What is the recommended acute and secondary management for a patient presenting with an acute ischemic stroke?

Acute Ischemic Stroke Management

Hyperacute Phase: Immediate Recognition and Transport

All suspected stroke patients must be transported directly to a comprehensive stroke center with pre-notification to activate stroke protocols before arrival, documenting the exact time the patient was last known to be neurologically normal—not when symptoms were discovered—as this determines treatment eligibility. 1, 2

• EMS should use FAST (Face, Arms, Speech, Time) screening, where even a single abnormality carries 72% probability of stroke. 1
• When large vessel occlusion is suspected, transport directly to comprehensive stroke centers capable of endovascular therapy rather than routing through primary stroke centers ("mothership" over "drip-and-ship"). 1

Emergency Department: Parallel Processing Protocol

Immediate non-contrast CT scan must be completed and interpreted within 45 minutes of arrival to rule out hemorrhage, followed immediately by CT angiography to identify large vessel occlusions—but imaging must never delay IV alteplase administration. 1, 2

• Perform NIHSS scoring during parallel processing while imaging is obtained. 1
• Obtain immediate labs: CBC with platelets, PT/INR, aPTT, glucose, electrolytes, renal function. 2
• Target door-to-needle time under 60 minutes for IV alteplase. 1

IV Alteplase Administration (0-3 Hours)

Administer IV alteplase 0.9 mg/kg (maximum 90 mg total) with 10% as IV bolus over 1 minute and remaining 90% infused over 60 minutes to all eligible patients within 3 hours of last known well time. 1, 3

Critical Inclusion Criteria:

• Clearly defined symptom onset within 3 hours 1
• Measurable neurologic deficit on NIHSS 1
• Age ≥18 years 1
• CT showing no hemorrhage 1

Absolute Exclusion Criteria:

• Blood pressure >185/110 mmHg (must lower first) 1, 3
• Platelet count <100,000 1
• INR >1.6 or PT >15 seconds 1
• Glucose <50 or >400 mg/dL 1
• Prior stroke or serious head injury within 3 months 1
• Major surgery within 14 days 1
• History of intracranial hemorrhage 1
• Patients on direct oral anticoagulants (DOACs) 1

Special Considerations for Alteplase:

• For patients with 1-10 cerebral microbleeds on prior MRI, alteplase administration is reasonable. 4
• For patients with >10 microbleeds, treatment may be reasonable if potential for substantial benefit outweighs increased hemorrhage risk. 4
• For concurrent acute MI and stroke, use cerebral ischemia dose followed by percutaneous coronary intervention. 4
• For unruptured intracranial aneurysms <10mm, alteplase is reasonable; for giant aneurysms, risk-benefit is uncertain. 4

Blood Pressure Management Around Alteplase

Before alteplase, blood pressure must be reduced to <185/110 mmHg; during and after infusion maintain ≤180/105 mmHg for 24 hours. 1, 3, 2

Pre-Alteplase BP Reduction (if >185/110):

• Labetalol 10-20 mg IV over 1-2 minutes (may repeat once) 1, 2
• Nicardipine infusion starting at 5 mg/h, titrated by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h 1, 2
• Clevidipine infusion 1-2 mg/h, doubled every 2-5 minutes, maximum 21 mg/h 1

BP Monitoring Schedule Post-Alteplase:

• Every 15 minutes during infusion and for 2 hours after 1, 3, 2
• Every 30 minutes for next 6 hours 1, 3, 2
• Hourly until 24 hours 1, 3, 2

If BP rises to 180-230/105-120 mmHg post-thrombolysis, treat with labetalol 10 mg IV followed by 2-8 mg/min infusion or nicardipine 5 mg/h titrated; if diastolic >140 mmHg, use sodium nitroprusside. 2

Endovascular Thrombectomy (0-24 Hours)

For proximal anterior circulation large vessel occlusions (ICA, M1, proximal M2), perform endovascular thrombectomy within 6 hours of symptom onset; extend to 24 hours in selected patients with favorable CT perfusion or MRI diffusion/perfusion mismatch. 1, 2

• Start IV alteplase while preparing angiography suite—do not delay either therapy. 1, 2
• Thrombectomy is indicated both for alteplase-eligible and alteplase-ineligible patients. 1
• Use combined stent-retriever and aspiration technique (BADDASS approach) with dual aspiration through balloon guide catheter and distal access catheter. 1
• Every 30-minute delay in recanalization decreases good functional outcome by 8-14%—speed is critical. 1, 2

Post-Alteplase Neurological Monitoring

Monitor neurological status every 15 minutes during and for 2 hours after infusion, every 30 minutes for next 6 hours, then hourly until 24 hours; immediately stop infusion and obtain emergent CT for severe headache, acute hypertension, nausea, vomiting, or any neurological worsening. 1, 3

Symptomatic Intracranial Hemorrhage Protocol:

• Stop alteplase immediately 1
• Emergent non-contrast head CT 1
• Check CBC, PT/INR, aPTT, fibrinogen, type and cross-match 1
• Administer cryoprecipitate AND tranexamic acid or ε-aminocaproic acid 1
• Consult hematology and neurosurgery emergently 1

Stroke Unit Care (First 24-48 Hours)

All stroke patients must be admitted to a geographically defined stroke unit with specialized interprofessional staff within 24 hours of arrival, as this reduces mortality (OR 0.76) and dependency (OR 0.80) compared to general ward care. 4, 2

• Begin frequent brief out-of-bed activity within 24 hours if no contraindications. 1, 2
• Perform swallowing screen on day of admission before any oral intake. 1, 2
• Initiate rehabilitation assessment within 48 hours. 1, 2

Physiological Parameter Management

Temperature Control:

• Monitor temperature every 4 hours for first 48 hours 1, 2
• Treat fever >37.5°C with antipyretics 1
• Identify and treat sources of hyperthermia 1, 2
• Avoid hypothermia except in clinical trial contexts 2

Glucose Management:

• Monitor blood glucose regularly 1, 2
• Treat hyperglycemia to maintain 140-180 mg/dL 1, 2
• Avoid hypoglycemia with close monitoring 1, 2

Blood Pressure (Non-Thrombolysis Patients):

• Only treat if systolic >220 mmHg or diastolic >120 mmHg 2
• Lower by 15-25% over first 24 hours when treatment indicated 2
• Permissive hypertension is acceptable below these thresholds to maintain cerebral perfusion 2

Early Antiplatelet Therapy

Start aspirin 160-325 mg within 24-48 hours after ruling out hemorrhage on follow-up imaging at 24 hours; delay aspirin for 24 hours if alteplase was given. 1

• The combination of aspirin and clopidogrel initiated within 24 hours appears safe for minor stroke (NIHSS <4) and reduces 90-day stroke risk. 4
• Do not combine aspirin with alteplase during acute administration—this doubles symptomatic ICH risk (4.3% vs 1.6%). 4

Management of Cerebral Edema and Increased ICP

Do not use corticosteroids for cerebral edema; use osmotherapy and hyperventilation for deteriorating patients. 1, 2

• For large cerebellar infarctions with brainstem compression, surgical decompression may be life-saving. 1, 2
• For malignant MCA infarction, perform decompressive hemicraniectomy urgently before significant GCS decline or pupillary changes, ideally within 48 hours of onset. 1, 3, 2
• Monitor closely for deterioration over 24-72 hours as large MCA infarcts can develop life-threatening edema. 3

Seizure Management

Treat new-onset seizures with short-acting medications (e.g., lorazepam IV); do not use prophylactic anticonvulsants. 1, 2

Secondary Prevention Workup

Initiate comprehensive workup to determine stroke etiology for appropriate secondary prevention before discharge. 5

• Continuous cardiac monitoring for 24-48 hours to detect atrial fibrillation 3
• Echocardiography (transthoracic initially, consider transesophageal if cardioembolic source suspected) 3
• Carotid imaging for anterior circulation strokes to identify revascularization candidates 5
• Address modifiable risk factors: hypertension, diabetes, hyperlipidemia, smoking 2, 5

Critical Pitfalls to Avoid

• Failure to obtain follow-up imaging at 24 hours before starting antiplatelets or anticoagulants increases hemorrhage risk. 1
• Inadequate blood pressure control before thrombolysis significantly increases symptomatic ICH risk. 1
• Using "time of symptom discovery" instead of "last known well time" inappropriately excludes eligible patients. 1
• Delaying CT angiography to obtain it should never postpone alteplase bolus. 1
• Overly selective treatment criteria exclude patients who could benefit—verbal aggression and confusion from acute stroke are not contraindications to thrombolysis. 3
• Failure to monitor for and treat swallowing difficulties, infections, and venous thromboembolism worsens outcomes. 2