Acute Reperfusion Therapy
› IV thrombolysis — alteplase
› Alteplase 0.9 mg/kg IV (maximum 90 mg)
› 10% of total dose as IV bolus over 1 minute
› Remaining 90% as continuous infusion over 60 minutes
› Standard window: within 4.5 hours of symptom onset
› EXPECTS trial: alteplase benefit extends to 4.5 to 24 hours in posterior circulation stroke
› Tenecteplase alternative
› Tenecteplase 0.25 mg/kg IV single bolus (maximum 25 mg)
› FDA-approved for acute ischemic stroke
› Simpler administration than alteplase
Endovascular Thrombectomy
› Mechanical thrombectomy for large-vessel occlusion
› Basilar artery occlusion — primary indication in Weber syndrome setting
› Eligibility window up to 24 hours per 2026 AHA/ASA guideline
› ATTENTION trial: EVT superior to medical management for basilar occlusion
› BAOCHE trial: confirmed benefit at 6 to 24 hours for basilar artery occlusion
› Device selection — stent retriever vs aspiration
› Both aspiration and stent retriever effective in posterior circulation
› No superiority demonstrated between techniques per CNS Neuroscience meta-analysis 2023
› Contraindications
› No accessible large-vessel occlusion on CTA or MRA
› Completed large infarct core with poor salvageability
Blood Pressure Management
› BP targets stratified by treatment
› Without thrombolysis or thrombectomy
› Permissive hypertension — do not treat unless systolic greater than 220 mmHg or diastolic greater than 120 mmHg
› Avoid aggressive lowering — worsens cerebral perfusion
› Pre-thrombolysis
› Target systolic less than 185 mmHg and diastolic less than 110 mmHg before alteplase
› Labetalol 10 to 20 mg IV over 1 to 2 minutes — may repeat once
› Nicardipine 5 mg/hour IV infusion — titrate up by 2.5 mg/hour every 5 to 15 minutes; maximum 15 mg/hour
› Post-thrombolysis
› Maintain systolic less than 180 mmHg and diastolic less than 105 mmHg for 24 hours
Antiplatelet and Anticoagulation
› Secondary prevention antiplatelet therapy
› Aspirin 325 mg orally within 24 to 48 hours if thrombolytics not administered
› Class I recommendation per 2026 AHA/ASA guideline
› Do not administer within 24 hours of alteplase
› Anticoagulation for cardioembolic source
› Initiate after acute phase if atrial fibrillation or other high-risk cardiac source
› Timing: typically 2 to 14 days post-stroke depending on infarct size and hemorrhagic transformation risk
› Direct oral anticoagulants preferred over warfarin for non-valvular AF
Glucose and Metabolic Management
› Metabolic targets during acute phase
› Glucose target 7.8 to 10.0 mmol/l
› Both hypoglycemia and hyperglycemia worsen ischemic injury
› Sliding scale insulin as needed
› Euvolemia maintenance — avoid dehydration which worsens ischemia
› NPO until dysphagia screening completed
› DVT prophylaxis — intermittent pneumatic compression in immobile patients
Non-Vascular Etiology Treatment
› Targeted therapy by underlying cause
› Tuberculoma
› Antitubercular therapy — standard four-drug regimen (isoniazid, rifampicin, pyrazinamide, ethambutol)
› Systemic corticosteroids to reduce inflammatory mass effect
› Brainstem abscess
› Empirical antibiotics plus neurosurgical consultation for drainage
› Behcet's disease
› Systemic corticosteroids — high-dose prednisolone
› Immunosuppressive therapy for refractory cases
› Midbrain hemorrhage with coagulopathy
› Reversal of coagulopathy — factor replacement for hemophilia
› Statin for secondary prevention
› High-intensity statin therapy — initiated during acute hospitalization
› Atorvastatin 40 to 80 mg orally once daily
› LDL target less than 1.8 mmol/l for high-risk cerebrovascular disease
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