Acute Ischemic Stroke Management

Initial Assessment and Treatment

Acute ischemic stroke should be treated as a medical emergency with intravenous recombinant tissue plasminogen activator (rtPA/alteplase) administered within 3 hours of symptom onset, followed by endovascular therapy for eligible patients with large vessel occlusions, as recommended by the American College of Cardiology and American Heart Association 1, 2
The primary therapeutic window for rtPA administration is 0-3 hours from symptom onset, with the strongest evidence being Class I, Level A, and the extended window is 3-4.5 hours for selected patients without contraindications 1, 2
Blood pressure should be maintained <185/110 mmHg before treatment for rtPA candidates, and cautious lowering of severely elevated BP for non-rtPA candidates, as recommended by the American Stroke Association and American Heart Association 2, 1

Cautious lowering of blood pressure is recommended only if it is extremely elevated (>220/120 mmHg) in non-rtPA candidates, and precipitous blood pressure reduction should be avoided, as recommended by the American College of Cardiology and American Stroke Association 1, 2
Permissive hypertension is generally allowed unless BP is extremely elevated, and avoid aggressive BP lowering, which may worsen cerebral perfusion, as suggested by the American Stroke Association 2
Labetalol or nicardipine can be used for blood pressure control, as recommended by the American Stroke Association 2

Endovascular therapy should be considered for patients with large vessel occlusion (ICA or proximal MCA) within 6 hours of symptom onset, as recommended by the American Stroke Association and American Heart Association 3, 1
Stent retrievers are the preferred mechanical thrombectomy device, and a combined approach using stent-retrievers and aspiration techniques is optimal, as suggested by the American Stroke Association and American Heart Association 3, 1
Endovascular therapy should not be delayed to observe for clinical response to IV rtPA, as recommended by the American Stroke Association 3

Aspirin (325 mg) should be administered within 24-48 hours after stroke onset for patients not receiving thrombolysis, and delayed for 24 hours for patients receiving rtPA, as recommended by the American Stroke Association and American Heart Association 2, 1
Urgent anticoagulation is not recommended for improving outcomes or preventing early recurrent stroke, but prophylactic low-dose subcutaneous heparin or LMWH is recommended for patients with restricted mobility to prevent DVT, as recommended by the American Heart Association and American Stroke Association 4, 1

Urgent neuroimaging (CT scan) should be performed to rule out hemorrhage, and follow-up CT or MRI should be obtained at 24 hours before starting anticoagulants or antiplatelets, as recommended by the American Heart Association and American Stroke Association 1, 2
MRI showing DWI/FLAIR mismatch may be beneficial in determining eligibility for alteplase in patients with unknown symptom onset, as suggested by the American Stroke Association 2, 5

Patients should be transported rapidly to the closest certified primary stroke center or comprehensive stroke center, and regional systems of stroke care should be developed to facilitate rapid treatment, as recommended by the American Stroke Association and American Heart Association 3, 1
Time is brain: each 30-minute delay reduces the probability of a favorable outcome by 10.6%, as suggested by the American Stroke Association and American Heart Association 2, 1
Centers providing initial emergency care should develop capability for emergency vascular imaging, as recommended by the American Stroke Association 3

Blood pressure and neurological evaluation should be monitored every 15 minutes during infusion and 2 hours after, then every 30 minutes for 6 hours, and hourly thereafter until 24 hours, as recommended by the American Stroke Association 2
Angioedema occurs in 1.3-5.1% of patients and should be monitored, with treatment including ranitidina IV, difenhidramina, and metilprednisolona, as suggested by the American Stroke Association 2
Deviations from the treatment protocol are associated with a higher risk of symptomatic intracranial hemorrhage and death, as suggested by the American College of Cardiology 6