What is the recommended acute treatment protocol for a patient presenting with an acute stroke?

Acute Stroke Treatment Protocol

For acute ischemic stroke, immediately administer intravenous alteplase (0.9 mg/kg, maximum 90 mg) within 4.5 hours of symptom onset after excluding hemorrhage with CT, and perform endovascular thrombectomy (EVT) within 24 hours for large vessel occlusions meeting imaging criteria—these are the only proven treatments that reduce mortality and disability. 1

Immediate Assessment & Imaging

Time is brain—every minute of delay results in 1.9 million neurons dying. 1

• Non-contrast CT scan must be obtained immediately upon arrival to exclude intracranial hemorrhage before any treatment. 1
• CT angiography (CTA) should be performed simultaneously during initial imaging to identify large vessel occlusions for potential EVT. 1
• Target door-to-imaging time <20 minutes and door-to-needle time <60 minutes (ideally 30 minutes median). 1

Intravenous Thrombolysis

Eligibility Criteria (0-4.5 hours)

Administer alteplase to all patients with:

• Disabling stroke symptoms (any NIHSS score) 1
• Symptom onset <4.5 hours (or last known well time) 1
• Age ≥18 years 1
• CT excludes hemorrhage 1

Dosing Protocol

Alteplase 0.9 mg/kg (maximum 90 mg total): 1

• 10% (0.09 mg/kg) as IV bolus over 1 minute
• Remaining 90% (0.81 mg/kg) as continuous infusion over 60 minutes
• Critical: This differs from MI dosing—verify dose calculation with second nurse before administration 1

Key Contraindications

Absolute contraindications: 1

• Intracranial hemorrhage on imaging
• Blood pressure >185/110 mmHg despite treatment
• Active internal bleeding
• Recent intracranial/intraspinal surgery (<3 months)
• Patients on direct oral anticoagulants (DOACs) should not routinely receive alteplase 1

Blood Pressure Management

Before alteplase: 1

• Must achieve BP <185/110 mmHg
• Use labetalol 10-20 mg IV over 1-2 minutes, may repeat
• Alternative: nicardipine 5 mg/h IV, titrate by 2.5 mg/h every 5 minutes (maximum 15 mg/h)

During and after alteplase (24 hours): 1

• Maintain BP <180/105 mmHg
• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours

Endovascular Thrombectomy (EVT)

Patient Selection (0-24 hours)

EVT is indicated for: 1

• Proximal anterior circulation occlusions (internal carotid artery or M1 segment of middle cerebral artery)
• ASPECTS score ≥6 (small-to-moderate ischemic core) 1
• Premorbid functional independence (modified Rankin Scale ≤1) 1
• Treatment can be initiated within 6 hours for all eligible patients 1

Extended Window (6-24 hours)

Highly selected patients may benefit from EVT up to 24 hours if: 1

• Advanced imaging (CT perfusion or MRI diffusion-weighted imaging) demonstrates salvageable tissue
• Large penumbra with small core on perfusion imaging 1
• Decision requires stroke specialist consultation 1

Bridging Therapy

Do NOT delay EVT to observe response to alteplase—patients eligible for both should receive alteplase immediately, then proceed directly to EVT without waiting. 1

Stent retrievers are the preferred mechanical device (Class I recommendation over older MERCI devices). 1

Antiplatelet Therapy

Standard Acute Management

For patients NOT receiving alteplase: 1

• Aspirin 160-325 mg loading dose immediately after CT excludes hemorrhage and dysphagia screening passed
• Continue aspirin 81-325 mg daily indefinitely 1

For patients receiving alteplase: 1

• Delay antiplatelet therapy for 24 hours until repeat imaging excludes hemorrhagic transformation

High-Risk TIA or Minor Stroke

For non-cardioembolic TIA (ABCD2 score >4) or minor stroke (NIHSS 0-3): 1

• Dual antiplatelet therapy: Clopidogrel 300-600 mg loading dose + aspirin 160 mg
• Continue clopidogrel 75 mg + aspirin 75-81 mg daily for 21-30 days only
• Then switch to monotherapy (aspirin or clopidogrel alone) 1
• Must initiate within 24 hours of symptom onset (ideally within 12 hours) 1

Caution: Dual therapy beyond 30 days increases major bleeding risk (5 additional major hemorrhages per 1000 patients treated). 1

Post-Treatment Monitoring

Neurological Surveillance

After alteplase administration: 1

• Neurological assessments every 15 minutes during infusion and for 2 hours after
• Then every 30 minutes for 6 hours
• Then hourly until 24 hours post-treatment
• Obtain 24-hour follow-up CT/MRI before starting any antithrombotic therapy 1

Hemorrhagic Transformation Management

If patient develops severe headache, acute hypertension, nausea/vomiting, or neurological worsening: 1

• Stop alteplase infusion immediately
• Obtain emergency head CT
• Send CBC, PT/INR, aPTT, fibrinogen, type and cross-match
• Consider cryoprecipitate 10 units over 10-30 minutes 1
• Consider tranexamic acid 1000 mg IV over 10 minutes 1
• Consult hematology and neurosurgery urgently 1

Critical Pitfalls to Avoid

Common errors that worsen outcomes:

• Delaying treatment to obtain "complete workup"—CT and CTA are sufficient to begin treatment 1
• Withholding alteplase due to "minor" symptoms—any disabling deficit warrants treatment 1
• Observing alteplase response before pursuing EVT—this delays definitive therapy 1
• Administering alteplase to patients on DOACs without specialized testing—high hemorrhage risk 1
• Using myocardial infarction alteplase dosing (100 mg) instead of stroke dosing (0.9 mg/kg, max 90 mg) 1
• Permitting blood pressure >180/105 mmHg during or after alteplase—increases hemorrhage risk 1
• Continuing dual antiplatelet therapy beyond 30 days—increases bleeding without additional benefit 1

Systems of Care

Stroke should be managed within organized systems including: 1

• Prehospital stroke scale assessment and direct transport to stroke centers
• 24/7 access to CT/CTA imaging
• Immediate stroke team availability (on-site or via telestroke)
• Neurointerventional capability for EVT at comprehensive stroke centers
• Designated stroke unit for post-acute care 1