Initial management of Acute Ischemic Stroke

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Acute ischemic stroke (AIS) is a leading cause of adult disability in the developed world.In AIS, a  thrombus impairs cerebral blood flow, resulting in brain tissue infarction. Collateral blood flow gives  rise  to  an  area  of  hypoperfused  tissue  (ischemic  penumbra)  that  is  at  risk  of  infarction  if  hypoperfusion persists. Prompt reopening of an occluded blood vessel to re-establish blood flow to  the ischemic area (reperfusion) in eligible patients, can rescue the ischemic penumbra from death  and spare the patient from serious long term disabilities.  

Clinical presentation 

  • Severe headache
  • Focal neurological deficits
  • decreased  level  of  consciousness that may progress to coma
  • seizures
  • symptom progression over minutes or hours
  • CT angiogram in potential candidates for reperfusion
  • CT/MR perfusion studies
  • MR angiography (MRA) with
  • DWI for selected patients. (contraindicated with cardiac pacemakers, metal implants)
  • Four-vessel catheter angiography
  • Baseline ECG and ECHO

Prehospital and lower level health facilities 

  • Provide initial airway management and hemodynamic stabilization
  • Exclude stroke mimics like hypoglycemia
  • International stroke guidelines recommend rapid identification of all fibrinolytic-eligible and mechanical thrombectomy-eligible patients to facilitate initiation of treatment in the fastest achievable onset-to-treatment time
  • Consider  prompt  referral  to  a  centre  that  can  handle  stroke  patients  including  rapid neuroimaging and administration of reperfusion therapy.

Referral hospital and specialized centres 

  • Provide initial stabilization of the patient as per ABCDE protocol
  • Perform rapid careful neurological examination.
  • Order emergency brain imaging evaluation before initiating any stroke specific treatments.
  • Screen for reperfusion eligible patients and initiate appropriate treatment protocol.
  • In patients with AIS who awake with stroke symptoms or have unclear time of onset > 4.5 hours  from  last-known-well  (LKW)  state,  perform  brain  MRI  to  identify  diffusion-positive, FLAIR-negative  lesions  to  aid  selecting  those  who  can  benefit  from  IV  alteplase administration.
  • In potential candidates for mechanical thrombectomy, consider imaging of the extracranial carotid and vertebral arteries, in addition to the intracranial circulation, to provide useful information on patient eligibility and endovascular procedural planning.

Reperfusion criteria: all must be met 

  • Onset of stroke or Last known well (LKW) state <4.5hours
  • No increased bleeding risk contraindications
  • Blood pressure controlled to <185/105mmHg target.
  • Non contrast brain CT has excluded intracranial hemorrhage and/or
  • Established a hypodense zone or hyperdense vessel sign.

Non-pharmacological Treatment 

  • Oxygenation—support airway, maintain O2 saturation >94%
  • Monitor BP, if elevated, initiate BP lowering treatment to target BP<185/110 mmHg
  • For patients who are non-eligible for fibrinolysis aim to lower BP by 15% in the first 24 hours
  • Monitor body temperature and initiate treatment when >38°C
  • In  immobile  stroke  patients  without  contraindications,  offer  compressive  stockings,  or pneumatic compression devices for DVT prophylaxis.
  • Start on enteral diet (PO/NGT) within 7days of admission after AIS.

Pharmacological treatment

A: acetylsalicylic acid (PO) 325mg 24hourly for 4weeks 

AND 

C: labetalol (IV) 10-20mg infusion 1-2min, repeated until target BP is attained. 

AND 

D: paracetamol (IV) 1g 8hourly for 3-5days then when required. 

Note: For those treated with alteplase, acetylsalicylic acid administration should be delayed until 24 hours later 

For seizure control: 

C: phenytoin (IV) 15mg/kg loading dose over 30min, then 100mg 8hourly for 4weeks. 

OR 

S: levetiracetam (PO/IV) 500mg 12hourly for 2-4 weeks 

Initiate statins in eligible patients and continue statins in patients already taking statins at the time of onset of AIS.

Reperfusion treatment:In  patients  qualified  for  intravenous  thrombolysis,  benefit  of  therapy  is  time  dependent,  and  treatment should be initiated as quickly as possible. 

Admit the patient to an ICU or designated stroke unit for monitoring and initiate, 

         S: alteplase (IV) 0.9mg/kg maximum dose 90mg (given over 60minutes with initial 10% of dose  given as bolus over 1 minute)  

Important precautions: 

  • Be prepared to treat potential emergent adverse effects, including bleeding complications and angioedema in patients undergoing fibrinolytic therapy.
  • Maintain BP at <180/105mmHg for at least 24 hours following Alteplase infusion.
  • Obtain a follow-up CT or MRI scan at 24 h after IV alteplase before starting anticoagulants or antiplatelet agents.

For management of intracranial hemorrhage complication within 24 hours following thrombolysis:

  • Stop alteplase, obtain an emergent non contrast head CT.
  • Obtain hematology and neurosurgery consultations
  • Provide supportive care and initiate

C: tranexamic acid (IV) 1g infused over 10 minutes. 

AND 

D: cryoprecipitate (includes factor VIII): 10 U infused over 10–30 min 

In  case  of  angioedema  following  Alteplase  infusion,  stop  alteplase  and  provide airway support as required. Give

D: methylprednisolone (IV) 125mg

AND 

A: chlorpheniramine (IV) 10mg stat 

If there is further increase in angioedema, administer 

A: adrenaline (S/C) (0.1%) 0.3 mL or by nebulizer 0.5 mL stat 

Non-pharmacological Treatment 

Mechanical thrombectomy 

  • Consider  for  selected  patients  who  present  between  6  and  16  hours  of  LKW  with  an anterior-circulation  large-vessel  occlusion  (ICA  or  proximal  MCA)  and  meet  other specified eligibility criteria based on expert assessment, clinical judgement, and availability of required resources.

Surgical management of AIS 

  • Consider  decompressive  craniectomy  in  patients  ≤60  years  of  age  who  deteriorate neurologically  within  48  hours  from  brain  swelling  associated  with  unilateral  MCA infarctions despite appropriate medical therapy.
  • Consider external ventricular drainage (EVD) in the treatment of obstructive hydrocephalus following cerebellar infarction.
  • Emergency carotid end arterectomy (CEA) in the acute stage is not well established hence not recommended in initial management of AIS.