Acute Ischemic Stroke Management

1. Prehospital care and triage

• Use a validated stroke scale and record the last known well time. Notify the receiving hospital early and transport rapidly.
• Check blood glucose, because hypoglycemia and hyperglycemia can mimic stroke.
• Give oxygen only if SpO2 is below 95%. Avoid dextrose in normoglycemic patients and avoid overhydration.
• Mobile stroke units are now endorsed where available. - AHA 2026 guideline summary
• NINDS time targets for potential thrombolysis candidates: door to doctor 10 min, door to CT 25 min, door to CT read 45 min, door to treatment 60 min. - Rosen's Emergency Medicine, Table 87.4

2. Emergency evaluation

• Non-contrast CT head is the first test. It separates ischemic stroke from hemorrhage. Early signs include the hyperdense artery sign, loss of the insular ribbon, loss of the gray-white interface, and sulcal effacement. CT is insensitive for posterior fossa strokes. - Rosen's Emergency Medicine, p. 1431-1432
• CTA or MRA from head to neck identifies a large vessel occlusion (LVO), dissection, or stenosis. It should not delay thrombolysis.
• CT perfusion or MRI (DWI-FLAIR mismatch) is mainly for extended-window or unknown-onset patients. Advanced imaging should not delay t-PA.
• Also obtain an ECG, glucose, and basic labs. Do not wait for coagulation results unless a coagulopathy is suspected.
• Consider mimics: hypoglycemia, seizure with Todd paralysis, complex migraine, subdural hematoma, Wernicke encephalopathy, and peripheral vestibular or facial palsies.

3. Reperfusion therapy

• Either alteplase or tenecteplase can be used within 4.5 hours of onset. - AHA 2026
  • Alteplase is 0.9 mg/kg (maximum 90 mg), with 10% as a bolus and the rest over 60 min.
  • Tenecteplase is 0.25 mg/kg as a single bolus (maximum 25 mg).
• Treat disabling deficits regardless of NIHSS score, without waiting for advanced imaging. - AHA 2026
• For non-disabling deficits such as an isolated sensory syndrome, thrombolysis has not shown benefit. Dual antiplatelet therapy is preferred. - AHA 2026
• Extended window (4.5 to 9 hours) or unknown onset: thrombolysis is supported for selected patients using advanced imaging, such as DWI-FLAIR mismatch or perfusion mismatch. - AHA 2026
• Absolute contraindications include intracranial hemorrhage on CT, recent major surgery, trauma or stroke, active internal bleeding, and uncontrolled severe hypertension. The usual blood pressure threshold is above 185/110 mmHg before treatment.
• Adjuvant argatroban or eptifibatide with thrombolysis is not recommended. - AHA 2026

• EVT is standard care for LVO. Eligible patients should get both IV thrombolysis and EVT, with no delay to "see if symptoms improve." - AHA 2026
• Eligibility has expanded to some patients with large ischemic cores. - AHA 2026
• EVT has a strong recommendation for basilar artery occlusion within 24 hours with NIHSS of 10 or higher. - AHA 2026
• Late-window EVT (up to 24 hours) uses perfusion or clinical-core mismatch.
• A 2025 meta-analysis of 6 randomized trials supports EVT in large-volume infarcts (PMID 40387344). This fits the updated guideline. I found nothing in my search that contradicts the library or guideline content.

4. Supportive care (first 24 to 72 hours)

• Blood pressure
  • Before thrombolysis, keep BP below 185/110 mmHg.
  • After thrombolysis, keep BP below 180/105 mmHg.
  • Without reperfusion therapy, permissive hypertension is allowed up to 220/120 mmHg unless there is a comorbid indication to treat.
  • Intensive lowering to systolic BP below 140 mmHg is not recommended after IVT or EVT, even with complete reperfusion. It may cause harm after EVT. - AHA 2026
• Glucose: treat hypoglycemia. Intensive control to 80 to 130 mg/dL is not recommended because it raises the risk of severe hypoglycemia. - AHA 2026
• Temperature: treat fever and look for a source. Even mild hyperthermia worsens injury. - Rosen's Emergency Medicine
• Keep the patient NPO until a swallow screen is done, to reduce aspiration risk.
• Keep the patient normovolemic. Avoid hypotonic fluids.
• Give VTE prophylaxis with intermittent pneumatic compression.
• Admit to a stroke unit. Start early mobilization (not very early, high-dose mobilization) and early rehabilitation.
• Watch for malignant cerebral edema, which usually peaks at days 2 to 5. Consider decompressive hemicraniectomy in selected younger patients with large MCA infarcts. Large cerebellar infarcts may need suboccipital decompression.
• Hemorrhagic transformation after thrombolysis: stop the infusion, get an urgent CT, and give cryoprecipitate, tranexamic acid, or other reversal per protocol.

5. Antithrombotic therapy and secondary prevention

• Aspirin 160 to 325 mg within 24 to 48 hours if no thrombolysis was given. After thrombolysis, wait until 24 hours and a follow-up CT without hemorrhage.
• Minor stroke (NIHSS 3 or less) or high-risk TIA: DAPT with aspirin plus clopidogrel for 21 days, then a single antiplatelet. Ticagrelor plus aspirin is an alternative in some populations.
• Atrial fibrillation: start a DOAC. Timing is individualized, typically within days for minor to moderate strokes and later for large infarcts.
• Statin: high-intensity, with an LDL target below 70 mg/dL.
• Blood pressure: long-term control, with a target below 130/80 mmHg.
• Carotid stenosis of 70% or more, symptomatic: endarterectomy within 2 weeks, or stenting in selected patients.
• Address diabetes, smoking, and obesity.
• Look for a cause: echocardiography, rhythm monitoring, and vessel imaging.

6. Other points

• The 2026 AHA guideline includes the first pediatric acute ischemic stroke recommendations.
• Most centers use a TOAST-type etiology classification: large artery, cardioembolic, small vessel, other, or undetermined.