In an adult with acute ischemic stroke presenting within 4.5 hours, what immediate treatments should be given?

Immediate Treatment for Acute Ischemic Stroke Within 4.5 Hours

Administer intravenous alteplase (0.9 mg/kg, maximum 90 mg) immediately to all eligible patients presenting within 4.5 hours of symptom onset or last known well, with 10% given as a bolus over 1 minute and the remaining 90% infused over 60 minutes. 1, 2

Pre-Treatment Requirements

Before initiating IV alteplase, you must:

• Perform immediate non-contrast CT scan to exclude intracranial hemorrhage 1, 2
• Check capillary blood glucose immediately—this is the ONLY laboratory test that must precede alteplase administration 1, 2
• Treat hypoglycemia (glucose <60 mg/dL or 3.3 mmol/L) with IV dextrose before proceeding 1
• Lower blood pressure to <185/110 mmHg before starting thrombolysis 1, 2

Other blood tests (complete blood count, electrolytes, creatinine, INR, PTT, troponin) and electrocardiography should be obtained but must not delay initiation of reperfusion therapy. 1

Supportive Care During Initial Assessment

While preparing for thrombolysis:

• Provide supplemental oxygen to maintain oxygen saturation ≥94% 1
• Correct hypotension and hypovolemia to maintain systemic perfusion 1
• Perform tracheal intubation only if there is compromised airway or insufficient ventilation due to impaired alertness or bulbar dysfunction 1
• Treat emergency hypertension only if there is concomitant acute myocardial ischemia, aortic dissection, or preeclampsia/eclampsia 1

Time-Window Specific Considerations

0-3 Hour Window

• All eligible patients should receive IV alteplase regardless of age (including >80 years), stroke severity (including NIHSS >25), or use of single or dual antiplatelet therapy 1, 2
• Earlier treatment yields exponentially better outcomes—every 15-minute delay reduces probability of favorable outcome 2

3-4.5 Hour Window

• Additional exclusion criteria apply: age >80 years, oral anticoagulant use (regardless of INR), NIHSS >25, or combined history of diabetes and prior stroke 1, 2
• All other standard eligibility criteria from the 0-3 hour window continue to apply 2

Mechanical Thrombectomy Evaluation (Parallel Workflow)

Do NOT delay IV thrombolysis to assess for mechanical thrombectomy eligibility. 1, 2

For patients with clinically suspected large vessel occlusion (LVO):

• Obtain CT angiography (CTA) from aortic arch to vertex immediately after non-contrast CT 1, 2
• Administer IV alteplase even if mechanical thrombectomy is being considered 1, 2
• Do NOT evaluate response to IV thrombolysis before proceeding with catheter angiography for mechanical thrombectomy 1, 2

For patients presenting 6-24 hours from last known well with suspected LVO:

• Perform advanced imaging (CT perfusion or diffusion-weighted MRI) to determine mechanical thrombectomy eligibility 1

Post-Thrombolysis Monitoring Protocol

Immediately after initiating alteplase:

• Perform neurological assessments every 15 minutes during infusion, every 30 minutes for 6 hours, then hourly until 24 hours 2, 3
• Monitor blood pressure every 15 minutes for 2 hours, every 30 minutes for 6 hours, then hourly until 24 hours 3
• Maintain blood pressure ≤180/105 mmHg for 24 hours after treatment 2, 3
• If severe headache, acute hypertension, nausea, vomiting, or neurological worsening occurs, stop infusion immediately and obtain emergent CT scan 2, 3

Critical Post-Treatment Restrictions

• Delay placement of nasogastric tubes, indwelling bladder catheters, and intra-arterial pressure catheters for 24 hours 2, 3
• Do NOT administer anticoagulants or antiplatelet agents for 24 hours after alteplase 2, 3
• Obtain follow-up CT scan at 24 hours before starting any anticoagulant or antiplatelet therapy 2, 3

Management of Symptomatic Intracranial Hemorrhage

Symptomatic intracranial hemorrhage occurs in approximately 2.4-6.4% of patients. 1, 4

If suspected:

• Immediately discontinue any remaining alteplase infusion 3
• Obtain emergent non-contrast CT scan 3
• Consider cryoprecipitate to restore fibrinogen levels 3
• Consider neurosurgical consultation for potential hematoma evacuation based on size and location 3

Common Pitfalls to Avoid

• Waiting for laboratory results other than glucose before initiating alteplase—this causes harmful delays 1, 2
• Delaying IV thrombolysis to obtain or interpret CTA for thrombectomy evaluation 1, 2
• Withholding alteplase from elderly patients (>80 years) presenting within 3 hours—age is NOT a contraindication in this window 1, 2
• Premature administration of antiplatelet or anticoagulant therapy before 24-hour follow-up imaging 3
• Inadequate blood pressure control in the first 24 hours, which significantly increases hemorrhagic transformation risk 3