Acute Ischemic Stroke Management

Diagnostic Evaluation

The American Heart Association recommends that all patients with suspected acute ischemic stroke must undergo non-contrast CT (NCCT) immediately to rule out hemorrhage and determine eligibility for thrombolysis 1, 2
Patients arriving within 6 hours who are potentially eligible for endovascular thrombectomy (EVT) should undergo CT angiography (CTA) from arch-to-vertex without delay to identify large vessel occlusions 2
A 12-lead ECG should be performed to assess cardiac rhythm and identify atrial fibrillation, but this must not delay thrombolysis assessment 2, 3

The American College of Cardiology recommends intravenous alteplase (0.9 mg/kg, maximum 90 mg) for eligible patients within 3 hours of symptom onset, with treatment extending to 4.5 hours for selected patients 1, 4, 3
Eligibility criteria for intravenous alteplase include age ≥18 years, all stroke severities, patients on antiplatelet monotherapy or dual antiplatelet therapy, and end-stage renal disease patients on hemodialysis with normal aPTT 1
Blood pressure must be lowered to <185/110 mmHg before alteplase administration and maintained <180/105 mmHg for 24 hours after treatment 1, 2, 4, 3

The American Heart Association recommends EVT with stent retrievers as first-line therapy over intra-arterial thrombolysis for patients with large vessel occlusions within 6 hours of onset 5, 3
EVT is indicated for patients with large vessel occlusions, including those who received IV alteplase and those ineligible for IV alteplase 3

The American College of Cardiology recommends oral aspirin (160-325 mg) within 24-48 hours after stroke onset for patients not receiving thrombolysis 6, 5, 3
For patients treated with IV alteplase, aspirin is generally delayed until 24 hours later 5
Dual antiplatelet therapy (aspirin plus clopidogrel) for 21 days begun within 24 hours can be beneficial for early secondary prevention up to 90 days in minor stroke patients 5

The American Heart Association recommends that for patients NOT receiving thrombolysis, blood pressure should generally not be routinely treated unless extremely elevated 2, 3
Extreme elevation (SBP >220 mmHg or DBP >120 mmHg) should be treated to reduce BP by approximately 15% (not more than 25%) over the first 24 hours 2, 3

Intensive monitoring is mandatory after alteplase administration, including neurological assessments and BP checks every 15 minutes during and for 2 hours after infusion 4
If symptomatic hemorrhage occurs within 24 hours of alteplase, stop alteplase infusion immediately and obtain emergent non-enhanced head CT 4

The American Heart Association recommends that all stroke patients should be admitted to a geographically defined stroke unit with specialized staff as soon as possible, ideally within 24 hours of hospital arrival 7
Maintain oxygen saturation >94% with supplemental oxygen, treat hyperthermia (>38°C) with antipyretics, and correct hypoglycemia (<60 mg/dL) immediately 3, 7
Begin frequent, brief, out-of-bed activity within 24 hours if no contraindications, and screen swallowing, nutritional, and hydration status on day of admission 7