Rapid Clinical Updates: Updates in Acute Stroke Management-Handout

Handout

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This rapid update on acute stroke management highlights current best practices and evolving guidelines to improve outcomes and reduce long-term disability. Stroke remains the fifth leading cause of death, primarily ischemic (80-90%) due to large vessel occlusion.<br /><br />Reperfusion therapy includes intravenous thrombolysis with Alteplase or Tenecteplase within 4.5 hours of symptom onset. Tenecteplase, given as a rapid IV bolus, is increasingly used despite lacking FDA approval for stroke. Prior to thrombolysis, blood pressure should be under 185/110 mmHg, fasting glucose checked, and a head CT done within 15 minutes. Avoid labeling uncontrolled strokes as cryptogenic without thorough evaluation to ensure appropriate treatment.<br /><br />For patients with unknown stroke onset time, MRI using diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) sequences helps identify strokes within 4.5 hours, supporting safe tPA administration. Mechanical thrombectomy is recommended up to 24 hours after symptom onset for large vessel occlusions, including those with large infarct areas, based on recent trials showing better functional outcomes. Patient selection criteria include pre-stroke mRS 0-1, occlusion location (internal carotid or MCA), NIHSS ≥6, and ASPECTS ≥6. Post-thrombectomy, antiplatelet or anticoagulation therapy is withheld for 24 hours.<br /><br />Transient ischemic attacks (TIAs) involve transient neurological deficits without infarction. Minor strokes show infarction with low NIHSS scores. Dual antiplatelet therapy (DAPT) is advised for 21-90 days depending on stroke severity and bleeding risk, ideally starting within 72 hours.<br /><br />Atrial fibrillation causes 5-15% of strokes and increases risk fivefold. For non-valvular AF, direct oral anticoagulants (DOACs) are recommended between 4-14 days post-stroke, including in patients with high BMI. Switching anticoagulant agents or adding antiplatelets after recurrent stroke lacks supporting evidence.<br /><br />These updates emphasize rapid, guideline-based interventions tailored to each patient’s stroke type and timing to maximize recovery and reduce disability.

Keywords

acute stroke management

ischemic stroke

large vessel occlusion

intravenous thrombolysis

Tenecteplase

mechanical thrombectomy

transient ischemic attack

dual antiplatelet therapy

atrial fibrillation stroke

direct oral anticoagulants