What is the recommended acute management protocol for an adult patient presenting with acute stroke symptoms?

Acute Stroke Management Protocol

For any adult presenting with acute stroke symptoms, immediately activate the stroke team, obtain non-contrast CT within 25 minutes of arrival, and administer IV alteplase 0.9 mg/kg (maximum 90 mg) if the patient is within 4.5 hours of symptom onset and has no contraindications. 1

Immediate Assessment and Stabilization

Airway, Breathing, and Circulation

• Secure the airway and provide ventilatory support if the patient has decreased consciousness (Glasgow Coma Scale ≤8) or bulbar dysfunction compromising airway protection 1
• Administer supplemental oxygen only if oxygen saturation falls below 94%—routine oxygen in non-hypoxic patients provides no benefit 1
• Initiate cardiac monitoring immediately for at least the first 24 hours to screen for atrial fibrillation and potentially serious arrhythmias requiring emergency intervention 1
• Correct hypovolemia with intravenous normal saline and treat cardiac arrhythmias that reduce cardiac output 1

Critical Time-Sensitive Actions

• Record the exact time of symptom onset or last known well—this single data point determines all treatment eligibility 2, 3
• Obtain non-contrast head CT immediately with a door-to-CT completion target of 25 minutes to exclude hemorrhage 3
• Measure fingerstick glucose on arrival—hypoglycemia (blood glucose <60 mg/dL) must be treated immediately as it mimics stroke and contraindicates thrombolysis 1, 2
• Draw baseline laboratories including complete blood count, metabolic panel, PT/INR, aPTT, and troponin without delaying imaging 2

Blood Pressure Management

For Thrombolysis Candidates (Within 4.5 Hours)

• Before administering IV alteplase, lower blood pressure to systolic <185 mm Hg and diastolic <110 mm Hg using labetalol 10-20 mg IV over 1-2 minutes (may repeat once) or nicardipine infusion 5 mg/hour, titrated by 2.5 mg/hour every 5-15 minutes to maximum 15 mg/hour 1, 2
• After alteplase administration, maintain blood pressure <180/105 mm Hg for at least 24 hours to reduce hemorrhagic transformation risk 1

For Non-Thrombolysis Candidates

• Withhold antihypertensive treatment unless systolic blood pressure is >220 mm Hg or diastolic >120 mm Hg 1
• If treatment is required, lower blood pressure by only 15% during the first 24 hours to avoid worsening cerebral ischemia in pressure-dependent perfusion 1, 2

Common pitfall: Aggressive blood pressure reduction in acute stroke can extend the infarct by reducing collateral flow to the ischemic penumbra. Permissive hypertension is protective in the acute phase. 1

Intravenous Alteplase Administration

Eligibility Criteria (0-3 Hours from Onset)

Administer IV alteplase 0.9 mg/kg (maximum 90 mg, with 10% as bolus over 1 minute and 90% as infusion over 60 minutes) to patients who can be treated within 3 hours of symptom onset or last known well. 1

Extended Window Eligibility (3-4.5 Hours from Onset)

Administer IV alteplase using the same dosing regimen for patients treatable within 3-4.5 hours, excluding those who are:

• Age >80 years 1
• Taking oral anticoagulants regardless of INR 1
• NIHSS score >25 1
• History of both diabetes mellitus AND prior ischemic stroke 1

Target Metrics

• Door-to-needle time: median ≤30 minutes, with 90th percentile ≤60 minutes 1, 3
• Each 15-minute reduction in door-to-needle time decreases in-hospital mortality by 5% 2

Critical consideration: When a patient cannot provide consent due to aphasia or confusion and no legally authorized representative is immediately available, proceed with IV thrombolysis in an otherwise eligible adult with disabling stroke—the proven benefit justifies treatment. 1

Post-Thrombolysis Monitoring

Blood Pressure Control

• Monitor blood pressure every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1
• Maintain blood pressure <180/105 mm Hg for 24 hours post-alteplase 1

Neurological Monitoring

• Perform neurological assessments every 15 minutes during alteplase infusion, every 30 minutes for 6 hours, then hourly for 18 hours 1
• If sudden neurological deterioration occurs, stop alteplase infusion immediately and obtain emergent CT to assess for intracranial hemorrhage 1

Hemorrhage Management

• Do NOT administer antiplatelet or anticoagulant medications for 24 hours after alteplase 1
• For symptomatic intracranial hemorrhage, there is insufficient evidence to routinely recommend cryoprecipitate, fresh frozen plasma, prothrombin complex concentrates, tranexamic acid, or factor VIIa—decisions should be individualized 1
• For angioedema (occurs in 1-5% of patients), use staged response with antihistamines, glucocorticoids, and standard airway management 1

Temperature and Glucose Management

Fever Control

• Identify and treat sources of hyperthermia (temperature >38°C) 1
• Administer antipyretic medications to lower temperature in hyperthermic patients—fever in the first 24 hours is associated with increased in-hospital mortality 1
• Do NOT use induced hypothermia outside of clinical trials—most studies show increased infection risk including pneumonia without proven benefit 1

Glucose Management

• Treat hyperglycemia to achieve blood glucose levels of 140-180 mg/dL during the first 24 hours—persistent hyperglycemia is associated with worse outcomes and increased hemorrhagic transformation 1
• Treat hypoglycemia (blood glucose <60 mg/dL) immediately with intravenous dextrose 1
• Monitor glucose closely to prevent hypoglycemia when using insulin protocols 1

Important nuance: The 2018 AHA/ASA guidelines 1 updated the target range to 140-180 mg/dL (down from the 2007 recommendation of 140-185 mg/dL 1), reflecting evolving evidence that tighter glucose control improves outcomes without excessive hypoglycemia risk.

Endovascular Thrombectomy Considerations

Patient Selection

• Consider mechanical thrombectomy for patients with proximal anterior circulation large vessel occlusion (internal carotid artery or middle cerebral artery M1 segment) 1
• Thrombectomy is effective within 6 hours for most patients and up to 24 hours for selected patients meeting advanced imaging criteria (favorable perfusion imaging or small infarct core) 2, 3
• Do NOT delay transfer for thrombectomy evaluation even after administering alteplase—mechanical thrombectomy remains highly effective after thrombolysis 2

Imaging Requirements

• Obtain CT angiography or MR angiography to identify large vessel occlusion 1, 2
• For patients beyond 6 hours, obtain CT perfusion or MRI with diffusion-weighted imaging to assess salvageable tissue 1

Stroke Unit Care

Admission and Monitoring

• Admit all stroke patients to a dedicated stroke unit with continuous monitoring of oxygen saturation, blood pressure, heart rhythm, and temperature 3
• Target admission to monitored bed within 3 hours of arrival 3

Antiplatelet Therapy

• Initiate aspirin 160-325 mg within 24-48 hours for patients not receiving thrombolysis, or 24 hours after thrombolysis 3
• Do NOT administer aspirin within 24 hours of alteplase 1

Common Pitfalls to Avoid

• Never delay imaging or treatment to obtain "complete" laboratory results—only glucose, INR (if on warfarin), and platelet count (if history suggests thrombocytopenia) are essential before thrombolysis 1, 2
• Do not withhold thrombolysis for "mild" or "rapidly improving" symptoms—early improvement does not predict sustained recovery, and large vessel occlusions can present with fluctuating deficits 2
• Never assume patients beyond 4.5 hours are ineligible for all reperfusion therapy—endovascular thrombectomy may be offered up to 24 hours with appropriate imaging selection 2, 3
• Do not routinely administer alteplase to patients on direct oral anticoagulants (DOACs)—endovascular therapy may be considered instead, with thrombolysis reserved for comprehensive stroke centers with DOAC level testing and reversal agents available 1
• Avoid over-treating blood pressure in the acute phase—permissive hypertension maintains collateral flow to the penumbra 1, 2