Acute Ischemic Stroke Management

Initial Evaluation and Management

The American Heart Association recommends that all patients with suspected acute ischemic stroke undergo immediate neurological evaluation and brain imaging studies (CT or MRI) to rule out hemorrhage and determine eligibility for reperfusion therapies 1, 3
A validated stroke severity scale (such as NIHSS) should be used to assess the severity of neurological deficit 1
The airway, breathing, and circulation should be monitored and maintained, with tracheal intubation indicated for patients with compromised airway or inadequate ventilation 1, 3
Supplemental oxygen should be provided to maintain saturation ≥94% 1
Hypotension and hypovolemia should be corrected to maintain adequate systemic perfusion levels 1

The American College of Cardiology recommends intravenous alteplase (0.9 mg/kg, maximum 90 mg) for selected patients within 4.5 hours of symptom onset, followed by mechanical thrombectomy for those with large vessel occlusion within 6-24 hours, according to specific imaging criteria 1, 2
Mechanical thrombectomy is also recommended between 6-24 hours in patients with significant mismatch between the ischemic core and at-risk tissue based on advanced imaging criteria 1, 5

In patients not receiving reperfusion therapies, antihypertensive treatment should be avoided unless systolic blood pressure is >220 mmHg or diastolic >120 mmHg 6, 4
Emergency treatment of hypertension is recommended if there is concomitant acute myocardial infarction, aortic dissection, acute renal failure, acute pulmonary edema, or preeclampsia/eclampsia 1, 6

Corticosteroids are not recommended for cerebral edema and increased intracranial pressure 3
Osmotic therapy and hyperventilation are recommended for patients who deteriorate 7, 3
Surgical decompression and evacuation of large cerebellar infarcts that cause brainstem compression and hydrocephalus are recommended 7, 3

Initial assessment by rehabilitation professionals should be performed within 48 hours of admission 3
Rehabilitation therapy should begin as soon as possible once the patient is medically stable 3

Emergency carotid endarterectomy is generally not performed in acute ischemic stroke settings, especially when the deficit is large, due to high risk of adverse events 8
The utility of induced hypothermia for the treatment of patients with acute ischemic stroke is not well established 9
Currently, there are no pharmacological agents with neuroprotective actions that have been shown to improve outcomes after an acute ischemic stroke 9