Acute Reperfusion Therapy
› IV thrombolysis
› IV alteplase (0.9 mg/kg, maximum 90 mg) within 4.5 hours of onset
› 10% of dose as IV bolus over 1 minute
› Remaining 90% as IV infusion over 60 minutes
› Hold antiplatelet and anticoagulant therapy for 24 hours post-alteplase
› Extended window alteplase (EXPECTS trial, 2025)
› 4.5-24 hours for posterior circulation ischemic stroke [14]
› 89.6% functional independence at 90 days vs 72.6% with standard care [14]
› Requires DWI-clinical mismatch confirmation
› Tenecteplase (0.25 mg/kg IV bolus, maximum 25 mg)
› FDA-approved for acute ischemic stroke [15]
› Single bolus administration; increasing use in posterior circulation [15-16]
› Standard thrombolysis contraindications apply
› Contraindications
› Intracranial hemorrhage on CT
› BP >185/110 mmHg that cannot be controlled
› Recent surgery, trauma, or intracranial procedure
› Active bleeding or coagulopathy
› Avoid if intracranial extension of VA dissection (risk of SAH) [20]
› Endovascular intervention
› Selected patients with VA or basilar occlusion within 6 hours of onset [31]
› Large vessel occlusion on CTA/MRA required for candidacy
› NIHSS underrepresents severity: low NIHSS does not exclude from consideration
› Extended window decisions individualized based on imaging penumbra
› Secondary prevention antithrombotics
› Vertebral artery dissection: AHA 2024 scientific statement [18]
› Antiplatelet therapy (aspirin 81-325 mg/day) or anticoagulation for 3-6 months
› Choice between antiplatelet and anticoagulation is individualized (CADISS trial showed no significant difference)
› Avoid anticoagulation if intracranial extension of dissection (SAH risk) [20]
› Atherosclerotic LMI: dual antiplatelet therapy (DAPT)
› Aspirin 325 mg loading dose then 81 mg/day
› Clopidogrel 300-600 mg loading dose then 75 mg/day
› DAPT duration: 21-90 days, then single antiplatelet [17]
› Cardioembolic (atrial fibrillation): anticoagulation per AF guidelines
› Direct oral anticoagulants preferred over warfarin for non-valvular AF
› Initiate after exclusion of hemorrhagic transformation (typically 48-72 hours post-stroke)
Blood Pressure Management
› Target blood pressure by phase
› Pre-thrombolysis: lower to <185/110 mmHg using labetalol or nicardipine
› Labetalol 10-20 mg IV over 1-2 minutes, may repeat every 10-20 minutes
› Nicardipine 5 mg/hour IV infusion, titrate by 2.5 mg/hour every 5-15 minutes, maximum 15 mg/hour
› Post-thrombolysis (first 24 hours): maintain <180/105 mmHg
› No thrombolysis: do not lower BP unless >220/120 mmHg (permissive hypertension)
› Long-term target: <130/80 mmHg for secondary stroke prevention
› High-intensity statin
› Atorvastatin 40-80 mg orally daily [19]
› Initiate in all patients regardless of baseline LDL
› Target LDL <1.8 mmol/l for atherosclerotic stroke
Supportive and Symptomatic Treatment
› Dysphagia and nutrition management
› NPO until formal swallowing assessment by speech-language pathology [21]
› Nasogastric tube if prolonged dysphagia anticipated
› Percutaneous endoscopic gastrostomy (PEG) if dysphagia persists beyond 2-3 weeks
› Swallowing rehabilitation: contralateral medullary swallowing center typically compensates [21]
› Antiemetics for persistent nausea and vomiting
› Ondansetron 4-8 mg IV every 6-8 hours
› Prochlorperazine 10 mg IV every 6-8 hours as alternative
› Central neuropathic pain management
› Gabapentin 300 mg orally three times daily, titrate to 900-3600 mg/day in divided doses
› Pregabalin 75 mg orally twice daily, titrate to 150-300 mg twice daily
› Amitriptyline 10-25 mg orally at bedtime, titrate gradually
› Glycemic control
› Target blood glucose 7.8-10 mmol/l in acute stroke
› Avoid hypoglycemia (<3.9 mmol/l)
› Venous thromboembolism prophylaxis
› Enoxaparin 40 mg subcutaneously daily for immobilized patients
› Graduated compression stockings
› Early mobilization when safe
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