Ischemic Stroke: Reperfusion Window

• For disabling deficits (not NIHSS alone) give alteplase 0.9 mg/kg or tenecteplase 0.25 mg/kg (max 25 mg, co-equal Class 1, AHA/ASA 2026) within 4.5 h; IVT can extend to 4.5–9 h when imaging shows mismatch, and thrombectomy treats LVO up to 24 h, now including large core (ASPECTS 3–5) and basilar occlusion.
• Bring BP below 185/110 before any IV lytic; otherwise allow permissive hypertension unless the patient is lysed (keep ≤180/105 post-lytic; driving SBP <140 after thrombectomy is harmful); screen swallowing before anything PO.
• Aspirin 24 h after lysis once imaging is repeated; statin + DVT prophylaxis.
• Large MCA with edema: decompressive hemicraniectomy if <60 y within 48 h.

Managing Malignant Cerebral Edema From Stroke

• Stage 1: Early ICU care and monitoring — check vitals and mental status at least every 2 hours · head of bed elevated 30 degrees · head midline to avoid jugular compression · keep normothermia and euglycemia · no hypotonic solutions · permissive hypertension — treat only if SBP >220 mm Hg or DBP >120 mm Hg · intubate if airway protection is impaired or oxygenation/ventilation cannot be maintained (GCS <9 often requires intubation)
• Stage 2: Osmotic therapy for intracranial hypertension — avoid hypercarbia (ensure adequate minute ventilation, treat fever) · intravenous mannitol boluses (see Chapter 60) · hypertonic saline an option if mannitol fails or is contraindicated
• Stage 3: Surgery for cerebral edema — neurosurgery consult for possible decompressive hemicraniectomy · get surgical evaluation before offering to family · continue osmotic therapy and medical management
• Stage 4: Experimental approaches (induced hypothermia)