STROKE Management

1. INITIAL APPROACH (GOLDEN MINUTES)

ABC + STROKE CODE ACTIVATION

A. Airway

• Intubate if:
• GCS ≤ 8
• Loss of airway reflex
• Severe bulbar dysfunction
• Avoid hypoxia (target SpO₂ >94%)

B. Breathing

• Maintain normoxia
• Avoid hyperventilation unless impending herniation

C. Circulation

• 2 large-bore IV lines
• Cardiac monitoring (AF detection)

 TIME TARGETS (DOOR TIMES )

2. DIFFERENTIATE STROKE TYPE 

 Immediate Imaging

• Non-contrast CT head → FIRST
• Rule out hemorrhage

 3. MANAGEMENT OF ACUTE ISCHEMIC STROKE (AIS)

 A. IV THROMBOLYSIS (ALTEPLASE)

• Alteplase (rtPA)
• Tenecteplase (TNK)

  MECHANISM OF ACTION

• Activates plasminogen → plasmin
• Plasmin degrades:
• Fibrin clot
• Fibrinogen
• Leads to clot lysis and recanalization

4. INDICATIONS 

• Symptom onset ≤ 4.5 hours

EXTENDED WINDOW (SELECTED PATIENTS)

• 4.5–9 hours OR wake-up stroke
• Based on advanced imaging:
• Perfusion mismatch (CT/MRI)
• DWI-FLAIR mismatch

5. ELIGIBILITY CRITERIA

ESSENTIAL (ALL REQUIRED)

• Age ≥ 18 years
• Clinical diagnosis of ischemic stroke
• Measurable neurological deficit (NIHSS)
• Onset time known (or imaging-based selection)

 7. CONTRAINDICATIONS

8. DOSING PROTOCOLS

A. ALTEPLASE (rtPA)

• Dose: 0.9 mg/kg (max 90 mg)
• 10% IV bolus (1 min)
• 90% infusion over 60 min

B. TENECTEPLASE (TNK)

• Dose: 0.25 mg/kg IV bolus (max 25 mg)
• Single bolus → faster, easier

9. BLOOD PRESSURE MANAGEMENT

Drugs used:

• Labetalol
• Nicardipine
• Clevidipine

MONITORING AFTER THROMBOLYSIS

FIRST 24 HOURS (CRITICAL)

• Neuro checks:
• Every 15 min × 2 hrs
• Every 30 min × 6 hrs
• Hourly till 24 hrs
• BP monitoring
• Avoid:
• Antiplatelets
• Anticoagulants

FOLLOW-UP IMAGING

• CT/MRI at 24 hours

COMPLICATIONS

1. Symptomatic Intracranial Hemorrhage (sICH)

• Incidence: ~6%
• Risk factors:
• Large infarct
• High BP
• Hyperglycemia

2. Orolingual Angioedema

• More common with ACE inhibitors

3. Systemic bleeding

 MANAGEMENT OF BLEEDING

If hemorrhage suspected:

• Stop infusion immediately
• Urgent CT

Reversal:

• Cryoprecipitate (fibrinogen replacement)
• Tranexamic acid
• Platelets (if needed)

 KEY TRIALS 

• NINDS trial → Established rtPA benefit ≤ 3 hrs
• ECASS III trial → Extended to 4.5 hrs
• WAKE-UP trial → Wake-up stroke
• EXTEND trial → 4.5–9 hrs
• EXTEND-IA TNK trial → TNK superior in LVO

 MECHANICAL THROMBECTOMY

  TARGET VESSELS (LVO)

• Internal carotid artery (ICA)
• Proximal middle cerebral artery (M1 ± proximal M2)
• Basilar artery (posterior circulation — strong emerging evidence)

INDICATIONS (AHA/ASA 2019–2023, ESO 2021)

EARLY WINDOW (0–6 HOURS) — CLASS I (STRONG)

• Pre-stroke mRS 0–1
• Age ≥18 years
• NIHSS ≥6
• Confirmed LVO (ICA/M1) on CTA/MRA
• ASPECTS ≥6
• Treatment can start within 6 hours

 Give IV thrombolysis first if eligible (“bridging therapy”)

 EXTENDED WINDOW (6–24 HOURS) — IMAGING-BASED SELECTION

Based on:

• DAWN trial
• DEFUSE 3 trial

Criteria (simplified exam form):

• Clinical–imaging mismatch:
• Small infarct core + large penumbra
• CT perfusion / MRI DWI–perfusion mismatch

 ANTIPLATELETS in Stroke

• If NO thrombolysis:
• Aspirin 160–325 mg within 24 hr
• If after tPA:
• Start after 24 hr (repeat CT first)

 DUAL ANTIPLATELET THERAPY (DAPT) Indication 

• Minor stroke (NIHSS ≤3) OR high-risk TIA
• Aspirin + Clopidogrel for 21 days (CHANCE, POINT trials)

After that:Switch to single antiplatelet

ANTICOAGULATION in stroke

 PATIENT ON DOAC / WARFARIN PRESENTS WITH STROKE — WHAT TO DO?

 IF ISCHEMIC STROKE —> Hold (temporarily stop) anticoagulant initially

Because Risk of hemorrhagic transformation

NEXT: RESTART TIMING 

 Thrombolysis decision

• If on Warfarin:
• Allowed only if INR ≤1.7
• If on Apixaban / Rivaroxaban / Dabigatran:
• Usually contraindicated unless:
• Last dose >48 hours and normal renal function
• OR drug-specific levels normal (rarely available)

 Bridging:No heparin bridging (↑ bleeding risk)

IF HEMORRHAGIC STROKE (ICH)-THIS IS AN EMERGENCY

 Immediately STOP anticoagulant and REVERSE ANTICOAGULATION

If on Warfarin:

• Vitamin K
• 4-factor PCC (preferred)

If on DOAC:

• Idarucizumab → for Dabigatran
• Andexanet alfa → for Xa inhibitors

Restart anticoagulation?

 Usually after 4–8 weeks, depending on:

• Cause of bleed
• Risk of recurrence
• Indication (AF vs mechanical valve)

 Indications of Heparin in Stroke  (AHA/ASA 2021 + ESC + ACCP) 

ABSOLUTE / STRONG INDICATIONS

NOT INDICATED

DECISION STRATEGY (Based on infarct size:)

 Choice of Anticoagulant

Initial:Unfractionated heparin (UFH)  ICU preferred

OR

• Low molecular weight heparin (LMWH) Then:
• Transition to:
• DOACs (preferred)
• Warfarin (if APS, mechanical valve)

 DVT PROPHYLAXIS IN STROKE PATIENTS

A. Mechanical Prophylaxis FIRST LINE 

1. Intermittent Pneumatic Compression (IPC)

Evidence:

• CLOTS 3 trial
  Start immediately (day 1)
• Use in:
• Ischemic stroke
• Hemorrhagic stroke

2. Graduated Compression Stockings (GCS)

NOT recommended Based on CLOTS 1 trial

B. Pharmacological Prophylaxis

• Low molecular weight heparin (LMWH) preferred
• Unfractionated heparin (UFH)

• Start within 24–48 hours
• AFTER:
• Brain imaging excludes hemorrhage
• No major bleeding risk

 Contraindications to Pharmacological Prophylaxis

• Active bleeding
• Large infarct with high hemorrhagic risk
• Uncontrolled hypertension
• Thrombocytopenia
• Recent surgery

SECONDARY PREVENTION OF STROKE

 A. NON-CARDIOEMBOLIC STROKE (Atherothrombotic / Lacunar)

1. ANTIPLATELET THERAPY (Cornerstone)

Options (LONG-TERM)

• Aspirin: 75–150 mg/day
• Clopidogrel: 75 mg/day (preferred if aspirin intolerance)
• Aspirin + Dipyridamole (less used in India)

 Guideline (AHA/ASA 2021, ESO):

• Single antiplatelet → long-term standard

 2. DUAL ANTIPLATELET THERAPY (DAPT)

 ONLY in:

• Minor stroke (NIHSS ≤3)
• High-risk TIA (ABCD² ≥4)

 Regimen:

• Aspirin + Clopidogrel
• Duration: 21–30 days ONLY

 Avoid long-term DAPT → ↑ bleeding risk

 B. CARDIOEMBOLIC STROKE (e.g., AF)

 1. ANTICOAGULATION (MAIN THERAPY)

Most commonly due to  Atrial Fibrillation

Options:

• DOACs (preferred):
• Apixaban
• Rivaroxaban
• Dabigatran
• Edoxaban
• Warfarin (INR 2–3) if:
• Mechanical valve
• Severe mitral stenosis

 2. TIMING OF ANTICOAGULATION 

 3. SPECIAL CASES

• Mechanical valve → Warfarin only
• LV thrombus → anticoagulation
• Endocarditis → usually NO anticoagulation (risk hemorrhage)

 WHAT IS CHA₂DS₂-VASc?

A clinical score used to estimate risk of thromboembolism in Atrial Fibrillation in primary prevention

Components:

 C. LARGE ARTERY ATHEROSCLEROSIS

 CAROTID STENOSIS MANAGEMENT

Indications:

• Symptomatic carotid stenosis:
• 70–99% → CEA recommended
• 50–69% → selective

Options:

• Carotid Endarterectomy (preferred)
• Carotid Artery Stenting (if high surgical risk)

 Timing:

• Within 2 weeks of stroke/TIA

3. RISK FACTOR MODIFICATION 

 A. HYPERTENSION CONTROL

 MOST IMPORTANT modifiable risk factor

Target BP:

• <130/80 mmHg (AHA/ASA, ESC)

Preferred drugs:

• ACE inhibitors (e.g., Perindopril)
• Thiazides (e.g., Indapamide)

 Evidence: PROGRESS trial

 B. DYSLIPIDEMIA MANAGEMENT

High-intensity statin (MANDATORY)

• Atorvastatin 40–80 mg
• Rosuvastatin 20–40 mg

Target:

• LDL <70 mg/dL (or ↓ ≥50%)

 If not controlled:

• Add ezetimibe
• Consider PCSK9 inhibitors

 C. DIABETES CONTROL

Target:

• HbA1c ~7%

Preferred:

• SGLT2 inhibitors
• GLP-1 agonists

 Avoid hypoglycemia (important in elderly stroke)

 D. SMOKING CESSATION

• Strong Class I recommendation
• Reduces recurrence significantly

 E. OBESITY & PHYSICAL ACTIVITY

• BMI target <25
• Moderate exercise:
• ≥150 min/week

F. DIET Mediterranean diet:

• Fruits, vegetables, nuts, olive oil
• Low salt (<5 g/day)

 4. LIFESTYLE + GENERAL MEASURES

 Alcohol

• Limit intake

 Sleep apnea

• Screen and treat (CPAP)

 Avoid:

• Oral contraceptives (in high-risk)
• Drug abuse (cocaine)