›Consider early percutaneous tracheostomy for anticipated prolonged ventilation
›Facilitates ventilator weaning protocols
›Improves secretion management and oral hygiene
›Timing: typically 7–14 days if no anticipated early extubation
Blood pressure management
›Acute ischemic stroke BP protocol
›Pre-reperfusion (no tPA, no EVT planned)
›Permissive hypertension up to SBP 220 mmHg if neurologically stable
›Avoid aggressive lowering — may worsen posterior circulation ischemia
›Post-tPA administration
›SBP < 180 mmHg, DBP < 105 mmHg for 24 hours
›Labetalol 10–20 mg IV over 1–2 minutes, repeat every 10 minutes (maximum 300 mg)
›Nicardipine infusion 5–15 mg/hr as alternative
›Post-EVT recanalization
›SBP < 140 mmHg target to reduce reperfusion hemorrhage risk
Antiplatelet and anticoagulation therapy
›Secondary prevention antiplatelet therapy
›Aspirin 325 mg loading dose within 24–48 hours of ischemic stroke (after tPA window)
›Followed by aspirin 81 mg daily long-term
›Class I recommendation for non-cardioembolic stroke
›Dual antiplatelet therapy (DAPT) for high-risk TIA or minor stroke
›Aspirin 325 mg plus clopidogrel 300–600 mg loading, then 75 mg daily
›Duration: 21 days for minor stroke (POINT/CHANCE protocol)
›Anticoagulation for cardioembolic source
›Atrial fibrillation confirmed: NOAC preferred over warfarin
›Apixaban 5 mg twice daily (2.5 mg twice daily if two of: age >80, weight <60 kg, creatinine >133 micromol/L)
›Rivaroxaban 20 mg daily with evening meal
›Start timing: typically 2–14 days post-stroke depending on infarct size
›Heparin bridging for high thromboembolic risk with intracardiac thrombus
Neuroprotective and supportive measures
›Glucose management
›Target serum glucose 6.0–10.0 mmol/L
›Avoid both hypoglycaemia and hyperglycaemia in acute brain injury
›Insulin infusion protocol if glucose persistently above 10.0 mmol/L
›Temperature management
›Target normothermia (36.0–37.5 degrees C)
›Fever worsens ischemic injury; treat aggressively
›Acetaminophen 650 mg IV/oral every 4–6 hours for fever
›Induced hypothermia: not currently standard of care in posterior circulation stroke
›Statin therapy
›High-intensity statin initiated acutely regardless of baseline cholesterol
›Atorvastatin 80 mg daily or rosuvastatin 40 mg daily
›Class I recommendation for all ischemic stroke patients
Anxiolytic and emotional support therapy
›Acute emotional distress management
›Patients are fully conscious and aware — may experience terror and panic
›Establish communication immediately (vertical gaze code: up = yes, down = no)
›Explain diagnosis, location, and care plan directly to patient
›Anxiolytic therapy
›Lorazepam 0.5–1 mg IV/sublingual for acute anxiety
›Midazolam 1–2 mg IV cautiously — avoid oversedation masking consciousness
›Antidepressant therapy in chronic LIS
›SSRIs (sertraline 50–100 mg daily) for depression management
›Depression reported in approximately 12.5% of chronic LIS patients
DVT prophylaxis and complication prevention
›Venous thromboembolism prophylaxis
›Enoxaparin 40 mg SC daily when hemorrhagic transformation risk acceptable
›Typically initiated 24–48 hours after ischemic stroke (or after 24-hour post-tPA CT)
›Pneumatic compression devices immediately for all immobilized patients
›IVC filter only if anticoagulation absolutely contraindicated with confirmed DVT
›Nutritional support
›NPO acutely — absent swallow reflex
›Nasogastric tube for early enteral nutrition (within 24–48 hours)
›Percutaneous endoscopic gastrostomy (PEG) for prolonged dysphagia
›Formal swallowing evaluation before any oral feeding trial
›Videofluoroscopic swallow study or FEES
›42% of patients may eventually recover swallow function