With thrombolysis, intravenous
alteplase (0.9 mg/kg
body weight, maximum 90 mg), with 10% of the dose given as a bolus followed by a 60-minute infusion, is recommended within 4.5 hours of onset of
ischemic stroke. When indicated, intravenous thrombolysis must be initiated as soon as possible. It is possible to use intravenous
alteplase in patients with
seizures at
stroke onset, if the neurological deficit is related to acute
cerebral ischemia. Intravenous
alteplase can be discussed for use on a case-by-case basis, according to risk of
bleeding, in selected patients under 18 years and over 80 years of age, although for the current European recommendations this would be an
off-label use. In hospitals with a
stroke unit, intravenous thrombolysis is prescribed by a neurologist (current French labelling) or a physician having the French certification for neurovascular diseases (outside the current French labelling). The patient must be monitored in the
stroke unit or in case of
multiple organ failure in an intensive and
critical care unit. In hospitals without a
stroke unit, thrombolysis must be decided by the neurologist from the corresponding
stroke unit via telemedicine. It is recommended to perform brain imaging 24 hours after thromboysis. Intra-arterial thrombolysis can be contemplated on a case-by-case basis after multidisciplinary discussion within a 6-hour time window for patients with acute middle cerebral artery or carotid occlusions, and within a larger time window for patients with basilar artery occlusion, because of their very poor spontaneous prognosis. Mechanical
thrombectomy can also be contemplated in the same situations. With
antiplatelet agents, it is recommended that patients receive
aspirin (160 mg-325 mg) within 48 hours of
ischemic stroke onset. When thrombolysis is performed or contemplated, it is recommended to delay the initiation of
aspirin or other antithrombotic drugs for 24 hours. The use of
antiplatelet agents that inhibit the
glycoprotein IIb/IIIa receptor is not recommended. Urgent anticoagulation using
heparin, low-molecular-weight heparins or
danaparoid with the goal to treat
ischemic stroke patients is not recommended.
Secondary prevention by anticoagulation can be used, immediately or within the first days, after minor
ischemic stroke or TIA in patients with a high risk for cardioembolism, if uncontrolled
hypertension is absent. In patients with large
infarcts and a high risk for cardioembolism, the timing for initiating anticoagulation must be decided on a case-by-case basis. In patients with anticoagulation who had an
ischemic stroke, the decision to temporarily stop or maintain anticoagulation must be made on a case-by-case basis, depending on thromboembolic risk, level of anticoagulation at
stroke onset and estimated risk of hemorrhagic transformation. It is not recommended to use
neuroprotective agents in
ischemic stroke patients. Patients with cerebral
venous thrombosis must be treated with therapeutic doses of
heparin, even in case of concomitant
intracranial hemorrhage related to cerebral
venous thrombosis. If the patient's status worsens despite adequate anticoagulation, thrombolysis may be used in selected cases. The optimal administration route (local or intravenous),
thrombolytic agent (
urokinase or
alteplase) and dose are unknown. There is currently no recommendation with regard to local
thrombolytic therapy in patients with dural
sinus thrombosis. Urgent
blood transfusions are recommended to reduce
hemoglobin S to <30% in patients with
sickle cell disease and
acute ischemic stroke.