›Neurologic checks every 15 minutes for 2 hours, then hourly for 22 hours
›BP under 180/105 mmHg for 24 hours post-infusion
›No antiplatelet or anticoagulant agents for 24 hours post-thrombolysis
›Repeat NCCT at 24 hours before initiating antithrombotics
Mechanical thrombectomy (EVT)
›Standard window (0–6 hours) — Class IA recommendation
›NIHSS 6 or greater, confirmed LVO (ICA or M1 occlusion), ASPECTS 6 or greater
›Pre-stroke mRS 0–1
›Age 18 or older (benefit in older adults confirmed; no upper age limit)
›Target: door-to-groin puncture under 90 minutes (direct) or under 60 minutes (transfer)
›Extended window (6–24 hours) — Class IA recommendation (DAWN/DEFUSE-3 criteria)
›DAWN criteria: clinical-core volume mismatch (age-stratified thresholds)
›Age 80 or older: NIHSS 10 or greater, core under 21 mL
›Age under 80: NIHSS 10 or greater, core under 31 mL
›DEFUSE-3 criteria: core under 70 mL, mismatch ratio 1.8 or greater
›CTP or DWI required for patient selection in this window
›Large core infarction (ASPECTS 3–5) — emerging indication
›ANGEL-ASPECT trial: EVT beneficial within 6–24 hours for core under 100 mL
›RESCUE-Japan LIMIT trial: EVT within 6 hours for core 70–100 mL
›Individualized decision; neurology-neurointerventional shared decision making
›Basilar artery occlusion thrombectomy
›Time window flexible (benefit beyond 24 hours reported)
›NIHSS under 10 at presentation does not exclude benefit
›High mortality without recanalization (greater than 85%); aggressive treatment warranted
›Thrombectomy technique options
›Stent retriever (Solitaire, Trevo): Class IA for M1 and ICA terminus occlusions
›Aspiration (direct contact aspiration, Penumbra): equivalent outcomes to stent retriever
›Combined technique (SAVE technique): improved first-pass recanalization rate
›General vs. conscious sedation: conscious sedation associated with better outcomes in most trials
Blood pressure management (detailed)
›Pre-thrombolysis BP lowering agents
›Labetalol 10–20 mg IV over 1–2 minutes; may repeat once (max 40 mg)
›Nicardipine infusion 5 mg/hour; titrate by 2.5 mg/hour every 5–15 minutes; max 15 mg/hour
›Clevidipine infusion 1–2 mg/hour; double every 2–5 minutes; max 21 mg/hour
›Hydralazine 10–20 mg IV as alternative; less titratable
›Post-reperfusion BP targets
›Post-thrombolysis: SBP under 180 mmHg for 24 hours
›Post-thrombectomy (successful recanalization): SBP under 180/105 mmHg; avoid below 120 mmHg
›Post-thrombectomy (failed recanalization): permissive hypertension up to 180 mmHg acceptable
›No active reperfusion: BP below 220/120 mmHg sufficient; avoid aggressive lowering
Antithrombotic therapy (post-acute)
›Aspirin 325 mg orally
›Start 24 hours after thrombolysis (after repeat NCCT excludes hemorrhage)
›Start within 24–48 hours if no thrombolysis given
›AHA/ASA Class IA recommendation for non-cardioembolic stroke
›High-intensity statin therapy
›Atorvastatin 40–80 mg daily or rosuvastatin 20–40 mg daily
›Initiate in acute phase; LDL target under 1.8 mmol/l for atherosclerotic etiology
›Anticoagulation for cardioembolic etiology (AF)
›DOAC (apixaban, rivaroxaban, dabigatran, edoxaban) preferred over warfarin
›Timing: minor stroke — start DOAC at 1–3 days; moderate — 3–7 days; large — 7–14 days
›Hemorrhagic transformation must be excluded before initiation
›Dual antiplatelet therapy (DAPT) for non-cardioembolic stroke
›Aspirin 81 mg plus clopidogrel 75 mg for 21 days (POINT trial)
›Indicated for minor noncardioembolic stroke (NIHSS under 5) or high-risk TIA
›Then single antiplatelet agent long-term
Neuroprotective and supportive care
›Glycemic control
›Target glucose 7.8–10.0 mmol/l in acute stroke
›Avoid hypoglycemia (worsens ischemia) and hyperglycemia (worsens infarct expansion)
›Insulin infusion for persistent hyperglycemia above 10.0 mmol/l
›Temperature management
›Normothermia target (under 37.5 C)
›Acetaminophen 650–1000 mg q4–6 hours for fever
›Treat underlying infection if fever source identified
›DVT prophylaxis
›Sequential compression devices immediately
›Pharmacologic prophylaxis (enoxaparin 40 mg SC daily) when bleeding risk acceptable
›Typically 24–48 hours post-thrombectomy if no hemorrhagic conversion
›24 hours post-thrombolysis for minor stroke without hemorrhagic conversion
›Dysphagia management
›NPO until formal swallow evaluation completed (standardized bedside or VFSS)
›Aspiration risk high in dominant hemisphere and brainstem strokes
›NG tube feeding if swallow unsafe; PEG if prolonged dysphagia expected
›Osmotherapy for malignant cerebral edema
›Mannitol 0.5–1 g/kg IV over 20 minutes; may repeat every 4–6 hours (maintain serum osmolality under 320 mOsm/l)
›Hypertonic saline 23.4% 30–60 mL via central line for refractory ICP
›Head of bed elevation to 30 degrees; avoid hypercarbia
›Seizure management
›Prophylactic antiepileptics not recommended for AIS
›Treat clinical or EEG-confirmed seizures with levetiracetam (preferred) or lacosamide