Hyperacute and Acute Stroke Management
Reperfusion
IV alteplase (0.9 mg/kg, max 90 mg; 10% bolus over one minute, remainder over 60 minutes) is approved within 4.5 hours of last known well; tenecteplase 0.25 mg/kg as a single bolus is an accepted alternative at many centers. Endovascular thrombectomy is standard for anterior large-vessel occlusion up to 6 hours, and up to 24 hours in selected patients with favorable imaging (DAWN/DEFUSE-3 criteria).
Blood pressure rules
Before thrombolysis: lower to below 185/110 mmHg using labetalol or nicardipine. After thrombolysis: maintain below 180/105 for at least 24 hours. Avoid aggressive lowering in ischemic stroke without reperfusion therapy, since pressure supports collateral flow.
Monitoring and complications
Neuro checks and vital signs every 15 minutes for 2 hours, every 30 minutes for 6 hours, then hourly to 24 hours. Withhold antiplatelets and anticoagulants for 24 hours and repeat imaging before restarting. Suspect symptomatic intracranial hemorrhage with any NIHSS worsening, new headache, nausea/vomiting, acute hypertension, or declining consciousness: stop the infusion, obtain emergent CT, check fibrinogen and coagulation studies, and prepare cryoprecipitate, antifibrinolytic therapy, and platelets per protocol. Orolingual angioedema (higher risk with ACE inhibitors) requires airway assessment and prompt management.
For intracerebral hemorrhage, priorities are blood pressure control, rapid reversal of anticoagulation, neurosurgical consultation, and head-of-bed positioning with avoidance of unnecessary lines.
Traps: do not give aspirin within 24 hours of thrombolysis; do not delay treatment for nonessential labs; recognize that a stable exam can deteriorate abruptly.
Rule of thumb: 185/110 to start, 180/105 to maintain.