Acute Ischemic Stroke Management

Initial Assessment and Treatment

The American Heart Association recommends that patients with suspected stroke should undergo rapid assessment within 10 minutes of arrival to the emergency department 3
Oxygen should be administered to hypoxemic stroke patients (oxygen saturation <94%) 3
The American College of Cardiology suggests establishing IV access and obtaining baseline blood studies (complete blood count, coagulation studies, blood glucose) 3
Perform neurological screening assessment and order emergent CT scan of the brain 3
Cardiac monitoring is recommended during the first 24 hours to detect atrial fibrillation and potentially life-threatening arrhythmias 3

The American Heart Association recommends IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% as bolus) should be administered to eligible patients within 4.5 hours of symptom onset 1
Treatment should be initiated as quickly as possible with a target door-to-needle time of less than 60 minutes 1
Blood pressure must be controlled below 185/110 mmHg before tPA administration and maintained below 180/105 mmHg for at least 24 hours after treatment 1
Mechanical thrombectomy is recommended for eligible patients with large vessel occlusions (internal carotid artery or MCA-M1) 1

Admission to a specialized stroke unit or neurocritical care unit is essential for optimal outcomes 1
Airway support and ventilatory assistance are recommended for patients with decreased consciousness or bulbar dysfunction 1
Identify and treat sources of hyperthermia (temperature >38°C) 1
Correct hypovolemia with intravenous normal saline 1
Treat hypoglycemia (blood glucose <60 mg/dL) to achieve normoglycemia 1
Manage hyperglycemia to achieve blood glucose levels between 140-180 mg/dL 1

Hospitals should function as primary stroke centers or have pre-established transfer protocols to appropriate stroke centers 5
Telemedicine can extend stroke expertise to underserved areas 7
Standardized stroke orders or integrated stroke pathways improve adherence to best practices 1
A stroke system should ensure that hospitals identified as "acute stroke capable" possess appropriate resources and deliver primary stroke care according to national recommendations 6