Acute Stroke Management Guidelines

Initial Assessment and Treatment

The American Heart Association recommends that all patients with suspected stroke should undergo ECG to assess baseline cardiac rhythm, though this should not delay assessment for thrombolysis 1

The American College of Cardiology recommends that eligible patients should receive intravenous alteplase (rtPA) as soon as possible after hospital arrival, with a target door-to-needle time of less than 60 minutes in 90% of treated patients 2, 3
Standard dosing for alteplase is 0.9 mg/kg to a maximum of 90 mg total dose, with 10% given as an intravenous bolus over one minute and the remaining 90% given as an intravenous infusion over 60 minutes 2, 3
Blood pressure must be controlled below 185/110 mmHg before rtPA administration and maintained below 180/105 mmHg for at least 24 hours after treatment 4, 5

The American Stroke Association recommends that EVT is indicated for patients with large vessel occlusions, including those who have received intravenous alteplase and those who are not eligible for intravenous alteplase 3
EVT should be offered within a coordinated system of care including rapid access to neurovascular imaging and specialized neurointerventional expertise 3

The American Heart Association recommends that for patients not receiving thrombolysis with markedly elevated blood pressure, a reasonable goal is to lower blood pressure by 15% during the first 24 hours, and medications should be withheld unless systolic blood pressure is >220 mmHg or diastolic blood pressure is >120 mmHg 4, 5
Airway support and ventilatory assistance are recommended for patients with decreased consciousness or bulbar dysfunction, and supplemental oxygen should be provided to maintain oxygen saturation >94% 4, 5
Sources of hyperthermia (temperature >38°C) should be identified and treated, and hypovolemia should be corrected with intravenous normal saline 4, 5
Hypoglycemia (blood glucose <60 mg/dL) should be treated, with a goal to achieve normoglycemia, and hyperglycemia should be treated to achieve blood glucose levels in a range of 140 to 180 mg/dL 4, 5

The American College of Cardiology recommends urgent neuroimaging to differentiate between ischemic and hemorrhagic stroke, with non-contrast CT (NCCT) as the primary imaging modality and CT angiography (CTA) to identify large vessel occlusions (LVOs) 6, 7
Intravenous recombinant tissue plasminogen activator (rtPA/alteplase) is strongly recommended for eligible patients within 3 hours of stroke onset, with treatment beyond 3 hours but within 4.5 hours considered in selected patients 8, 6
Blood pressure should be lowered and maintained below 185/110 mmHg before rtPA administration and below 180/105 mmHg for 24 hours after treatment, with very high blood pressure (>185/110 mmHg) treated in patients eligible for thrombolytic therapy 9
Oral aspirin (325 mg initial dose) is recommended within 24-48 hours after stroke onset for patients not receiving thrombolysis, with aspirin not administered within 24 hours of rtPA treatment 8, 10, 11, 12
Endovascular thrombectomy (EVT) is recommended for eligible patients with large vessel occlusions, with CTA performed to identify patients who may benefit from EVT 7, 9

Surgical decompression and evacuation of large cerebellar infarctions causing brain stem compression and hydrocephalus is recommended, with surgical interventions used to treat increased intracranial pressure secondary to hydrocephalus 13
Osmotherapy and hyperventilation are recommended for patients deteriorating due to increased intracranial pressure, with corticosteroids not recommended for managing cerebral edema and increased intracranial pressure following ischemic stroke 13

Comprehensive stroke unit care with specialized rehabilitation should be initiated as early as medically possible, with early mobilization strongly recommended to prevent complications 14
Management of modifiable risk factors including blood pressure and cholesterol is essential, with appropriate antithrombotic therapy prescribed based on stroke etiology 14