Post Ischemic Stroke Management

Immediate Assessment and Diagnosis

The American Heart Association recommends performing non-contrast CT immediately upon arrival to exclude hemorrhagic stroke and determine thrombolysis eligibility 1
The American College of Cardiology suggests obtaining CT angiography from arch-to-vertex for patients arriving within 6 hours who may be candidates for endovascular thrombectomy to identify large vessel occlusions 1
Complete a 12-lead ECG to assess for atrial fibrillation and cardiac arrhythmias, but do not delay thrombolysis assessment, as recommended by the American Heart Association 1
Initiate cardiac monitoring for at least 24 hours to screen for paroxysmal atrial fibrillation, according to the American College of Cardiology 2

The American Heart Association recommends avoiding routine blood pressure lowering unless systolic BP >220 mmHg or diastolic BP >120 mmHg 3, 1
The goal when treating is to lower blood pressure by 15% during the first 24 hours, as suggested by the American Heart Association 3
Maintain strict BP control with target <185/110 mmHg before alteplase administration, according to the American College of Cardiology 1

The American Diabetes Association recommends treating hypoglycemia immediately to achieve normoglycemia 3
Treat persistent hyperglycemia >140 mg/dL, as it is associated with poor outcomes in the first 24 hours, according to the American Heart Association 3

The American College of Cardiology recommends administering oral aspirin 160-325 mg within 24-48 hours after stroke onset for patients not receiving thrombolysis 1
Consider dual antiplatelet therapy (aspirin plus clopidogrel) only for minor noncardioembolic strokes and high-risk transient ischemic attacks, converting to single antiplatelet therapy after 21-90 days, as suggested by the American Heart Association 5

Admit all stroke patients to a geographically defined stroke unit with specialized interdisciplinary staff within 24 hours of hospital arrival, according to the American College of Cardiology 1, 2, 4
Provide airway support and ventilatory assistance for patients with decreased consciousness or bulbar dysfunction, as recommended by the American Heart Association 1

Monitor patients with major hemispheric or cerebellar infarctions closely for signs of brain edema and neurological worsening, according to the American Heart Association 6
Use osmotherapy and hyperventilation for patients deteriorating due to increased intracranial pressure or herniation syndromes, as suggested by the American College of Cardiology 1

Use intermittent pneumatic compression devices for patients who cannot receive anticoagulation, according to the American College of Cardiology 2
Initiate early mobilization when the patient is neurologically stable, as recommended by the American Heart Association 2

Complete a comprehensive diagnostic workup to define ischemic stroke etiology and identify targets for treatment to reduce recurrent stroke risk, according to the American Heart Association 5
Initiate high-intensity statin therapy regardless of baseline cholesterol levels, as suggested by the American College of Cardiology 4
Evaluate for carotid stenosis and perform urgent carotid revascularization (endarterectomy or stenting) within 2 weeks if ≥70% symptomatic stenosis is identified, according to the American College of Cardiology 2, 4

Do not aggressively lower blood pressure in watershed or hemodynamic strokes, as these result from hypoperfusion and require adequate perfusion pressure, according to the American College of Cardiology 2, 4
Avoid routine therapeutic anticoagulation in acute non-cardioembolic stroke, as it increases hemorrhagic risk without proven benefit, as suggested by the American Heart Association 2, 4
Do not use hyperbaric oxygen therapy (except for air embolization), as it may be harmful, according to the American Heart Association 3
Do not use induced hypothermia, as insufficient evidence exists to recommend it for acute stroke treatment, as recommended by the American Heart Association 3