by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h) 1
- Avoid precipitous drops in blood pressure 1
Blood Pressure Management for Non-Thrombolysis Candidates
For patients NOT receiving thrombolysis: 1, 6
- Do NOT routinely treat hypertension in acute ischemic stroke 1
- Only treat if systolic BP >220 mmHg or diastolic BP >120 mmHg 1
- Target: reduce blood pressure by 15% (not more than 25%) over first 24 hours 1
- Avoid rapid or excessive lowering as this may worsen ischemia 1
Endovascular Thrombectomy (EVT)
- Large vessel occlusion identified on CT angiography
- Presentation within 6 hours of symptom onset (may extend to 24 hours with advanced imaging selection)
- Use validated triage tool (such as ASPECTS) to identify EVT candidates 1
- Combined IVT plus EVT is preferred over EVT alone when IVT is not contraindicated 1
- Direct aspiration is suggested over stent retriever as first-line EVT strategy 1
Transfer Protocol: 1
- Primary stroke centers without EVT capability should complete non-contrast CT, administer IV alteplase if appropriate, then rapidly transfer to comprehensive stroke center for EVT consideration
Post-Treatment Monitoring and Care
Neurological Monitoring
- Monitor NIHSS every 15 minutes during thrombolysis 7
- Then hourly for 6 hours 7
- Then every 2 hours for 18 hours 7
- Obtain repeat non-contrast CT at 24 hours or sooner if neurological deterioration 7
Blood Pressure Monitoring After Thrombolysis
- Every 15 minutes for 2 hours from start of rtPA 1
- Every 30 minutes for next 6 hours 1
- Every hour for next 16 hours 1
Swallowing Assessment
- Keep patient NPO until formal swallowing screen completed 1, 7
- Perform bedside swallowing screen within 24 hours using validated tool 1, 7
- This should not delay acute treatment decisions 1
Admission and Supportive Care
- Admit all acute stroke patients to specialized stroke unit with continuous monitoring 7
- Maintain oxygen saturation >94% 6
- Treat fever if temperature >38°C (or >37.5°C per some protocols) 6, 7
- Correct hypoglycemia (<60 mg/dL); maintain glucose 140-180 mg/dL 6, 7
- Begin venous thromboembolism prophylaxis with intermittent pneumatic compression devices within 24 hours 2, 7
- Consider subcutaneous heparin or enoxaparin after 24 hours if no hemorrhagic transformation 7
Early Mobilization and Rehabilitation
- Begin early mobilization within 24 hours if patient stable 2, 7
- Initiate physical therapy, occupational therapy, and speech therapy consultations within 24 hours 7
Antiplatelet Therapy
- For patients NOT receiving thrombolysis: Start aspirin 160-325 mg within 24-48 hours 6
- For patients who received thrombolysis: Delay aspirin for 24 hours and obtain repeat CT to exclude hemorrhage before starting 6, 7
Critical Pitfalls to Avoid
- Do not delay imaging for laboratory results - CT should be performed immediately upon arrival 1
- Do not aggressively lower blood pressure in non-thrombolysis candidates - permissive hypertension maintains cerebral perfusion to penumbra 1, 7
- Do not give oral intake before swallowing assessment - aspiration pneumonia significantly worsens outcomes 1, 7
- Do not use advanced imaging if it delays thrombolysis - door-to-needle time is critical 1
- Do not delay mobilization beyond 24 hours unless contraindicated - prolonged immobility increases complications 2, 7
Hemorrhagic Stroke Considerations
For patients with intracranial hemorrhage on initial CT: