What is the recommended acute evaluation and treatment for a patient presenting with an acute ischemic stroke (cerebral infarction)?

Acute Ischemic Stroke: Immediate Evaluation and Treatment

For acute ischemic stroke, immediately administer IV alteplase (or tenecteplase) within 4.5 hours of symptom onset if no contraindications exist, and perform emergent endovascular thrombectomy for large vessel occlusions within 6-24 hours based on imaging selection criteria. 1, 2

Time-Critical Initial Assessment

The cornerstone principle is "time is brain"—every minute of delay results in irreversible neuronal death. Upon patient arrival:

Immediate Actions (Door-to-Needle Goal: <60 minutes)

• Obtain non-contrast CT head immediately to exclude hemorrhage and assess for early ischemic changes
• Perform vascular imaging (CTA or MRA) simultaneously with or immediately after CT to identify large vessel occlusion 1, 3
• Check blood glucose, coagulation studies, and platelet count while imaging is being performed
• Assess NIHSS score to quantify stroke severity (score ≥2 generally indicates treatment candidacy)
• Establish precise time of symptom onset or last known well time

Intravenous Thrombolysis

Standard Treatment Window (0-4.5 hours)

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) with 10% as bolus and 90% as infusion over 60 minutes for patients presenting within 4.5 hours of symptom onset 1, 4, 2. Recent evidence supports tenecteplase as an alternative, particularly in centers with endovascular capabilities 5, 2.

Extended Window (Wake-Up Stroke)

For patients who awaken with stroke symptoms or have unknown onset time, administer IV thrombolysis if MRI shows DWI-FLAIR mismatch (ischemia present on diffusion-weighted imaging but not yet visible on FLAIR sequences), indicating stroke occurred <4.5 hours ago 4, 2.

Key Contraindications to Avoid

The 2026 guidelines have liberalized many previous contraindications 2:

• Absolute: Active internal bleeding, intracranial hemorrhage on CT, BP >185/110 mmHg despite treatment
• Relative but often acceptable: Recent MI (non-STEMI or right/inferior STEMI within 3 months is reasonable) 1, small-moderate unruptured aneurysms <10mm 1, 1-10 cerebral microbleeds on MRI 1
• High risk but may treat if severe deficit: >10 cerebral microbleeds, giant aneurysms, cardiac thrombus 1

Blood Pressure Management During Thrombolysis

Maintain BP <180/105 mmHg during and for 24 hours after thrombolysis 1, 6. Pre-treatment BP must be reduced to <185/110 mmHg before administering alteplase 6, 2.

Endovascular Thrombectomy

Patient Selection Criteria

Perform mechanical thrombectomy for patients with:

• Proximal anterior circulation occlusion (ICA, M1, or proximal M2 segment) 3, 2
• NIHSS ≥6 (indicating moderate-to-severe deficit)
• Presentation within 6 hours of symptom onset (Class I evidence) 3
• Extended window 6-24 hours if imaging shows salvageable tissue (small core infarct with significant penumbra on CT perfusion or MRI) 3, 2

Critical Timing Benchmarks

The landmark trials (MR CLEAN, ESCAPE, SWIFT PRIME, EXTEND-IA, REVASCAT) demonstrated 59-88% successful recanalization rates with stent retrievers, achieving door-to-groin puncture times of 85-127 minutes 3. Every 15-minute delay reduces the probability of good outcome by 4%.

Thrombectomy + Thrombolysis

Administer IV alteplase even if thrombectomy is planned—do not delay thrombolysis to wait for thrombectomy 3, 2. The combination provides better outcomes than thrombectomy alone in most cases, though recent trials are exploring direct thrombectomy approaches.

Acute Blood Pressure Management (Non-Thrombolysis Candidates)

For patients NOT receiving reperfusion therapy:

• Do not lower BP unless SBP ≥220 mmHg or DBP ≥120 mmHg 1, 6, 2
• If lowering required, reduce by only 15% in first 24 hours—aggressive reduction worsens outcomes by reducing perfusion to penumbral tissue 6
• Target SBP 140-180 mmHg in the acute phase

Posterior Circulation Strokes

Basilar artery occlusions warrant aggressive endovascular treatment given the high mortality (80-90%) without intervention 2. Extended time windows up to 24 hours may be reasonable given the devastating natural history.

Critical Early Management Pitfalls

Common Errors to Avoid:

• Delaying imaging for "complete history"—obtain imaging within 20 minutes of arrival
• Withholding thrombolysis for "minor" symptoms—NIHSS ≥2 with disabling deficits warrants treatment
• Over-aggressive BP lowering in non-thrombolysis patients—this extends infarct size
• Assuming "too old" or "too mild"—age alone is not a contraindication; functional outcome potential matters
• Waiting to see if symptoms improve—irreversible damage occurs during observation

Immediate Post-Treatment Care

• Admit to stroke unit (reduces mortality by 20% compared to general wards)
• NPO status until swallow screen completed—aspiration pneumonia is a leading cause of post-stroke mortality 2
• Manage hyperglycemia (target glucose 140-180 mg/dL)—both hypo- and hyperglycemia worsen outcomes 2
• Avoid antithrombotics for 24 hours post-thrombolysis, then start aspirin 325 mg daily
• Monitor neurologically every 15 minutes × 2 hours, then hourly × 6 hours for hemorrhagic transformation

Secondary Prevention Initiation

Before discharge:

• Start high-intensity statin (atorvastatin 80 mg) regardless of baseline LDL 2
• Initiate antiplatelet therapy: aspirin 325 mg or aspirin-clopidogrel for 21 days if minor stroke/TIA 2
• Screen for atrial fibrillation with continuous monitoring—if detected, anticoagulation reduces recurrence by 68%
• Target long-term BP <130/80 mmHg for secondary prevention 6, 2

The evidence strongly supports that organized stroke systems with rapid triage, immediate imaging, and protocol-driven reperfusion therapy reduce mortality and severe disability by 30-40% compared to standard care 3, 7.