Acute Ischemic Stroke Management

Immediate Emergency Management

The American College of Cardiology recommends administering intravenous tissue plasminogen activator (tPA) at 0.9 mg/kg (maximum 90 mg) if the patient presents within 3 hours of symptom onset and has no contraindications, followed by comprehensive stroke unit care, early rehabilitation, and aggressive secondary prevention to reduce mortality and improve functional outcomes 1, 2
Document the precise time of symptom onset as this determines eligibility for reperfusion therapies—this is the single most critical piece of information 1, 2
Perform rapid CT imaging immediately to confirm ischemic stroke and rule out hemorrhage before initiating any treatment 1, 2
Assess stroke severity using the NIH Stroke Scale to guide treatment decisions and prognosis 1
Stabilize airway, breathing, and circulation, particularly in seriously ill or comatose patients 1
Administer IV tPA 0.9 mg/kg (maximum 90 mg) if no contraindications exist, which is a Class I recommendation with the strongest evidence for reducing mortality and disability 1, 2
Consider IV thrombolysis in eligible patients without extended contraindications presenting within 3-4.5 hours 2
Consider mechanical thrombectomy if within appropriate time window, which can extend beyond the thrombolysis window in selected patients 2

Maintain blood pressure <180/105 mmHg for at least 24 hours after thrombolysis to prevent hemorrhagic transformation 1, 2
Cautiously lower elevated blood pressure, avoiding aggressive reduction in the acute phase if no thrombolysis is administered 1, 2
Target systolic blood pressure 130-150 mmHg for hemorrhagic stroke 2

Administer aspirin 160-300 mg within 48 hours of stroke onset 1, 2
Delay aspirin for 24 hours if thrombolysis was given to reduce bleeding risk 1
Transfer all patients to a comprehensive stroke unit regardless of stroke severity—this intervention alone reduces mortality and improves functional outcomes 1, 2
Implement early swallowing assessment before allowing any oral intake to prevent aspiration pneumonia 1
Use nasogastric or nasoduodenal tube feeding to maintain nutrition for patients with impaired swallowing 1
Aggressively monitor for and treat pneumonia, urinary tract infections, and deep vein thrombosis 1
Watch for cerebral edema (peaks at 3-5 days but can occur earlier with large infarctions) 1
Monitor for seizures and hemorrhagic transformation 1

Initiate statin therapy regardless of baseline cholesterol levels, which is a Class I recommendation 1, 2, 3
Start antihypertensive therapy 24-48 hours post-stroke 1, 2, 3
Consider anticoagulation after ruling out hemorrhagic transformation for patients with atrial fibrillation 1, 2
Consider carotid endarterectomy within 2 weeks for symptomatic carotid stenosis >70% 2

Begin early mobilization as soon as the patient is medically stable 1, 2
Initiate physical, occupational, and speech therapy assessments immediately 2
Assess for cognitive deficits and provide cognitive retraining for attention deficits, visual neglect, memory deficits, and executive function problems 3
Implement compensatory strategies for memory deficits in patients with mild short-term memory impairments 3
Use subcutaneous anticoagulants, intermittent external compression stockings, or aspirin to prevent deep vein thrombosis in immobilized patients 1
Implement measures to prevent aspiration, malnutrition, pulmonary embolism, and pressure sores 1

For cerebral venous thrombosis (CVT), initiate anticoagulation with IV heparin or subcutaneous LMWH even if intracranial hemorrhage is present—hemorrhage from CVT is NOT a contraindication 4
Continue oral anticoagulation for 3-12 months depending on underlying etiology for CVT 4
Treat extracranial cervical artery dissection in children with UFH or LMWH as a bridge to oral anticoagulation 5
Treat with subcutaneous LMWH or warfarin for 3-6 months (target INR 2.0-3.0) for pediatric stroke (cervical artery dissection) 5
Consider hyperbaric oxygen therapy (100% oxygen over 9 hours) for retinal artery occlusion, which has demonstrated efficacy in small randomized trials 6
Administer corticosteroids immediately for giant cell arteritis-related retinal artery occlusion 6
Perform thorough cardiac evaluation including ECG monitoring for at least 24 hours to detect atrial fibrillation for multifocal ischemic CVA 1
Consider advanced vascular imaging to identify potential embolic sources for multifocal ischemic CVA 1
Screen aggressively for vascular risk factors including hypertension, diabetes mellitus, and hypercholesterolemia for multifocal ischemic CVA 3

Never delay imaging to obtain detailed history—time is brain 1, 2
Never withhold anticoagulation in cerebral venous thrombosis even if hemorrhage is present—this is a common and dangerous misconception 4
Never aggressively lower blood pressure in acute ischemic stroke unless thrombolysis is given—this can worsen outcomes 1, 2
Never allow oral intake before swallowing assessment—aspiration pneumonia significantly increases mortality 1
Never assume older patients should not be referred for acute stroke evaluation—age alone should not determine treatment eligibility 6, 1