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What if the patient is not a candidate for intravenous tissue plasminogen activator?
In patients not treated with thrombolysis, aspirin (orally or rectally) reduces the chances of recurrent stroke when given within 48 hours.
Optimal blood pressure for nonthrombolysed patients is not known but is often permitted to run high as long as there are no signs of hypertensive end-organ damage.
This “permissive hypertension” is theoretically designed to increase perfusion of brain tissue at continued risk for ischemia, but it is not clear that this strategy improves outcomes.
Avoid sudden drops or rises in blood pressure: relative hypotension associated with neurologic worsening should be treated with IV fluids. Lowering the head of the bed and administering vasopressors may also be considered.
Sources
Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 333(24):1581-1587, 1995.
Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al.: Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359(13):1317-1329, 2008.
