Acute Stroke Management
Acute Ischemic Stroke Management
What Do You Need to Know?
- Initial evaluation, stroke code workflow, and stroke mimics
- NIHSS scoring categories, interpretation, and limitations
- IV tPA time windows and landmark trials (NINDS, ECASS III, EXTEND, WAKE-UP)
- tPA dosing, exclusion criteria, and orolingual angioedema
- Mechanical thrombectomy criteria and extended windows (DAWN, DEFUSE 3)
- ASPECTS scoring and TICI grading
- Blood pressure management targets before and after reperfusion therapy
- Complications: hemorrhagic transformation, malignant MCA syndrome, seizures, DVT, aspiration
- Supportive care essentials (aspirin timing, swallow eval, glucose, statins)
Initial Evaluation & Stabilization
- ABCs first → then establish Last Known Well (LKW) time — the single most critical piece of information for treatment decisions
- “Onset time” = when the patient was LAST SEEN NORMAL — NOT when found with deficits
- Wake-up stroke: LKW = when last seen normal before sleep
Stroke Code Rapid Assessment
- Activate stroke code immediately upon suspicion
- Perform NIHSS at bedside
- Stat NCCT head — rule out hemorrhage before tPA
- Establish IV access, draw labs, obtain blood glucose
- Goal: door-to-CT <25 min; door-to-needle <60 min
Stroke Mimics
- Seizure with Todd’s paralysis: Witnessed seizure activity; resolves within 24 hours
- Hypoglycemia: Check glucose immediately; focal deficits resolve with correction
- Complicated migraine: Gradual onset “marching” symptoms; headache follows
- Conversion disorder: Inconsistent exam, doesn’t follow vascular territory; Hoover’s sign
💎 Board Pearl
The ONLY tests required before giving tPA are NCCT head (rule out hemorrhage) and blood glucose. Do NOT delay tPA for any other lab results unless clinical suspicion of coagulopathy.
NIH Stroke Scale (NIHSS)
Standardized stroke severity scale. Total range: 0–42.
| Item | Category | Score |
|---|---|---|
| 1a | Level of Consciousness | 0–3 |
| 1b | LOC Questions (month, age) | 0–2 |
| 1c | LOC Commands (open/close eyes, grip/release) | 0–2 |
| 2 | Best Gaze | 0–2 |
| 3 | Visual Fields | 0–3 |
| 4 | Facial Palsy | 0–3 |
| 5a/5b | Motor Arm (L/R) — hold 90° for 10 sec | 0–4 each |
| 6a/6b | Motor Leg (L/R) — hold 30° for 5 sec | 0–4 each |
| 7 | Limb Ataxia | 0–2 |
| 8 | Sensory | 0–2 |
| 9 | Best Language | 0–3 |
| 10 | Dysarthria | 0–2 |
| 11 | Extinction/Inattention | 0–2 |
Score Interpretation
- 0: No stroke symptoms
- 1–4: Minor stroke
- 5–15: Moderate stroke
- 16–20: Moderate-to-severe stroke
- 21–42: Severe stroke
- NIHSS ≥6 is generally the threshold for thrombectomy eligibility
💎 Board Pearl
NIHSS is biased toward anterior/left hemisphere strokes. It heavily weights language and right-sided motor deficits. Posterior circulation strokes (vertigo, ataxia, diplopia) may score very low despite life-threatening deficits.
IV Thrombolysis (tPA / Alteplase)
Time Windows & Evidence
- <3 hours (NINDS, 1995): FDA-approved. 16% absolute increase in favorable outcomes. NNT ~8. Standard of care — no informed consent required
- 3–4.5 hours (ECASS III, 2008): AHA/ASA recommended (Class I) but NOT FDA-approved. Additional exclusions: age >80, NIHSS >25, oral anticoagulant use, history of BOTH diabetes AND prior stroke
- Up to 9 hours (EXTEND trial): Showed benefit using perfusion imaging selection (penumbral mismatch), but with increased risk of symptomatic ICH
- Wake-up strokes (WAKE-UP trial): DWI-FLAIR mismatch (DWI+ / FLAIR−) identifies patients with unknown onset who benefit from tPA
Dosing
- 0.9 mg/kg (max 90 mg total)
- 10% as IV bolus over 1 minute, remaining 90% infused over 60 minutes
Absolute Exclusion Criteria (<3 Hours)
- Significant head trauma or prior stroke in past 3 months
- Symptoms suggestive of SAH
- Arterial puncture at noncompressible site within 7 days
- History of previous intracranial hemorrhage
- Intracranial neoplasm, AVM, or aneurysm
- Recent intracranial or intraspinal surgery
- BP >185/110 that cannot be lowered
- Active internal bleeding
- Platelet count <100,000
- Heparin within 48 hours with elevated aPTT
- INR >1.7 or PT >15 seconds
- DOAC use with elevated lab tests
- Blood glucose <50 mg/dL
- CT showing multilobar infarction (>1/3 hemisphere)
Relative Contraindications
- Minor or rapidly improving symptoms
- Pregnancy
- Seizure at onset with postictal neurological impairments
- Major surgery or serious trauma within 14 days
- Recent GI or GU hemorrhage (within 21 days)
Orolingual Angioedema
- Occurs in 1.3–5.1% of patients; increased risk with ACE inhibitors
- Contralateral to the ischemic hemisphere
- Management: stop infusion if severe, epinephrine, antihistamines, airway management
💎 Board Pearl
tPA is only FDA-approved for <3h (NINDS). The 3–4.5h window (ECASS III) is AHA-recommended but NOT FDA-approved. Tenecteplase (TNK) is emerging as a potential alternative with single-bolus dosing and possibly superior efficacy in LVO.
Mechanical Thrombectomy
Five landmark trials in 2015 (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT) all proved benefit of endovascular thrombectomy with stent retrievers for LVO in the anterior circulation.
Standard Criteria (0–6 Hours)
- Prestroke mRS 0–1 (functionally independent)
- Causative occlusion of ICA or proximal MCA (M1)
- NIHSS ≥6
- ASPECTS ≥6 on NCCT (small infarct core)
- Groin puncture achievable within 6 hours of onset
- Does NOT replace IV tPA — give tPA first if eligible (“bridging therapy”)
Extended Windows (6–24 Hours)
- DAWN trial (2018): Thrombectomy up to 24 hours — clinical-imaging mismatch selection (high NIHSS with small infarct core on CTP/DWI). NNT ~2.8. Stopped early for overwhelming efficacy
- DEFUSE 3 trial (2018): Thrombectomy 6–16 hours — perfusion mismatch selection (core <70 mL, mismatch ratio ≥1.8, mismatch volume ≥15 mL)
- Both trials proved “tissue-based” rather than “time-based” selection — advanced imaging (CTP or MRI perfusion) is REQUIRED in extended windows
Key Terms
- ASPECTS: 10-point CT score for MCA territory. Subtract 1 point per region with early ischemic changes. ≥6 = good candidate; <6 = large core, poor candidate
- TICI scale: 0 = no perfusion; 2b = ≥2/3 territory reperfused; 3 = complete perfusion. Goal = TICI 2b/3
💎 Board Pearl
Thrombectomy = LVO only (ICA or M1 MCA). ASPECTS ≥6 + NIHSS ≥6 within 6h. DAWN extended to 24h, DEFUSE 3 to 16h — both require perfusion imaging showing small core with large mismatch. Without mismatch on imaging, extended windows do NOT apply.
Blood Pressure Management
| Scenario | BP Target |
|---|---|
| Not a tPA candidate | Permissive hypertension up to 220/120; treat only if above |
| Before tPA | Must lower to <185/110 before administering |
| After tPA (first 24h) | Maintain <180/105 |
| Post-thrombectomy | Same as post-tPA (<180/105) |
Agents
- Labetalol: 10–20 mg IV bolus, may repeat; avoid in asthma/bradycardia
- Nicardipine: 5 mg/hr IV infusion, titrate by 2.5 mg/hr q5–15 min (max 15 mg/hr) — preferred for precise BP control
- Clevidipine: Ultra-short-acting CCB; rapid onset/offset
💎 Board Pearl
BP >185/110 is a CONTRAINDICATION to tPA — lower it first. After tPA, maintain <180/105 for 24h. In non-tPA patients, do NOT lower BP aggressively — the penumbra depends on pressure-dependent collateral perfusion.
Complications of Acute Ischemic Stroke
Hemorrhagic Transformation
- Symptomatic ICH: ~6% with tPA vs ~0.6% placebo
- Risk factors: Large infarct, high NIHSS, hyperglycemia, advanced age, elevated BP
- If patient deteriorates during/after tPA:
- Stop tPA immediately
- Stat NCCT head
- Check fibrinogen → give cryoprecipitate (10 units) if fibrinogen <200 mg/dL
- Consider tranexamic acid or aminocaproic acid
Cerebral Edema & Malignant MCA Syndrome
- Edema peaks at 3–5 days after onset
- Younger patients (<60) are at higher risk — less atrophy, less room for swelling
- Decompressive hemicraniectomy (DECIMAL, DESTINY, HAMLET trials): Indicated in patients <60 years within 48 hours. Reduces mortality from ~78% to ~29%, but may increase survival with moderate-to-severe disability (mRS 4) — requires goals-of-care discussion
- Medical management: HOB 30°, osmotic therapy (mannitol, hypertonic saline), avoid hyperthermia and hyperglycemia
Other Complications
- Seizures: Early seizures in ~5%; more common with cortical involvement. Treat acute seizures but do NOT use prophylactic antiepileptics
- DVT/PE: Start IPC devices immediately; pharmacologic prophylaxis after 24–48h if no hemorrhage
- Aspiration pneumonia: Leading cause of subacute death — swallow evaluation before any oral intake
💎 Board Pearl
If deterioration during tPA: stop infusion, stat CT, check fibrinogen, give cryoprecipitate if <200. Do NOT use prophylactic antiepileptics after stroke. Decompressive hemicraniectomy in patients <60 reduces mortality but increases survival with disability.
Supportive Care
- Aspirin 160–325 mg within 24–48 hours for ALL ischemic stroke patients. If tPA given, wait 24 hours before starting (confirm no ICH on follow-up imaging)
- Swallow evaluation: NPO until bedside screen completed — aspiration pneumonia is the leading cause of post-stroke mortality
- DVT prophylaxis: IPC devices immediately; subcutaneous heparin/LMWH after 24–48 hours (IPC preferred over compression stockings — CLOTS 3 trial)
- Glucose: Target 140–180 mg/dL. Hyperglycemia worsens outcomes; treat hypoglycemia aggressively
- Temperature: Treat fever (≥38°C) aggressively — independent predictor of worse outcomes
- Statin: High-intensity statin for atherosclerotic stroke regardless of LDL; do NOT stop statins in the acute phase (rebound effect)
- Rehabilitation: Initiate early once medically stable (PT, OT, speech)
💎 Board Pearl
Aspirin within 24–48h for all ischemic strokes (wait 24h if tPA given). Swallow eval before oral intake. Do NOT stop statins acutely.
References
- National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581-1587.
- Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke (ECASS III). N Engl J Med. 2008;359(13):1317-1329.
- Ma H, Campbell BCV, Parsons MW, et al. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke (EXTEND). N Engl J Med. 2019;380(19):1795-1803.
- Thomalla G, Simonsen CZ, Boutitie F, et al. MRI-guided thrombolysis for stroke with unknown time of onset (WAKE-UP). N Engl J Med. 2018;379(7):611-622.
- Berkhemer OA, Fransen PSS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke (MR CLEAN). N Engl J Med. 2015;372(1):11-20.
- Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct (DAWN). N Engl J Med. 2018;378(1):11-21.
- Albers GW, Marks MP, Kemp S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging (DEFUSE 3). N Engl J Med. 2018;378(8):708-718.
- Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis (DECIMAL, DESTINY, HAMLET). Lancet Neurol. 2007;6(3):215-222.
- Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update. Stroke. 2019;50(12):e344-e418.