Stroke
Topic Discussion
Piedmont Atlanta Hospital
Emergency Department Rotation
Resources/Guidelines
2019 AHA/ASA ischemic stroke treatment guidelines (as of January 2025)
Types of Stroke
Acute Ischemic Stroke (AIS)
o Account for most strokes (87%)
o Caused by obstructions (thrombus or embolism) reducing blood flow
Hemorrhagic Stroke
o Caused by a ruptured blood vessel, leading to bleeding in the brain
o Includes intracerebral and subarachnoid hemorrhage
Transient Ischemic Attack (TIA)
o Temporary blockage of blood flow that resolves without permanent damage
o Often a warning sign for future strokes
Ischemic Stroke Background
Symptoms
o Facial drooping
o Unilateral weakness
o Slurred speech
Signs
o Ischemic changes on CT
Pharmacological Management for Ischemic Stroke
IV Thrombolysis – Alteplase (Activase) (tPA)
o MOA: Recombinant tissue plasminogen activator (tPA) – initiates local
fibrinolysis by binding to fibrin in a thrombus and converting plasminogen into
plasmin, in turn, plasmin breaks up the thrombus.
o The only drug FDA approved for treating acute ischemic stroke
o Indication: Patients presenting within 3–4.5 hours of symptom onset
o Dose: 0.9 mg/kg IV (maximum dose: 90 mg); 10% as a bolus over 1 minute,
remaining infused over 1 hour
Patient weight < 100kg:
Bolus: 0.09 mg/kg IV over 1 minute (10% of 0.9 mg/kg dose)
Continuous infusion: 0.81 mg/kg (90% of 0.9 mg/kg dose) over
one hour
If patient weight > 100kg:
Bolus: 9mg over 1 minute (e.g. 10% of full dose)
Continuous infusion: 81 mg over one hour
o Contraindications:
Intracranial or subarachnoid hemorrhage
Active internal bleeding
Recent head trauma or stroke (within 3 months)
Severe uncontrolled hypertension (SBP > 185 mmHg or DBP > 110
mmHg)
IV Thrombolysis – Tenecteplase
o Modified version of alteplase, used off-label for acute ischemic stroke. Also used
for pulmonary embolism, and STEMI in centers that do not have percutaneous
coronary intervention (PCI) capability (preferred)
o Single bolus dosing provides faster and easier administration, translating to faster
door-to-needle times compared with alteplase
o Indication (off-label) – acute ischemic stroke presenting within 4.5 hours of
symptom onset
o Dose: IV 0.25mg/kg, max total dose: 25mg once
o Contraindications:
Contraindications for the treatment of AIS:
Intracranial hemorrhage (history or current)
Subarachnoid hemorrhage (suspicion of or confirmed)
Active internal bleeding, recent or within 3 months
Head/spine surgery or severe head trauma within 3 months
Previous ischemic stroke within 3 months
GI malignancy or bleed within 21 days
Persistent BP elevation (SBP >185 or DBP >110)
Current use within 48 hours of oral anticoagulants with INR > 1.7
or PT > 15 seconds, current use of direct factor Xa inhibitors or
thrombin inhibitors
Previous full treatment dose LMWH within previous 24 hours
o Additional Pearls:
Wait 24 hours after administration to give antiplatelet or anticoagulant
therapy
No renal dosing adjustment necessary
Mechanical Thrombectomy
o Indication: Large vessel occlusion up to 24 hours after symptom onset.
o Pharmacological support may include anticoagulation and antiplatelet therapy
post-procedure
Antiplatelet Therapy
o Aspirin: Administer within 24–48 hours (160–325 mg daily) if no thrombolysis
o Dual antiplatelet therapy (DAPT): Short-term aspirin + clopidogrel for minor
strokes or TIA
Anticoagulation
o Reserved for cardioembolic strokes due to atrial fibrillation.
o Common agents: warfarin, direct oral anticoagulants (DOACs).
Pharmacological Management of Hemorrhagic Stroke
Blood pressure management
o Goal SBP < 140-160 mmHg
o Agents: Nicardipine or Labetalol
Reverse anticoagulation
o Agent depends on cause
o Warfarin reversal Vitamin K and prothrombin concentrates
o Dabigatran reversal Idarucizumab
o Apixaban or Rivaroxaban Reversal Andexanet alfa
o NOTE: Edoxaban does NOT currently have a reversal agent, reversal relies on
non-specific agents (activated prothrombin complex or fresh frozen plasma)
Seizure prophylaxis (if clinically indicated)
o Levetiracetam or fosphenytoin
Managing Intracranial Pressure (ICP)
o Hyperosmolar agents: Mannitol or hypertonic saline
o Goal: gradual reduction in intracranial pressure
Secondary Prevention
Ischemic Stroke:
o Antihypertensive therapy (ACE inhibitors, ARBs)
o Lipid-lowering agents (high-intensity statins)
o Antiplatelet agents (aspirin, clopidogrel)
Hemorrhagic Stroke:
o Address modifiable risk factors (e.g., hypertension)
