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 infarct deteriorating from swelling: urgent neurosurgical review for decompressive hemicraniectomy within 48 h. Benefit is proven at age ≤60; selected older patients may be considered after discussing likely disability and goals.

Managing Malignant Cerebral Edema From Stroke

• Early ICU care: frequent neuro and BP checks; head midline, head up about 30° when ICP or aspiration risk calls for it; keep oxygenation, temperature and glucose normal. No hypotonic fluids. If not reperfused, allow BP up to 220/120 unless another emergency needs it lower; after reperfusion use the separate post-reperfusion targets. Protect the airway when needed.
• 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
• Deteriorating from malignant hemispheric swelling: get neurosurgery now — do not wait for osmotherapy to fail. Consider decompressive hemicraniectomy within 48 h, especially at age ≤60. In selected older adults, first discuss likely survival, disability and goals. Continue supportive care meanwhile.
• Do not use hypothermia, barbiturates or corticosteroids to treat ischaemic brain swelling. Escalate standard ICP measures and definitive surgery; experimental treatments belong in a trial.

Acute Ischemic Stroke: The Reperfusion Decision

• Suspected stroke → record the last-known-well time, check glucose, score the NIHSS and secure airway and breathing; move straight to non-contrast CT with CT angiography, aiming for door-to-imaging within 20 minutes
• Haemorrhage on the scan?
• Yes
• Stop the thrombolysis pathway and switch to the intracerebral haemorrhage bundle — blood pressure, anticoagulant reversal and a neurosurgical opinion
• No
• Disabling deficit within 4.5 hours of last-known-well, with no absolute contraindication?
• Eligible
• Bring the blood pressure below 185/110 mm Hg first with labetalol or nicardipine, then give IV thrombolysis: tenecteplase 0.25 mg/kg as a single bolus (maximum 25 mg) or alteplase 0.9 mg/kg (10% as a bolus, the rest over 60 minutes, maximum 90 mg). Target door-to-needle within 60 minutes
• After thrombolysis keep the blood pressure under 180/105 mm Hg for 24 hours, withhold antiplatelets and anticoagulants for 24 hours, and repeat imaging before starting them
• Not eligible
• Beyond 4.5 hours, with an unclear onset or a wake-up stroke, use CT perfusion or MRI DWI–FLAIR mismatch to identify salvageable tissue. Time alone is no longer a sufficient reason to exclude a patient
• Large-vessel occlusion — intracranial carotid, M1, or basilar — on CT angiography?
• Yes
• CTA-confirmed eligible large-vessel occlusion: call the thrombectomy team now. Selection rests on occlusion site, deficit, baseline function, time and infarct size; selected patients benefit up to 24 h, including some large cores and basilar occlusions. Advanced imaging helps but is not required for every late-window patient. Give indicated IV thrombolysis without delaying transfer.
• A large established core is no longer an automatic exclusion — recent trials show benefit from thrombectomy in selected large-core infarcts, so discuss rather than decline
• No
• Stroke-unit care: aspirin within 24–48 h once bleeding is excluded; after IV thrombolysis, wait 24 h and repeat imaging first. 21-day aspirin–clopidogrel only for eligible noncardioembolic minor stroke or high-risk TIA without IV thrombolysis (see the Treatment popup). Swallow screen before anything by mouth, avoid hypoglycaemia, treat fever, mobilise when stable and assess VTE prophylaxis.
• In a patient not receiving reperfusion, do not lower the blood pressure acutely unless it exceeds 220/120 mm Hg or there is another indication such as aortic dissection or heart failure — permissive hypertension protects the penumbra.

Neurological Deterioration After Reperfusion

• Any new headache, vomiting, fall in GCS, new deficit or sudden hypertension during or within 24 hours of reperfusion → stop the thrombolytic infusion and get an immediate non-contrast CT head
• Haemorrhage confirmed?
• Yes
• Send CBC, PT/INR, aPTT, fibrinogen and crossmatch. Give cryoprecipitate 10 units IV now; recheck fibrinogen and repeat to keep it ≥1.5 g/L. If cryoprecipitate is unavailable or blood products are declined, give tranexamic acid 1 g IV over 10 min instead. Call haematology and neurosurgery; platelets are not routine.
• Control systolic blood pressure to 140–160 mm Hg, reverse any other anticoagulant the patient is on, and manage raised intracranial pressure as for any space-occupying bleed
• No
• Look for the other causes before accepting 'progression': malignant cerebral oedema, re-occlusion of the treated vessel, seizure, hypoglycaemia, hypoxia, sepsis and residual sedation. Repeat imaging if the clinical picture does not fit the scan
• Orolingual angio-oedema complicates roughly 1–5% of alteplase treatments and is commoner in patients taking an ACE inhibitor: stop the infusion, secure the airway early while it is still possible, and treat with an antihistamine, a corticosteroid and adrenaline if it is progressing.