Management of Ischemic Stroke

Initial Evaluation and Management

• The American Heart Association recommends immediate neurological evaluation and brain imaging (CT or MRI) to rule out hemorrhage and determine eligibility for reperfusion therapies in patients with suspected acute ischemic stroke 1
• A validated stroke severity scale (such as NIHSS) should be used to assess the severity of neurological deficit, as recommended by the American Stroke Association 1

Reperfusion Therapies

• The American College of Cardiology recommends intravenous rtPA (0.9 mg/kg, maximum 90 mg) administration to eligible patients within 3 hours of stroke onset 1
• Mechanical thrombectomy is recommended for patients with large vessel occlusion within 6-24 hours based on advanced imaging criteria showing salvageable tissue, according to the American Heart Association 4

Blood Pressure Management

• The American Heart Association recommends avoiding antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg in patients not receiving reperfusion therapies 5
• Blood pressure should be lowered to <185/110 mmHg before rtPA treatment, as recommended by the American College of Cardiology 5

Management of Physiological Parameters

• The American Heart Association recommends controlling body temperature, treating sources of fever, and using antipyretics to control elevated temperatures 5
• Glucose management involves monitoring blood glucose regularly and treating hyperglycemia to maintain levels <300 mg/dL, as recommended by the American Diabetes Association 5

Prevention of Complications

• The American College of Chest Physicians recommends deep vein thrombosis prophylaxis using subcutaneous heparin or low molecular weight heparin for immobile patients 6
• Enoxaparin 40 mg once daily is more effective than unfractionated heparin 5000 IU twice daily for DVT prevention, according to the American College of Chest Physicians 6

Rehabilitation and Supportive Care

• The American Heart Association recommends initial assessment by rehabilitation professionals within 48 hours of admission 2
• Rehabilitation therapy should begin as soon as possible once the patient is medically stable, as recommended by the American Stroke Association 2

Surgical Interventions

• The American Heart Association recommends against emergency carotid endarterectomy for most patients with acute ischemic stroke due to high risk 7
• Immediate extracranial-intracranial (EC-IC) arterial bypass is not recommended due to high risk of intracranial hemorrhage, according to the American Stroke Association 7

Common Pitfalls to Avoid

• Delays in recognition and treatment significantly worsen outcomes, with every 30 minutes of delay decreasing the probability of good functional outcome by 8-14%, as reported by the American Heart Association 2
• Overly aggressive blood pressure lowering in patients not receiving thrombolysis can worsen outcomes, according to the American College of Cardiology 5