Nonthrombolytic therapy for patients who are not candidates for rTPA after ischemic stroke

TARGET: 

✔️optimization of CBF

✔️prevention of secondary brain injury, infarct extension & hemorrhagic conversion 

✔️avoid post-stroke complications (e.g., pulmonary embolus and aspiration pneumonia)

✔️ early mobilization and rehabilitation

✔️ attention to psychiatric ( e.g. Depression) and social consequences of stroke and assistance with daily activities.

(1) Airway management, hemodynamic monitoring, and treatment of increased ICP 

(2) aggressive antihypertensive therapy may exacerbate ischemia by decreasing CBF. A generally accepted cutoff for the administration of antihypertensive therapies is SBP >220 mm Hg, DBP >120 mm Hg, or MAP >130 mm Hg. 

(3) In the absence of hemorrhage on a CT scan, antiplatelet therapy is initiated in the form of aspirin starting with 325 mg by mouth followed by 81 to 160 mg daily.

(4) Multiple studies have failed to show a benefit to heparin administration ; but anticoagulation is usually initiated when atrial fibrillation is present.

(5) Hyperglycemia worsens neurologic outcome. So , euglycemia (80 to 110 mg/dL) is beneficial if it can be achieved without substantially increasing the risk of hypoglycemia.

(6) Seizures are treated with phenytoin, loading dose 15 mg/kg i.v. over 20 minutes followed by 5 to 7 mg/kg/day, or fosphenytoin, loading dose PE 15 to 20 mg/kg i.v., and then 4 to 6 PE mg/kg/day.

(7) DVT prophylaxis is provided using pneumatic compression or low-molecular-weight heparin e.g. enoxaparin, 0.5 mg/kg subcutaneously twice a day.

(8) After the evaluation of airway reflexes and adequacy of swallowing, nutrition is provided via a suitable route.

(9) A few studies suggest that positioning the head end of the bed at 15° for patients who have normal ICP improves CBF and neurologic function.

(10) Rehabilitation and psychiatric evaluation. e.g. Treatment of depression and other psychiatric comorbidities facilitates rehabilitation and improves functional status.

Ref: Seth Manoach, Jean G. Charchaflieh, Handbook of Neuroanesthesia, 4th Edition, Lippincott Williams & Wilkins