Ischemic Stroke Management Guidelines

Immediate Assessment and Diagnosis

The American College of Cardiology recommends that all patients with suspected acute ischemic stroke must undergo non-contrast CT immediately to rule out hemorrhage and determine thrombolysis eligibility 1, 2
CT angiography (CTA) from arch-to-vertex should be performed for patients arriving within 6 hours who may be candidates for endovascular thrombectomy to identify large vessel occlusions 2
A 12-lead ECG should be obtained to assess cardiac rhythm and identify atrial fibrillation, but should not delay thrombolysis assessment 1, 2

The American Heart Association recommends administering intravenous alteplase 0.9 mg/kg (maximum 90 mg) to eligible patients within 3 hours of symptom onset, with treatment extending to 4.5 hours for selected patients 1, 2
The dosing protocol for alteplase includes a 10% intravenous bolus over 1 minute, followed by infusion of the remaining 90% over 60 minutes 1
The target door-to-needle time is less than 60 minutes in 90% of treated patients 1

The American Stroke Association recommends performing EVT with stent retrievers as first-line therapy for patients with large vessel occlusions within 6 hours of onset 2
EVT should be delivered within a coordinated system with rapid neurovascular imaging access and specialized neurointerventional expertise 1, 2

The American College of Cardiology recommends administering oral aspirin 325 mg within 24-48 hours after stroke onset for patients not receiving thrombolysis 3, 1, 2
Aspirin should not be given within 24 hours of rtPA administration 3, 4, 2

The American Heart Association recommends not routinely treating blood pressure unless extremely elevated (SBP >220 mmHg or DBP >120 mmHg) in patients not receiving thrombolysis 1, 2
For patients receiving thrombolysis, strict BP control is recommended, with a target of <185/110 before and <180/105 after alteplase administration 1, 2

The American Stroke Association recommends admitting all stroke patients to a geographically defined stroke unit with specialized staff within 24 hours of hospital arrival 2, 5
Airway support and ventilatory assistance should be provided for patients with decreased consciousness or bulbar dysfunction 1
Oxygen saturation should be maintained >94% with supplemental oxygen 1, 2

The American Heart Association recommends not using corticosteroids for cerebral edema management following ischemic stroke 5, 1
Osmotherapy and hyperventilation should be used for patients deteriorating due to increased intracranial pressure, including herniation syndromes 5, 1
Surgical drainage of cerebrospinal fluid should be performed for hydrocephalus 5, 1