Neurocritical Care
Reduce blood pressure cautiously to avoid hypotension or underperfusion of infarcted area (less
than 15% blood pressure lowering).
Resumption of home blood pressure medications is reasonable 24 hours after the onset of stroke.
| d. | Recommended to treat blood pressure in patients who do not receive thrombolytics if it exceeds |
|---|
SBP greater than 220 mm Hg or DBP greater than 120 mm Hg
Seizure prophylaxis. Use of anticonvulsant medications for seizure prophylaxis is not indicated after
ischemic stroke.
Mechanical thrombectomy and neuroendovascular interventions for ischemic stroke
Neuroendovascular devices may be used to remove or disrupt clot to facilitate recanalization.
No difference in safety outcomes when comparing usual care with usual care plus mechanical
thrombectomy
Many clinical trials support mechanical thrombectomy in patients with acute ischemic stroke.
Increases the likelihood of independence or improved modified Rankin Scale score compared with
standard therapy
Does not increase the risk of intracerebral hemorrhage (ICH)
Extends the treatment window to 24 hours after last known well for both patients receiving tissue
plasminogen activator (tPA) within the therapeutic window and those who are ineligible for tPA if
they meet selection criteria
Blood pressure management after thrombectomy
Current literature suggest that intensive blood pressure lowering should be avoided following
thrombectomy. The conventional target systolic BP of 140–180 mm Hg appears reasonable following
successful thrombectomy and is associated with better outcomes following thrombectomy (Mistry
2023; Nam 2023).
Secondary prevention
Initiating aspirin (325 mg × 1; then 81–325 mg/day), a high-intensity statin, and an intensive blood
pressure regimen is necessary.
Ideally, give as soon as feasible after the onset of stroke.
ii.
Aspirin should not be initiated within 24 hours of alteplase.
Clopidogrel 75 mg daily is also an option in patients whose aspirin therapy has failed or who have
an aspirin allergy.
Aggrenox (dipyridamole/aspirin) and ticagrelor plus aspirin (less than 100 mg) are also effective
alternatives to aspirin for secondary prevention.
| d. | Control/modification of other disease states is often necessary. |
|---|
Hypertension: typical blood pressure goal is less than 130/80 mm Hg (Stroke 2021;52:e364-467).
Atrial fibrillation
Rate or rhythm control
ii.
Anticoagulation (warfarin, direct-acting oral anticoagulants)
iii.
Typically, anticoagulant therapy is delayed until at least 5–14 days after stroke to reduce the
risk of hemorrhagic conversion.
iv.
Avoid using loading doses of warfarin.
Carotid artery stenosis: Stent versus endarterectomy (usually for patients with greater than 70%
blockage and/or clinically evident symptoms)
Aspirin 81–325 mg daily after endarterectomy
ii.
Dual antiplatelet therapy should be given for 3 months if stent placement is required, followed
by one antiplatelet agent thereafter.
Control of diabetes (blood glucose 140–180 mg/dL)
Identification and treatment of inherited or acquired hypercoagulable states