Management of Acute Ischemic Stroke

Initial Assessment and Stabilization

The American Heart Association recommends performing rapid assessment of airway, breathing, and circulation as the first priority for patients with acute ischemic stroke 1, 2
A standardized neurological examination using a validated stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) should be conducted to determine focal deficits and stroke severity 2, 3
Oxygen saturation should be monitored and supplemental oxygen provided only if oxygen saturation is below 94% 2, 5

Urgent non-contrast CT scan of the brain should be performed to exclude hemorrhage and assess for other structural causes 3, 6
CT angiography (CTA) may be considered to identify large vessel occlusions that may be eligible for endovascular thrombectomy 3, 6
Baseline ECG should be obtained to assess cardiac rhythm and identify atrial fibrillation or evidence of structural heart disease 5, 6

The American Heart Association recommends avoiding routine treatment of hypertension in the acute setting for patients not eligible for thrombolytic therapy 5, 6
Extreme blood pressure elevations (systolic >220 mmHg or diastolic >120 mmHg) should be treated by reducing blood pressure by approximately 15%, and not more than 25%, over the first 24 hours 5, 7

The American Heart Association recommends that all patients with acute ischemic stroke be admitted to a stroke unit as soon as possible, ideally within 3 hours of hospital arrival 1, 2
Stroke unit care has been shown to reduce mortality and improve functional outcomes with benefits comparable to those achieved with IV thrombolysis 1, 2

Temperature should be monitored routinely and treated if above 37.5°C as hyperthermia is associated with increased morbidity and mortality 1, 5
Bedside dysphagia screening should be performed before oral intake to prevent aspiration pneumonia 2

Patients with large vessel occlusion may still be candidates for endovascular thrombectomy (EVT) even when intravenous thrombolysis is contraindicated 3, 8
Eligible patients with large vessel occlusion who can be treated with EVT within 6 hours of symptom onset should receive EVT 8

Early aspirin therapy (160-325 mg daily) should be initiated for patients with acute ischemic stroke who are not receiving thrombolysis 1