Acute Ischemic Stroke Management

Initial Assessment and Imaging

• The American Heart Association recommends providing advance notice to the emergency department when transporting a patient with suspected acute ischemic stroke, and the optimal imaging protocol should include non-contrast CT to rule out hemorrhage and estimate the ischemic core, and multifaceted CT angiography to detect and localize the occlusion, estimate risks and benefits of treatment, as recommended by the American College of Cardiology 1, 2
• Urgent brain imaging (CT or MRI) and non-invasive vascular imaging (CTA or MRA from arch to vertex) should be completed without delay for patients with recurrent TIAs, according to the International Journal of Stroke guidelines 3
• Rapid neuroimaging is crucial to rule out intracranial hemorrhage, identify vessel occlusion location, and assess risk/benefit ratio for treatment, according to the American College of Cardiology 2
• Non-contrast CT (NCCT) is preferred due to time efficiency, wide availability, and ability to exclude hemorrhage, as recommended by the American College of Cardiology 2
• CT angiography (CTA) should be performed to identify vessel occlusions, particularly large vessel occlusions (LVOs), as suggested by the American College of Cardiology 2

Occlusion Classification and Treatment

• Occlusion of the Middle Cerebral Artery (MCA) can result in severe neurological deficit with high NIHSS scores (median 17) for M1 occlusions, and moderate deficit for M2 occlusions, which can affect specific functions depending on the affected branch 4
• Occlusion of the Internal Carotid Artery (ICA) can result in severe neurological deficit, often combined with M1 occlusion (27% of cases) 4
• Occlusion of the Posterior Circulation requires evaluation with CT angiography or MR angiography, as Doppler ultrasound is not useful 5
• Recanalization (TICI 2b/3) can be achieved in 59-81.5% of cases with thrombectomy 4
• The benefit of thrombectomy decreases significantly with time, and is no longer statistically significant if reperfusion occurs after 6 hours and 19 minutes 4

Treatment Outcomes and Timing

• Expansion of the hematoma is predictive of clinical deterioration and increased morbidity and mortality 1
• Patients presenting with symptoms of stroke after recurrent transient ischemic attacks (TIAs) should be immediately sent to an emergency department with capacity for advanced stroke care, as recommended by the International Journal of Stroke guidelines 3
• A history of recurrent TIAs may indicate unstable cerebrovascular disease with high risk of stroke recurrence (up to 10% within the first week), as reported by the International Journal of Stroke 3
• Patients with recurrent TIAs who develop stroke should be considered high-risk patients requiring aggressive secondary prevention measures, as stated by the International Journal of Stroke guidelines 3

Thrombolysis and Endovascular Therapy

• The recommended loading dose of alteplase for acute ischemic stroke is 0.9 mg/kg with a maximum dose of 90 mg, administered as a 10% bolus over one minute followed by the remaining 90% as an intravenous infusion over 60 minutes, as supported by the Canadian Stroke Best Practice Recommendations and the American Heart Association/American Stroke Association Guidelines 6, 7
• Treatment with alteplase should be initiated within 3 hours of symptom onset for the strongest evidence, and within 3-4.5 hours for eligible patients, as recommended by the American Heart Association/American Stroke Association 7
• Contraindications for tPA administration include:

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• Endovascular therapy is indicated for patients with proximal large vessel occlusions and can be performed within 6 hours of symptom onset, as recommended by the American Heart Association 6, 4
• Mechanical thrombectomy is the preferred option for endovascular therapy, and can be performed up to 24 hours in selected patients based on imaging criteria, as stated by the American Heart Association/American Stroke Association 7

Blood Pressure Management and Antiplatelet Therapy

• The American Heart Association recommends maintaining blood pressure below 185/110 mmHg as per guidelines 9
• Blood pressure must be <185/110 mmHg before initiation of thrombolysis, and antihypertensive medications should be administered to maintain BP below 180/105 mmHg during and for 24 hours after treatment, as recommended by the American Heart Association 7, 10, 5, 11
• Aspirin 160-325 mg should be given within 24-48 hours after stroke onset, but delayed for 24 hours in patients treated with intravenous alteplase, as recommended by the American College of Cardiology and the American Heart Association 11, 5, 7, 12, 13
• Antiplatelet agents, such as aspirin, should be delayed until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage in patients treated with alteplase, as recommended by the American College of Cardiology 6, 3
• Long-term antiplatelet therapy is indicated, with options including aspirin 75-100 mg daily, clopidogrel 75 mg daily, or aspirin/extended-release dipyridamole 25/200 mg twice daily, as recommended by the American College of Chest Physicians 10, 11, 14

Prevention of Venous Thromboembolism and Other Complications

• Prophylactic-dose subcutaneous heparin (preferably LMWH) should be started between days 2-4 for patients with restricted mobility, as recommended by the American College of Chest Physicians and the American Heart Association 11, 15
• Intermittent pneumatic compression devices can be used as an alternative to prophylactic-dose subcutaneous heparin for patients with restricted mobility, as recommended by the American College of Chest Physicians 11, 12
• Elastic compression stockings should be avoided (Grade 2B), as recommended by the American College of Chest Physicians 11
• Early mobilization and adequate hydration should be encouraged for all acute stroke patients to help prevent VTE, as recommended by the American Heart Association 6

Monitoring and Management of Complications

• Neurological assessments should be performed every 15 minutes during infusion and for 2 hours, then every 30 minutes for the next 6 hours, and hourly until 24 hours after treatment, as recommended by the American Heart Association 5, 11, 8, 3
• Angioedema should be managed with a staged response using antihistamines, glucocorticoids, and standard airway management, as recommended by the American Heart Association 6
• Bleeding should be managed with an individualized approach, as there is insufficient evidence for the routine use of blood products, as recommended by the American Heart Association 6