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

Acute Management of Ischemic Stroke

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, with 37% of treated patients recovering to fully independent function when guidelines are followed. 1

Immediate Assessment (Door-to-Decision: 60 Minutes)

Time-Critical Actions

• Establish exact time of last known well—this is zero-hour for all treatment decisions, not when symptoms were discovered 2, 1
• Obtain fingerstick glucose immediately to exclude hypoglycemia as a stroke mimic 1
• Calculate NIHSS score to quantify severity and guide treatment intensity 2, 1
• Perform non-contrast head CT within 25 minutes of arrival to exclude hemorrhage 2, 1
• Complete CT interpretation within 45 minutes for thrombolytic candidates 1

Essential Laboratory Tests

• Complete blood count, PT/INR, aPTT, comprehensive metabolic panel, troponin 2, 3
• ECG to detect atrial fibrillation and acute coronary syndrome 2

Reperfusion Therapy

Intravenous Thrombolysis (Primary Treatment)

Administer alteplase 0.9 mg/kg (maximum 90 mg) if patient presents within 3-4.5 hours and meets eligibility criteria: 1

• Give 10% as IV bolus over 1 minute, remaining 90% infused over 60 minutes 1
• Blood pressure MUST be reduced to <185/110 mmHg BEFORE starting alteplase 2, 1
• Maintain BP ≤180/105 mmHg during and for 24 hours after infusion 2, 1

Endovascular Thrombectomy (For Large Vessel Occlusion)

Consider mechanical thrombectomy with stent retrievers if ALL criteria met: 1

• Pre-stroke mRS 0-1 (functionally independent)
• Large vessel occlusion confirmed on CT angiography
• Age ≥18 years
• NIHSS ≥6
• ASPECTS ≥6 on non-contrast CT
• Groin puncture possible within 6 hours of symptom onset

For basilar artery occlusion specifically, combined IVT plus EVT is suggested over direct EVT alone when IVT is not contraindicated 2

Intra-Arterial Thrombolysis (Alternative for Select Cases)

• Consider for major middle cerebral artery occlusion presenting <6 hours after onset in patients ineligible for IV alteplase 1
• Requires comprehensive stroke center with immediate angiography capability and experienced interventionalists 1
• Do NOT delay IV alteplase to pursue intra-arterial therapy if patient is eligible for IV treatment 1

Blood Pressure Management

For Patients NOT Receiving Thrombolysis

Practice permissive hypertension—do NOT treat unless: 2, 1

• Systolic BP >220 mmHg OR
• Diastolic BP >120 mmHg

If treatment required, reduce BP by only 15% during first 24 hours 2, 1

Rationale: Aggressive BP lowering jeopardizes penumbral perfusion and may worsen neurological outcomes 1

For Thrombolysis Candidates

Pre-treatment requirements: 2, 1

• Reduce systolic/diastolic to <185/110 mmHg before initiating alteplase
• Use labetalol 10-20 mg IV over 1-2 minutes (may repeat once) OR nicardipine infusion 5 mg/h, titrate up by 2.5 mg/h at 5-15 minute intervals to maximum 15 mg/h 2

During and post-treatment: 2, 1

• Maintain BP ≤180/105 mmHg throughout infusion and for 24 hours after
• Monitor BP every 15 minutes during treatment, then every 30 minutes for 6 hours, then hourly for 16 hours 2

Antiplatelet Therapy

Start aspirin 325 mg within 24-48 hours after stroke onset 1

• If thrombolysis given, wait 24 hours and obtain repeat head CT to exclude hemorrhage before starting aspirin 1, 3
• Never administer aspirin within 24 hours of alteplase—this increases hemorrhage risk 1
• Aspirin is NOT a substitute for IV alteplase in eligible patients 1

Clopidogrel alone or combined with aspirin is NOT recommended for acute ischemic stroke (Class III) 1

Intravenous glycoprotein IIb/IIIa inhibitors are NOT recommended outside clinical trials (Class III) 1

Anticoagulation

Do NOT use full-dose unfractionated heparin or low-molecular-weight heparin for acute ischemic stroke treatment: 1

• Does not improve outcomes and increases hemorrhage risk (Class III, Level A)
• Does not lower risk of early recurrent stroke, even with cardioembolic sources
• Does not prevent early neurological worsening

Hospital Admission and Monitoring

Stroke Unit Care

Admit to dedicated stroke unit with continuous monitoring—this intervention provides mortality and morbidity benefits comparable to IV thrombolysis itself 1, 3

Neurological Monitoring

• NIHSS every 15 minutes during thrombolysis 3
• Hourly for 6 hours post-thrombolysis 3
• Every 2 hours for 18 hours thereafter 3

Vital Signs Management

Temperature: 1, 3

• Check every 4 hours for first 48 hours
• Treat fever aggressively if >37.5°C (99.5°F) with acetaminophen and cooling measures—hyperthermia worsens neurological damage

Oxygen: 1

• Maintain peripheral oxygen saturation ≥92% using pulse oximetry
• Provide supplemental oxygen only when saturation falls below 94%

Repeat Imaging

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

Swallowing Assessment and Nutrition

Keep patient NPO until formal swallowing assessment completed 3

• Perform bedside swallowing screen (water swallow test) within 24 hours before allowing any oral intake 3
• Patients with brainstem infarctions, multiple strokes, major hemispheric lesions, depressed consciousness, dysphonia, cranial nerve palsies, or high NIHSS scores are at highest aspiration risk 3

Maintain euvolemia with IV normal saline at maintenance rate (75-100 mL/hr) until swallowing cleared 3

Mobilization and Rehabilitation

Begin early mobilization within 24 hours if patient stable: 1, 3

• Initial bed rest with head of bed flat or at 30 degrees (avoid extreme head elevation which may reduce cerebral perfusion)
• Progress to sitting, standing, brief ambulation as tolerated
• Close observation during transition to upright posture—some patients experience neurological worsening

Physical therapy, occupational therapy, and speech therapy consultations within 24 hours 3

Venous Thromboembolism Prophylaxis

Use 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

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

Secondary Prevention Initiation

Start high-intensity statin (atorvastatin 80 mg or rosuvastatin 40 mg daily) regardless of baseline LDL 3

Special Consideration: Drowsiness with Normal CT

If patient presents with decreased consciousness and normal non-contrast CT: 4

• Obtain MRI with diffusion-weighted imaging immediately—early ischemic stroke is frequently invisible on CT, particularly within first few hours 4
• Perform CT angiography or MR angiography to identify large vessel occlusion 4
• Drowsiness indicates either brainstem involvement, large hemispheric infarction with mass effect, bilateral involvement, or hypoxia 4
• Assess airway patency, protective reflexes, oxygen saturation, and respiratory pattern systematically 4
• Consider intubation if airway protective reflexes are compromised 4

Critical Time-Dependent Outcomes

Every 15-minute reduction in door-to-needle time decreases in-hospital mortality by 5% 1

Every 30-minute delay in reperfusion reduces probability of favorable outcome by 10.6% 1

Treatment within 90 minutes of onset is most likely to result in favorable outcomes 1

Common Pitfalls to Avoid

• Never aggressively lower BP in acute stroke unless giving thrombolytics or BP >220/120 mmHg—permissive hypertension maintains penumbral perfusion 1, 3
• Never give oral medications, food, or water before swallowing assessment—aspiration pneumonia significantly worsens outcomes 3
• Never delay mobilization beyond 24 hours unless contraindicated—prolonged immobility increases complications 3
• Never give aspirin as adjunctive therapy with alteplase or within 24 hours of thrombolysis 1
• Never delay alteplase for "minor" symptoms—early treatment is critical even for seemingly mild deficits 1
• Never postpone IV thrombolysis to obtain advanced multimodal imaging (perfusion CT/MRI)—rapid treatment is critical 1