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Stroke Management: Ischemic & Hemorrhagic

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🧠 UNDERSTANDING STROKE TYPES FIRST

⚠️ Critical rule: You MUST do a CT scan before ANY treatment — thrombolytics are lifesaving in ischemic stroke but lethal in hemorrhagic stroke.

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PART 1: ISCHEMIC STROKE MANAGEMENT

Step 1 — Emergency Stabilization (ABC)

• Airway: Protect; if GCS ≤8 → intubate
• Breathing: Pulse oximetry; supplemental O₂ if SpO₂ <94%
• Circulation: IV access, cardiac monitoring (detect AF, arrhythmias)
• Temperature: Treat fever aggressively (hyperthermia worsens ischemia)
• Glucose: Correct hypoglycemia (glucose <50 mg/dL must be treated before alteplase)
• Swallowing screen: NPO until speech pathology evaluates — aspiration pneumonia kills 15–25% of stroke patients
• Stroke unit admission: Reduces mortality, hospital stay, and nursing home discharge

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Step 2 — Blood Pressure Management in Ischemic Stroke

If NOT giving thrombolytics:

Only treat if BP > 220/120 mmHg

• The elevated BP is often a protective physiological response to the vessel occlusion
• Low BP (SBP <155, DBP <70, or MAP <100) on arrival correlates with increased 90-day mortality
• Goal: reduce by only 10–15%
• Preferred drugs: IV labetalol (intermittent), hydralazine (intermittent), or nicardipine infusion
• If DBP >140 mmHg: use sodium nitroprusside infusion

If giving thrombolytics (alteplase):

BP must be <185/110 mmHg BEFORE giving alteplase Maintain <180/105 mmHg for ≥24 hours AFTER alteplase

• Same drugs apply: labetalol, nicardipine
• Monitor BP every 15 min for 2 hours, then every 30 min for 6 hours, then hourly for 16 hours

After endovascular thrombectomy:

Keep BP <180/105 mmHg

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Step 3 — IV Thrombolysis (Alteplase / tPA)

Dose:

• 10% given as IV bolus over 1 minute
• Remaining 90% infused over 60 minutes

Time Windows:

3–4.5 hour window — all 4 conditions must be met:

1. Age ≤80 years
2. No history of both diabetes AND prior stroke together
3. NIHSS score ≤25
4. Not on oral anticoagulants
5. Ischemic injury NOT involving more than 1/3 of the MCA territory on imaging

Absolute Contraindications to Alteplase:

Relative Contraindications / Use with Caution:

• Prior stroke + diabetes (in 3–4.5 hr window)
• Large ischemic territory (>1/3 MCA) — higher hemorrhagic transformation risk
• >10 cerebral microbleeds on MRI — symptomatic ICH risk 30–47% vs 1–4% normally
• Antiplatelet use before stroke — can still give alteplase (benefit outweighs small sICH risk)
• End-stage renal disease — can give alteplase cautiously

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Step 4 — Mechanical Thrombectomy (Endovascular)

Indications (0–6 hours):

• No significant pre-stroke disability (mRS ≤1)
• Causative occlusion of ICA or M1 (proximal)
• Age ≥18
• Can be combined with alteplase (give alteplase first if eligible)

Extended window (6–24 hours):

• Carefully selected patients with mismatch imaging (salvageable penumbra on CT perfusion or MRI)

Key time principle:

Every 1-hour delay to reperfusion = worse disability outcome. Time is brain.

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Step 5 — Antiplatelet Therapy

• Use oral anticoagulation — warfarin (INR 2–3) or DOACs (apixaban, rivaroxaban, dabigatran, edoxaban)
• Do NOT use antiplatelets alone for AF-related stroke

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Step 6 — Preventing Complications

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PART 2: HEMORRHAGIC STROKE (ICH) MANAGEMENT

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Step 1 — Emergency Stabilization

• Airway: If GCS ≤8 → endotracheal intubation; pretreat with fentanyl 2–3 mcg/kg IV to blunt ICP spike from laryngoscopy
• Glucose: Check and correct
• CT scan: Immediately — establishes location, size, and guides surgical decision
• Labs: CBC, coagulation studies (PT, INR, aPTT), fibrinogen, toxicology screen, LFTs
• Neurosurgical consult: Immediate

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Step 2 — Blood Pressure Management in ICH

Note: Rapidly lowering BP in moderate ICH does not significantly impair peri-hematomal cerebral perfusion and does not cause neurological deterioration.

Preferred IV Drugs for ICH:

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Step 3 — Reversal of Coagulopathy (Critical)

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Step 4 — ICP Management

Medical Management includes:

• Control seizures (seizures increase ICP and worsen outcome)
• Stool softeners (Valsalva raises ICP)
• Maintain euglycemia

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Step 5 — Hemostatic Agents (to Stop Hematoma Expansion)

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Step 6 — Surgical Management of ICH

Indications for Surgery:

Contraindications to Surgery:

• GCS 3–5 with large deep (infratentorial) ICH
• Very small hematomas (<10 mL) with minimal deficit
• Brainstem hemorrhage (surgery inaccessible, very high risk)

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QUICK COMPARISON TABLE

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MNEMONICS TO REMEMBER

Balance, Eyes, Face drooping, Arm weakness, Speech difficulty, Time to call

BP >185/110, Recent surgery/trauma, Active bleeding, Intracranial tumor/AVM, No glucose correction, Bleeding disorders, Low platelets, Excessive time (>4.5 hr), Extensive infarct (>1/3 MCA), Drugs (anticoagulants with high INR)

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• BP targets table — 4 scenarios (no tPA / before tPA / after tPA / post-thrombectomy) with exact mmHg cutoffs
• Alteplase dosing (0.9 mg/kg, bolus + infusion) with 0–3 h and 3–4.5 h window criteria
• All absolute contraindications to alteplase in a 2-column grid
• Antiplatelet/anticoagulation table — aspirin, clopidogrel, Aggrenox, dual APT, DOACs with doses and indications

• BP targets with debate note on SBP <140 (INTERACT2/ATACH-II)
• 6 IV antihypertensive drugs — labetalol, nicardipine, esmolol, enalaprilat, nitroprusside, hydralazine — with doses and caveats
• Coagulopathy reversal table — warfarin, dabigatran, Xa inhibitors, heparin, thrombolytic-related, and antiplatelet-related ICH with specific reversal agents and doses