What is the current protocol for managing an adult presenting with acute stroke—including initial neurological assessment, blood pressure targets, imaging, eligibility and dosing for intravenous thrombolysis, criteria for endovascular thrombectomy, post‑reperfusion blood pressure management, antiplatelet and statin therapy, glucose control, secondary prevention of atrial fibrillation, and reversal of anticoagulation in hemorrhagic stroke?

Acute Stroke Management Protocol – Recent Update

All patients with suspected acute stroke require immediate non-contrast head CT to exclude hemorrhage, followed by rapid assessment for reperfusion therapy eligibility using standardized protocols that prioritize time-dependent interventions within strict blood-pressure parameters. 1

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Initial Emergency Department Assessment

Immediate Stabilization (First 10 Minutes)

• Secure airway, breathing, and circulation; provide supplemental oxygen only if peripheral saturation falls below 94%. 2, 1
• Perform rapid NIHSS scoring to quantify stroke severity and guide treatment decisions. 2, 1
• Check capillary blood glucose immediately on arrival; treat hypoglycemia (<60 mg/dL) with intravenous dextrose before any other intervention. 1
• Correct hypotension and hypovolemia to maintain mean arterial pressure >70 mmHg for adequate cerebral perfusion. 1
• Obtain 12-lead ECG to identify atrial fibrillation or acute coronary syndrome. 2, 1

Critical Laboratory Studies

• Blood glucose measurement is the only laboratory test that must be completed before administering alteplase; do not delay imaging for other laboratory results. 1
• Order CBC, electrolytes, renal function, coagulation profile (INR, aPTT), and troponin after imaging is obtained. 2, 1

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Neuroimaging Protocol

First-Line Imaging (Within 25 Minutes of Arrival)

• Non-contrast CT of the head is mandatory to exclude intracranial hemorrhage before any reperfusion therapy. 2, 1
• Non-contrast CT is preferred over MRI because it is faster and more widely available, minimizing treatment delays. 1

Advanced Imaging for Thrombectomy Candidates

• Perform CTA from aortic arch to vertex immediately after non-contrast CT in all patients presenting within 6 hours to identify large-vessel occlusion. 2, 1
• For patients presenting 6–24 hours after last known well, obtain CT perfusion or MRI diffusion-weighted imaging to assess core-penumbra mismatch before deciding on reperfusion therapy. 1

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Intravenous Alteplase (tPA) Protocol

Dosing and Administration

• Alteplase dose: 0.9 mg/kg (maximum 90 mg); administer 10% as IV bolus over 1 minute, then infuse remaining 90% over 60 minutes. 1

Time Windows and Eligibility

• 0–3 hour window (Class I, Level A): All patients ≥18 years with measurable neurological deficit are eligible, regardless of age or NIHSS severity. 1
• 3–4.5 hour window (Class I, Level B-R): Same eligibility as 0–3 hours, but exclude patients >80 years, those with combined diabetes plus prior stroke, NIHSS >25, or on oral anticoagulants (regardless of INR). 1
• 4.5–9 hour extended window: Alteplase may be given when advanced perfusion imaging shows favorable core-penumbra mismatch and thrombectomy is not planned. 1
• Wake-up strokes: If MRI shows DWI-FLAIR mismatch, alteplase can be administered within 4.5 hours of symptom recognition. 1

Blood Pressure Requirements for Thrombolysis

• Lower systolic/diastolic BP to <185/110 mmHg before starting alteplase; maintain <180/105 mmHg for the first 24 hours after infusion. 2, 1, 3
• Use titratable IV agents: labetalol (10–20 mg bolus over 1–2 minutes, repeatable every 10 minutes) or nicardipine (start 5 mg/h, titrate by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h). 1, 3
• If BP cannot be reduced below 185/110 mmHg despite appropriate therapy, alteplase is contraindicated. 2, 1

Imaging Eligibility Criteria

• No intracranial hemorrhage on CT/MRI. 1
• Early ischemic changes must involve <1/3 of the MCA territory; an ASPECTS ≥6 is required. 1

Absolute Contraindications

• Intracranial hemorrhage on imaging 1
• Ischemic stroke within the prior 3 months 1
• Severe head trauma within the prior 3 months 1
• Extensive hypodensity >1/3 MCA territory on CT 1

Post-Alteplase Management

• Avoid all antithrombotic agents (aspirin, heparin, anticoagulants) for the first 24 hours after alteplase. 1
• Monitor neurologic status every 15 minutes during infusion, every 30 minutes for 6 hours, then hourly for the next 16 hours. 2, 1, 3
• Obtain emergent repeat CT if the patient develops neurological deterioration, severe headache, or hypertensive spikes. 1

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Mechanical Thrombectomy

Indications (0–6 Hours)

• Age ≥18 years, pre-stroke mRS 0–1, ICA or M1 occlusion on CTA, NIHSS ≥6, ASPECTS ≥6, and ability to achieve groin puncture ≤6 hours from symptom onset. 1

Extended Window (6–24 Hours)

• Anterior-circulation large-vessel occlusion with favorable advanced imaging (core-penumbra mismatch, small core relative to clinical deficit). 1

Coordination with Thrombolysis

• Do not wait for a response to alteplase before proceeding to angiography; thrombolysis and thrombectomy should be coordinated in parallel. 1
• Administer IV alteplase even when thrombectomy is planned (bridging therapy). 1

Blood Pressure Management During Thrombectomy

• Before thrombectomy, maintain BP <185/110 mmHg. 4
• During thrombectomy, prevent significant hypotension; target systolic BP >140 mmHg or MAP >70 mmHg to maintain collateral flow. 4
• After successful thrombectomy, prevent hypertension; target systolic BP <160 mmHg or MAP <90 mmHg to reduce reperfusion injury risk. 4

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Blood Pressure Management (Non-Thrombolysis Patients)

Permissive Hypertension Strategy (First 48–72 Hours)

• Adopt permissive hypertension; do not lower BP unless SBP ≥220 mmHg or DBP ≥120 mmHg during the first 48–72 hours. 2, 1, 3, 5
• Rationale: Cerebral autoregulation is impaired in the ischemic penumbra, making cerebral blood flow directly dependent on systemic perfusion pressure; lowering BP below 220/120 mmHg does not reduce death or dependency and may worsen outcomes by compromising collateral flow. 2, 6

Management When BP ≥220/120 mmHg

• If BP reaches ≥220/120 mmHg, reduce mean arterial pressure by only approximately 15% over the first 24 hours (e.g., from ~153 mmHg to ~130 mmHg). 2, 6, 3
• Use IV labetalol (10–20 mg bolus, repeatable every 10 minutes) or nicardipine (start 5 mg/h, titrate by 2.5 mg/h every 15 minutes, maximum 15 mg/h). 6, 3

Critical Exceptions Requiring Immediate BP Control

• Override permissive hypertension guidelines and treat BP immediately in cases of hypertensive encephalopathy, acute aortic dissection, acute myocardial infarction, acute pulmonary edema, or acute renal failure. 6, 3

Post-Acute Phase (After 48–72 Hours)

• Restart antihypertensive therapy in neurologically stable patients with BP ≥140/90 mmHg for long-term secondary prevention. 2, 6, 3
• Target BP <130/80 mmHg using thiazide diuretics, ACE inhibitors, ARBs, or combination therapy. 6, 3

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Glucose Management

• Target blood glucose 140–180 mg/dL during the first 24 hours; persistent hyperglycemia >180 mg/dL is linked to worse outcomes and higher risk of hemorrhagic transformation. 1
• Treat hypoglycemia (<60 mg/dL) immediately with IV dextrose. 1
• Continuous glucose monitoring is recommended to avoid hypoglycemia, which can mimic stroke symptoms. 1

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Temperature Management

• Prevent fever (>37.7°C) using antipyretics and active cooling measures. 1
• Therapeutic hypothermia is not recommended outside clinical trials because it raises pneumonia risk without proven benefit. 1

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Seizure Management

• Treat new-onset seizures at stroke onset with short-acting benzodiazepines (e.g., lorazepam 2–4 mg IV) if they do not self-terminate. 2, 1
• A single, self-limiting seizure within 24 hours of stroke onset does not require long-term anticonvulsant medication. 2, 1
• Prophylactic anticonvulsants are not recommended; there is no evidence of benefit and possible harm with negative effects on neural recovery. 2, 1

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Antiplatelet and Anticoagulation (Acute Phase)

• Do not give aspirin, clopidogrel, or any anticoagulant for the first 24 hours after alteplase. 1
• For patients with atrial fibrillation, parenteral anticoagulation within 48 hours is associated with increased risk of hemorrhagic transformation and is not recommended. 7
• Direct oral anticoagulant initiation within 2 days of acute ischemic stroke is associated with a 5% rate of hemorrhagic transformation; infarct size and presence of hemorrhage should guide timing decisions. 7

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Hemorrhagic Stroke Management

Blood Pressure Targets in Intracerebral Hemorrhage

• Target systolic BP 140–179 mmHg for patients presenting within 6 hours with SBP 150–220 mmHg; lowering SBP <140 mmHg offers no mortality or disability benefit and increases renal complications. 2, 3
• If SBP >220 mmHg, initiate continuous IV antihypertensive infusion with close monitoring. 3
• Avoid rapid SBP reductions >70 mmHg within one hour; a modest reduction of 30–45 mmHg over the first hour is recommended. 3

Preferred Agents for ICH

• Labetalol (10–20 mg IV bolus, repeatable every 10 minutes, or continuous infusion 2–8 mg/min) is first-line. 3
• Nicardipine (start 5 mg/h IV, titrate by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h) is an effective alternative. 3

Agents to Avoid in ICH

• Sodium nitroprusside is contraindicated due to adverse effects on cerebral autoregulation and intracranial pressure. 3
• Sublingual nifedipine is contraindicated because it cannot be titrated and may cause precipitous BP drops. 3

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Common Pitfalls to Avoid

• Never delay alteplase for "complete" laboratory results; only a bedside glucose check is required before treatment. 1
• Do not withhold alteplase from patients on single or dual antiplatelet therapy; the benefit outweighs the modest increase in hemorrhage risk. 1
• Avoid sublingual nifedipine for acute BP control; it causes unpredictable, precipitous drops that may compromise cerebral perfusion. 1, 3
• Do not automatically restart home antihypertensives during the first 48–72 hours in non-thrombolysis patients; permissive hypertension supports collateral flow. 6