IM18.10-14 | Stroke Acute Management — Summary & Reflection

KEY TAKEAWAYS

Acute stroke management integrates supportive care, reperfusion therapy (ischaemic), and haematoma control (haemorrhagic) based on a precise protocol.

Supportive care (all stroke): O2 only if SpO2 <94%; BP permissive ≤220/120 for ischaemic (without thrombolysis), <185/110 before thrombolysis and <180/105 after; <140 for ICH (INTERACT-2); glucose 7.8–10 mmol/L; temperature <37.5°C; swallowing assessment; VTE prophylaxis.

IV thrombolysis (ischaemic stroke):
- Alteplase 0.9 mg/kg (max 90 mg; 10% bolus, 90% over 60 min) OR tenecteplase 0.25 mg/kg IV bolus (max 25 mg)
- Window: ≤4.5 hours from last known well
- BP threshold: <185/110 before administration; maintain <180/105 for 24 hours
- Key contraindications: haemorrhage on CT, prior ICH, stroke within 3 months, INR >1.7, anticoagulated (DOAC within 48h), BP >185/110 despite treatment, platelet <100,000

Mechanical thrombectomy: proximal LVO (ICA, M1, basilar), NIHSS ≥6, ASPECTS ≥6, within 6 hours (or up to 24h with favourable penumbra mismatch). Give IV thrombolysis first if eligible (tandem therapy).

Antiplatelet: aspirin 300 mg within 48h (no thrombolysis) or at 24h (after thrombolysis); DAPT (aspirin + clopidogrel) for 21 days for minor stroke/TIA.

Anticoagulation in AF: delay based on 1-3-6-12 rule; NOAC for non-valvular AF; warfarin INR 2–3 for valvular AF.

ICH management: BP <140 mmHg (INTERACT-2); reverse anticoagulation (PCC + VitK for warfarin; idarucizumab for dabigatran); ABC/2 volume; mannitol/hypertonic saline for ICP; surgical indications: cerebellar ICH >3 cm, IVH with hydrocephalus (EVD), accessible lobar ICH in young deteriorating patient, AVM/aneurysm, malignant MCA infarction (decompressive hemicraniectomy <60 years).

REFLECT

Return to the hook scenario: the 65-year-old man with left hemiplegia and BP 188/108 at 09:58. He is within the thrombolysis window. The BP is above 185/110. You know what to do: labetalol 10–20 mg IV, recheck BP in 5 minutes, and if it drops below 185/110, give tenecteplase 0.25 mg/kg IV bolus (or alteplase 0.9 mg/kg) immediately. While the drug is being prepared, the CTA should be reviewed for M1 occlusion — if present, the thrombectomy team needs to be activated in the same breath.

Reflect on this broader question: in a district hospital in India where IV thrombolysis is available but thrombectomy is not, you cannot offer the patient the full treatment algorithm. You can give thrombolysis within the window; you cannot offer mechanical extraction. How does this reality change your counselling of the family? And what documentation must you produce to ensure that the limitation of care is clearly recorded — not as a failure, but as an honest account of what was available and what was done? Acute stroke management is both a clinical science and an exercise in ethical transparency.