What is the recommended acute management approach for a patient presenting with an ischemic cerebrovascular accident (cerebral infarction)?

Acute Management of Ischemic Cerebrovascular Accident (CVA)

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) immediately if the patient presents within 4.5 hours of clearly defined symptom onset, with 10% given as a bolus over 1 minute and the remaining 90% infused over 60 minutes. 1

Immediate Emergency Department Actions

Brain Imaging (Door-to-Imaging <25 minutes)

• Obtain non-contrast CT of the head immediately upon arrival to exclude intracranial hemorrhage before any specific therapy 2, 3
• The CT must be interpreted within 45 minutes of patient arrival by a physician with expertise in neuroimaging 2, 1
• Proceed with CT angiography from arch-to-vertex without delay if the patient arrives within 6 hours to identify large vessel occlusions eligible for endovascular thrombectomy 2, 1
• Do not delay IV alteplase for advanced imaging such as CT perfusion or MRI if the patient is otherwise eligible based on non-contrast CT alone 2, 1

Blood Pressure Management Before Thrombolysis

• Reduce blood pressure to <185/110 mmHg before initiating alteplase using IV labetalol or nicardipine 1, 2
• Maintain blood pressure ≤180/105 mmHg during the infusion and for 24 hours after treatment 2, 1
• Avoid precipitous drops in blood pressure by choosing appropriate pharmacological agents and routes 2

Laboratory Testing (Do Not Delay Treatment)

• Obtain electrolytes, random glucose, complete blood count, coagulation studies (INR, aPTT), and creatinine 2
• These tests should not delay imaging or treatment decisions for IV thrombolysis or endovascular therapy 2

IV Thrombolysis Protocol (Door-to-Needle <60 minutes)

Alteplase Administration

• Dose: 0.9 mg/kg with maximum dose of 90 mg 1, 2
• Give 10% as IV bolus over 1 minute, then infuse remaining 90% over 60 minutes 1, 2
• Every 30-minute delay reduces probability of favorable outcome by approximately 10.6%, so target door-to-needle time of <60 minutes 1

Eligibility Criteria (3-4.5 Hour Window)

• Clearly defined symptom onset within 4.5 hours 1, 2
• No evidence of intracranial hemorrhage on CT 2, 3
• Administer even if early ischemic changes are present on CT, regardless of extent, unless frank hypodensity involves >1/3 of MCA territory 2, 3
• INR <1.5 if taking oral anticoagulants 2
• Platelet count >100,000/mm³ 2
• Blood glucose >50 mg/dL 2

Post-Thrombolysis Monitoring

• Monitor neurological status and vital signs every 15 minutes during and for 2 hours after infusion, then every 30 minutes for 6 hours, then hourly until 24 hours 1, 2
• Maintain blood pressure ≤180/105 mmHg throughout the 24-hour monitoring period 2, 1
• Obtain repeat CT at 24 hours to exclude symptomatic intracranial hemorrhage before starting antiplatelet therapy 1
• Symptomatic intracranial hemorrhage occurs in approximately 6.4% of rtPA-treated patients 1

Endovascular Thrombectomy (Door-to-Groin <90 minutes)

Immediate Thrombectomy Criteria

• Large vessel occlusion (internal carotid, M1 or proximal M2 segment of MCA, or basilar artery) confirmed on CT angiography 1, 2
• Groin puncture can be initiated within 6 hours of symptom onset 1, 2
• Age ≥18 years 1
• NIHSS score ≥6 1
• ASPECTS score ≥6 on non-contrast CT 1
• Pre-stroke modified Rankin Scale (mRS) score 0-1 1

Thrombectomy Technique

• Use stent retriever devices (Solitaire FR, Trevo) as first-line therapy over coil retrievers 1, 2
• Use proximal balloon-guide catheter or large-bore distal-access catheter with the stent retriever to improve recanalization 1
• Target final angiographic result of TICI 2b/3 for highest probability of good functional outcome 1

Critical Timing Principle

• Do not delay IV alteplase while awaiting endovascular therapy—both treatments are complementary and should be delivered promptly 1, 2
• Do not wait for clinical response to IV rtPA before initiating thrombectomy, as delaying worsens outcomes 1

Acute In-Hospital Care (First 24-48 Hours)

Stroke Unit Admission

• Admit all patients to a geographically defined stroke unit with specialized nursing staff 2, 1
• If critically ill with malignant cerebral edema, transfer to intensive care unit 2
• Stroke unit care reduces mortality and disability across all stroke types, ages, and severities 1

Cardiac Monitoring

• Continuous cardiac monitoring for at least 24 hours to screen for atrial fibrillation and serious arrhythmias 2

Antiplatelet Therapy

• Delay aspirin for 24 hours after IV alteplase administration 2, 1
• After 24-hour post-thrombolysis CT excludes hemorrhage, initiate aspirin 150-325 mg daily 1, 2
• For patients who did not receive thrombolysis, administer aspirin within 24-48 hours of stroke onset 2

Temperature Management

• Monitor body temperature and treat fever (>38°C) aggressively 2
• Investigate and treat sources of fever 2

Seizure Management

• Treat new-onset seizures at stroke onset with short-acting medications (e.g., IV lorazepam) if not self-limited 2
• Do not use prophylactic anticonvulsants—they are only indicated for documented seizures 2
• A single self-limiting seizure within 24 hours should not be treated with long-term anticonvulsants 2

Venous Thromboembolism Prophylaxis

• Use thigh-high intermittent pneumatic compression devices for patients with limited mobility 2

Management of Malignant Cerebral Edema

Identification of High-Risk Patients

• Monitor closely for neurological deterioration in patients with large territorial infarctions involving >50% of MCA territory 1, 2
• Perform serial physical examinations and repeat head CT when appropriate to identify worsening brain swelling 2

Decompressive Hemicraniectomy

• Perform decompressive hemicraniectomy within 48 hours of symptom onset for patients ≤60 years with malignant MCA infarction who deteriorate neurologically despite medical therapy 2, 1
• Surgery reduces mortality by approximately 50%, with 55% of surgical survivors achieving moderate disability (mRS 3, able to walk) and 18% achieving independence (mRS 0-2) at 12 months 2
• For patients >60 years, surgery may be considered but reduces mortality to 42% while none achieve independence (mRS 0-2) and only 11% achieve moderate disability (mRS 3) 2, 1
• Transfer patients at risk for malignant edema to a center with neurosurgical expertise early 2

Cerebellar Infarction with Mass Effect

• Perform decompressive suboccipital craniectomy within 48 hours for cerebellar infarction with neurological deterioration and brainstem compression 2
• Ventriculostomy is recommended for symptomatic obstructive hydrocephalus after cerebellar infarction 2

Critical Pitfalls to Avoid

• Never delay thrombolysis to obtain perfusion imaging or MRI if the patient is eligible based on non-contrast CT 2, 1
• Never use full-dose anticoagulation (IV or subcutaneous heparin) in acute ischemic stroke, as it increases hemorrhage risk without improving outcomes 1
• Never delay endovascular thrombectomy while waiting for clinical response to IV alteplase 1
• Never administer antiplatelet agents or anticoagulants within 24 hours after rtPA 1, 2
• Never assume behavioral symptoms (confusion, agitation) are contraindications to thrombolysis—they may reflect the stroke pathology itself 1

Secondary Prevention Before Discharge

Cardiac Evaluation

• Obtain transthoracic echocardiography to assess for cardioembolic sources 1
• Consider transesophageal echocardiography if cardioembolic source is suspected but not identified on transthoracic study 1

Medical Therapy

• Initiate high-intensity statin therapy regardless of baseline lipid levels 1
• Begin antihypertensive therapy for long-term blood pressure control 1