Acute Ischemic Stroke Management

Immediate Assessment and Treatment

The American Heart Association recommends administering IV tPA at 0.9 mg/kg (maximum 90 mg total) after confirming eligibility, with 10% given as a bolus over 1 minute and the remaining 90% infused over 60 minutes, for acute ischemic stroke presenting within 4.5 hours of symptom onset 1, 2
Blood pressure must be reduced to <185/110 mmHg before initiating tPA, and labetalol or nicardipine can be used for blood pressure control 1, 2
A non-contrast CT should be obtained immediately to exclude hemorrhagic stroke and assess for contraindications, such as hemorrhagic transformation or extensive early ischemic changes >1/3 MCA territory 2
Patients on direct oral anticoagulants (DOACs) should not receive tPA due to substantially elevated bleeding risk 1, 2

For acute ischemic stroke presenting within 0-3 hours of symptom onset, administer IV tPA (Grade 1A recommendation), which has the strongest evidence-based intervention with the greatest absolute benefit (NNT=8 for minimal or no disability) 3, 4, 2, 5
For acute ischemic stroke presenting within 3-4.5 hours of symptom onset, offer IV tPA using ECASS III criteria (Grade 2C recommendation), which has a smaller but still clinically meaningful benefit (NNT=14) 3, 4, 2, 5
Do not administer IV tPA beyond 4.5 hours of symptom onset (Grade 1B recommendation against use) 3, 4, 5

Monitor blood pressure every 15 minutes during infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly for 16 hours, and maintain BP <180/105 mmHg during and after treatment 1
Do not give anticoagulants or antiplatelet agents for 24 hours after tPA administration 1, 5
After 24-48 hours, initiate aspirin 160-325 mg for patients not receiving anticoagulation (Grade 1A) 3, 4, 1, 2, 5

Do not exclude patients with minor strokes from tPA consideration, as they may still benefit significantly 1, 5
Proceed with standard tPA dosing (0.9 mg/kg) for patients on antiplatelet therapy, accepting the 3% absolute increased ICH risk 1, 2
Never give tPA to patients on DOACs, as this is an absolute contraindication 1, 2

Recommend long-term antiplatelet therapy, such as aspirin 75-100 mg daily, clopidogrel 75 mg daily, aspirin/extended-release dipyridamole 25/200 mg twice daily, or cilostazol 100 mg twice daily (Grade 1A), for noncardioembolic ischemic stroke or TIA 3, 4
Prefer clopidogrel or aspirin/extended-release dipyridamole over aspirin alone (Grade 2B) 3, 4

The American Heart Association suggests that a prior TIA one week ago is NOT a contraindication to tPA for a new acute ischemic stroke, as TIA patients were included in the landmark trial that established tPA efficacy 6
The baseline symptomatic intracranial hemorrhage (sICH) rate is 6.4% with tPA versus 0.6% with placebo (NNH = 17), with strongest evidence (Grade 1A) 6

The risk of symptomatic intracranial hemorrhage (sICH) may be higher if the prior stroke had significant edema or mass effect (OR 7.8 for sICH), or if the current NIHSS score is high (OR 1.8 per category increase) 6