Acute Ischemic Stroke Management

Patient Selection and Treatment

The American Heart Association recommends administering IV alteplase (0.9 mg/kg, maximum 90 mg) over 60 minutes with 10% given as a bolus over 1 minute for eligible patients within 3 hours of symptom onset (Class I, Level A evidence) 1
Eligible patients should have a measurable neurological deficit, blood pressure ≤185/110 mmHg, no evidence of intracranial hemorrhage on CT, and meet other specific criteria 1
CT scans should be performed to rule out multilobar infarction (hypodensity <1/3 cerebral hemisphere) before administering IV alteplase, as recommended by the American Heart Association 1
The American College of Chest Physicians strongly recommends thrombolysis within 3 hours of symptom onset (Grade 1A) and recommends thrombolysis 3-4.5 hours after symptom onset, but with lower evidence (Grade 2C) 2
Determine the exact time of symptom onset, as it is crucial for thrombolysis eligibility, as recommended by the American Heart Association 1

Patients should be admitted to intensive care or stroke unit and undergo neurological assessments every 15 minutes during infusion, every 30 minutes for the next 6 hours, then hourly until 24 hours after treatment 1
Blood pressure should be measured every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, then hourly until 24 hours after treatment 1
A follow-up CT scan should be obtained at 24 hours before starting anticoagulants or antiplatelet agents 1
Monitor vital signs, including heart rate, rhythm, blood pressure, temperature, and oxygen saturation, and check blood glucose levels immediately, as hypoglycemia can mimic stroke symptoms 3

The risk of symptomatic intracranial hemorrhage with thrombolysis is reported to be around 6.4% in the original NINDS trial, though recent community studies report lower rates 1
Contraindications for thrombolysis must be strictly observed to minimize bleeding complications 1
Seizures at presentation do not necessarily preclude thrombolysis if evidence suggests residual deficits are due to ischemia rather than the postictal state 1

Complete imaging, including CT scans, should be done within 24 hours of symptom onset, as suggested by the European Stroke Organisation 3
Use advanced imaging, such as CT perfusion or MRI with diffusion-weighted imaging, to identify salvageable tissue in patients presenting beyond 6 hours from symptom onset, as recommended by the American Stroke Association 4
Use CT angiography to identify large vessel occlusions, as recommended by the American Heart Association 4

Administer IV thrombolysis with alteplase 0.9 mg/kg (maximum 90 mg) over 60 minutes, with blood pressure ≤185/110 mmHg before treatment, as recommended by the American College of Cardiology 4, 5
Early aspirin therapy is recommended within 48 hours at a dose of 160-325 mg (Grade 1A) 2
Aspirin (325 mg initially, then 81-325 mg daily) should be administered within 24-48 hours after stroke onset, unless the patient has received IV thrombolysis, in which case aspirin administration should be delayed until >24 hours, as recommended by the American Heart Association 6, 3
Endovascular thrombectomy should be performed within 6 hours for standard cases and has an extended window of 6-24 hours for selected patients with salvageable tissue, with every 30-minute delay in recanalization decreasing good functional outcome chance by 8-14%, as recommended by the American College of Cardiology 7
A combined approach using stent-retrievers and aspiration is the preferred technique for fastest reperfusion in patients with large vessel occlusion (LVO) 7

Blood pressure management is critical in patients receiving thrombolysis or endovascular therapy, with a target of ≤180/105 mmHg during and for 24 hours after the procedure, and consideration can be given to lower blood pressure targets (BP <140/90 mmHg) after successful reperfusion with endovascular therapy 4
Withhold antihypertensive agents unless diastolic BP >120 mmHg or systolic BP >220 mmHg for patients not receiving thrombolysis, and maintain BP ≤180/105 mmHg for patients receiving thrombolysis, with easily titrated agents like labetalol when treatment is needed, as recommended by the American College of Cardiology 4, 5
Administer antithrombotic treatment with either anticoagulant or antiplatelet therapy for at least 3-6 months, with antiplatelet therapy recommended for non-cardioembolic ischemic stroke and anticoagulation recommended for cardioembolic stroke (e.g., atrial fibrillation), as recommended by the American Heart Association 8, 9

Begin rehabilitation as early as possible, ideally within 24-48 hours for stable patients, and include physical therapy, occupational therapy, speech therapy, and cognitive assessment and rehabilitation, as recommended by the American Heart Association 5, 10, 11
Manage modifiable risk factors, including hypertension, diabetes, hyperlipidemia, and smoking cessation, with a target LDL level of less than 100 mg/dl and fasting blood glucose levels less than 126 mg/dl (7 mmol/L), as recommended by the American Heart Association 12, 9
Regular moderate to vigorous physical activity is recommended, along with avoiding prolonged sedentary behavior during waking hours, as recommended by the American Heart Association 13, 14

Patients should be admitted to a dedicated stroke unit or ICU, and cardiac monitoring should be performed for at least 24 hours to detect atrial fibrillation, as recommended by the American Heart Association 6, 11
Body temperature should be monitored and treated if fever (>38°C) occurs, as recommended by the American Heart Association 6, 11
Teleradiology systems are recommended for timely review of brain imaging in facilities without in-house expertise, and telestroke evaluations can effectively guide IV alteplase eligibility decisions, as recommended by the American Heart Association 4
DVT prophylaxis with intermittent pneumatic compression devices or low molecular weight heparin should be implemented for patients with limited mobility, as recommended by the American Heart Association 6, 11