Recent Stroke Management Guidelines (2024–2025 Update)

1. ACUTE ISCHEMIC STROKE (AIS)

Initial Assessment & General Measures

• Airway/Breathing/Circulation: Secure airway in obtunded patients; supplemental O₂ only if SpO₂ <94%
• Blood pressure: Do not lower BP unless >185/110 mmHg (thrombolysis candidate) or >220/120 mmHg (non-thrombolysis); use labetalol or nicardipine IV
• Blood glucose: Treat hyperglycemia to 140–180 mg/dL; treat hypoglycemia (<60 mg/dL) with IV dextrose
• Fever: Treat sources of hyperthermia (>38°C); antipyretics recommended
• NIHSS: Rapid neurological assessment with NIHSS score

IV Thrombolytic Therapy

Alteplase (primary FDA-approved agent)

Tenecteplase (increasingly preferred)

• 0.25 mg/kg IV single bolus (max 25 mg) — easier to administer than alteplase infusion
• Comparable efficacy and safety to alteplase at 90 days (NIHSS, sICH, mortality)
• Preferred over alteplase when the patient is eligible for mechanical thrombectomy (EXTEND-IA TNK: superior reperfusion rates)
• A 2024 meta-analysis (PMID: 39413337, Neurology) confirms non-inferiority of tenecteplase vs. alteplase within 4.5 h across RCTs

Mechanical Thrombectomy (EVT)

Time is brain: Every 1-hour delay to reperfusion worsens disability outcomes. Target door-to-puncture ≤90 min.

Contraindications to Thrombolytics (selected)

• Active intracranial hemorrhage on CT
• Recent intracranial/spinal surgery (<3 months)
• Platelet count <100,000; INR >1.7 (on anticoagulants)
• Serum glucose <50 mg/dL
• Cerebral microbleeds >10 on MRI — benefit uncertain

2. INTRACEREBRAL HEMORRHAGE (ICH)

Blood Pressure Management

• Target SBP 130–150 mmHg acutely (INTERACT2, ATACH-2 evidence)
• Rapid lowering to <140 mmHg is safe and may modestly improve outcomes if started within 6 hours

Anticoagulant Reversal

ICP Management

• GCS ≤8 or clinical herniation → ICP monitoring; target CPP 50–70 mmHg
• External ventricular drain for hydrocephalus/intraventricular hemorrhage
• Mannitol or HTS (3% or 23.4%) for elevated ICP — meta-analysis shows HTS slightly superior
• No corticosteroids for ICP in ICH

Surgical Intervention

• Cerebellar ICH with deterioration, brainstem compression, or hydrocephalus → urgent surgical evacuation (neurosurgical emergency)
• Supratentorial ICH: Open craniotomy not routinely beneficial; consider for neurological deterioration, coma, midline shift, or refractory ICP
• Minimally invasive surgery (catheter/MISTIE approach) shows mortality benefit in meta-analyses; ENRICH trial ongoing

3. PRIMARY PREVENTION OF STROKE

• Aligns with Life's Essential 8 framework (BP, lipids, glucose, weight, smoking, sleep, physical activity, diet)
• New: sex-specific recommendations — screening for gestational hypertension, preeclampsia, hormone therapy risks, atrial fibrillation in women
• Hypertension control remains #1 modifiable risk factor
• Statin therapy for patients with atherosclerotic CVD risk ≥10% (10-year)
• Anticoagulation for AF — CHA₂DS₂-VASc ≥2 (men), ≥3 (women)

4. SECONDARY PREVENTION

Antiplatelet Therapy

• Aspirin 75–325 mg/day for non-cardioembolic ischemic stroke/TIA
• Dual antiplatelet therapy (DAPT): Aspirin + clopidogrel for 21 days after minor stroke/high-risk TIA (POINT and CHANCE trials) — then transition to monotherapy
• Aspirin + ticagrelor (THALES trial) — alternative in first 30 days for non-cardioembolic minor stroke

Anticoagulation

• Atrial fibrillation: Prefer DOAC over warfarin (dabigatran, apixaban, rivaroxaban)
• Initiation timing post-stroke: "1-3-6-12 rule" based on infarct size (minor: 1 day, moderate: 3 days, large: 6 days, hemorrhagic transformation: 12 days)
• Cervical artery dissection (PMID: 38739383, JAMA Neurol 2024): Antiplatelet and anticoagulation equivalent in safety/efficacy — individualize

PFO Closure

• PFO closure recommended for cryptogenic stroke patients ≤60 years after excluding other etiologies
• Antithrombotic therapy (antiplatelet or anticoagulant) recommended if closure is deferred

Risk Factor Control

5. STROKE SYSTEMS OF CARE

• Stroke unit care reduces mortality and dependency — strongest Level A evidence
• Telestroke networks extend access to expert evaluation in non-comprehensive centers
• Door-to-CT: ≤25 min | Door-to-needle (alteplase): ≤60 min | Door-to-groin puncture: ≤90 min

Key Recent Guidelines Referenced

Note: The AHA/ASA 2024 Acute Ischemic Stroke Treatment Guideline update (anticipated) had not been fully published as of the textbook editions available. The 2019 AHA/ASA criteria remain the current backbone for thrombolysis eligibility; tenecteplase has been increasingly incorporated as an equivalent alternative. Always verify local institutional protocols and the most current AHA/ASA full-text guidelines at AHA Professional Heart Daily.

Posterior Circulation Stroke: Management Guidelines

Anatomy & Clinical Framework

• Proximal: Vertebral arteries → basilar artery (proximal/middle/distal segments)
• Perforators: Anterior inferior cerebellar artery (AICA), posterior inferior cerebellar artery (PICA), superior cerebellar artery (SCA)
• Distal: Posterior cerebral arteries (PCA)

1. RECOGNITION & DIAGNOSIS

Key Clinical Features by Territory

⚠️ Up to 25% of posterior fossa infarcts have a normal non-contrast CT — if posterior circulation stroke is suspected with normal CT, obtain urgent diffusion-weighted MRI. CTA/MRA is essential to identify vascular occlusion. — Tintinalli's Emergency Medicine

NIHSS Caveat

2. ACUTE PHASE: GENERAL MANAGEMENT

• Airway: Secure early — brainstem strokes impair airway reflexes faster than hemispheric strokes
• BP: Permissive hypertension (do not lower unless >185/110 if thrombolysis candidate, or >220/120 otherwise); allow collateral flow
• Glucose: Maintain 140–180 mg/dL; treat hypoglycemia (<60 mg/dL) with IV dextrose
• Fever: Treat aggressively (>38°C)
• Stroke unit admission: Reduces mortality and dependency (Level A evidence)

3. INTRAVENOUS THROMBOLYSIS (IVT)

Alteplase

• Standard dosing: 0.9 mg/kg IV (max 90 mg) over 60 min — applies to posterior circulation strokes within 4.5 hours
• No separate posterior circulation contraindications beyond standard criteria
• Meta-analysis (Knapen et al., J Stroke Cerebrovasc Dis, 2024 — PMID 38395096):
  • Pooled favorable outcome (mRS 0–2): 63% with IVT
  • Mortality 19%; sICH 4%
  • Standard window (<4.5 h): 77% favorable outcome vs 38% in extended window (>4.5 h)
  • IVT is safe and effective in both standard and extended time windows in posterior circulation strokes

Tenecteplase — Extended Window for BAO (NEW 2026)

• Tenecteplase 0.25 mg/kg IV bolus (max 25 mg) within 24 hours of BAO onset
• Primary outcome (mRS 0–1 or return to baseline): 38% tenecteplase vs 29% standard treatment (aRR 1.50; 95% CI 1.09–2.08; p=0.014)
• sICH: 2% vs 3% (non-significantly lower with tenecteplase)
• Mortality at 90 days: similar between groups (~29–31%)
• Conclusion: Tenecteplase within 24 h after BAO onset significantly improves functional outcomes compared to standard medical treatment

🔑 Key ESO/ESMINT 2024 expert consensus: IVT (including beyond 4.5 h) is suggested for BAO patients up to 24 hours unless contraindicated, given the very poor natural history of untreated BAO.

4. ENDOVASCULAR THROMBECTOMY (EVT) FOR BASILAR ARTERY OCCLUSION

Landmark Evidence

VERITAS Meta-Analysis (Lancet, Jan 2025 — PMID 39674187)

• mRS 0–3: 45% EVT vs 30% control (aOR 2.41; 95% CI 1.78–3.26; p<0.0001)
• Functional independence (mRS 0–2): 35% vs 21% (aOR 2.52; p<0.0001)
• Mortality: 36% vs 45% (aOR 0.60; p<0.0001)
• sICH: 5% vs <1% (significantly higher with EVT)
• Key subgroup findings:
  • NIHSS ≥10: Clear benefit from EVT
  • NIHSS <10 (mild strokes): Uncertain benefit — BMT non-significantly better and safer than EVT
  • Proximal/middle BAO: Greater benefit than distal BAO

1-Year Outcomes (ATTENTION Extension, JAMA Neurol 2024 — PMID 39186280)

• mRS 0–3 at 1 year: 44.6% thrombectomy vs 19.4% control (aRR 2.23)
• Excellent outcome (mRS 0–1) at 1 year magnified vs 90-day benefit (27.9% vs 8.3%)
• Mortality continues to increase in both groups at 1 year; thrombectomy advantage sustained

5. ESO/ESMINT 2024 GUIDELINE RECOMMENDATIONS FOR BAO

6. CEREBELLAR INFARCTION — SPECIAL MANAGEMENT

Monitoring Protocol

• Serial neurological exams every 1–2 hours in acute phase — watch for:
  • Decreasing consciousness / deteriorating GCS
  • New gaze palsy (VI nerve palsy or conjugate gaze paresis) — sentinel sign of brainstem compression
  • Hemiparesis ipsilateral to ataxia
  • Worsening headache + vomiting
• Early neurosurgical consultation for all cerebellar infarcts

Imaging

• Repeat CT/MRI at any sign of deterioration to assess edema, brainstem compression, hydrocephalus
• Even small cerebellar edema can compress the 4th ventricle → obstructive hydrocephalus

Treatment of Cerebellar Edema & Herniation

⚠️ Ventricular drainage alone is inadequate for cerebellar herniation — surgical decompression of swollen tissue is required as soon as edema becomes clinically apparent. A brief observation period is acceptable only if 4th ventricle and perimesencephalic cisterns remain open and patient is awake. — Adams & Victor's Principles of Neurology, 12th Ed.

7. SECONDARY PREVENTION IN POSTERIOR CIRCULATION STROKE

Cause-Directed Therapy

Risk Factor Targets

8. REVASCULARIZATION STRATEGY COMPARISON

Combined EVT + IVT has the highest probability of best functional outcome for posterior circulation LVO. However, IVT alone is safest (lowest sICH, lowest mortality). Individualize based on patient profile.

Key Guidelines Summary Table

Practice Pearls

1. Do not withhold thrombolysis in posterior circulation stroke — the natural history of untreated BAO carries >80% mortality/severe disability
2. Tenecteplase up to 24 hours is now supported by Phase 3 evidence (TRACE-5) for BAO
3. EVT benefits moderate-severe BAO (NIHSS ≥10) in both 0–12 h and 6–24 h windows; evidence for mild stroke (NIHSS <10) is uncertain
4. Cerebellar infarcts require urgent neurosurgical consultation — edema can cause fatal herniation within hours; do not delay decompression
5. MRI DWI is mandatory if CT is negative and posterior stroke is clinically suspected
6. NIHSS underestimates posterior circulation deficits — use clinical judgment alongside scoring

Posterior Circulation Stroke Management — Key Points

Recognition

• Up to 25% of posterior fossa infarcts have a normal CT → order DWI-MRI if clinically suspected
• NIHSS underscores posterior circulation deficits — use clinical judgment
• Watch for: bilateral weakness, diplopia, dysarthria, vertigo, ataxia, crossed cranial nerve signs, decreased consciousness

IV Thrombolysis

Endovascular Thrombectomy (EVT) for Basilar Artery Occlusion

Cerebellar Infarction — Critical Steps

1. Early neurosurgical consultation for all cerebellar infarcts
2. Monitor every 1–2 h for: new gaze palsy, decreasing consciousness, worsening headache
3. Obstructive hydrocephalus → external ventricular drain
4. Cerebellar edema + brainstem compression → urgent suboccipital craniectomy (do not delay; EVD alone is insufficient)
5. Bridge with mannitol or hypertonic saline while preparing for surgery

Secondary Prevention

Key Guidelines