From the Guidelines
The clinical course of stroke is a complex and dynamic process that requires immediate attention and management to minimize morbidity and mortality, with the most critical period being the first 24-48 hours after onset of symptoms. The clinical presentation of stroke typically begins with sudden onset of neurological deficits that reflect the affected brain region, including symptoms like facial drooping, arm weakness, speech difficulties, vision problems, or severe headache. According to the most recent guidelines 1, the initial imaging for adult patients with recent ischemic infarct, less than 24 hours, should focus on rapid stroke diagnosis and triage, particularly in the setting of possible large vessel occlusion (LVO).
The first step in managing stroke patients is to determine the type of stroke, whether ischemic or hemorrhagic, as this will guide treatment decisions. The American Stroke Association guidelines 1 recommend that all patients with suspected acute ischemic stroke should undergo immediate diagnostic studies, including brain CT or MRI, electrocardiogram, blood glucose, serum electrolytes, renal function tests, complete blood count, and coagulation studies.
During the acute phase (first week), patients require close monitoring of vital signs, neurological status, and prevention of complications. Medical management includes antiplatelet therapy (aspirin 325mg initially, then 81mg daily) for ischemic stroke or blood pressure control for hemorrhagic stroke. The use of thrombolytic agents, such as tissue plasminogen activator (tPA), is also crucial in the management of ischemic stroke, but the decision to use these agents should be made on a case-by-case basis, taking into account the time of onset of symptoms, the severity of the stroke, and the presence of any contraindications.
After stabilization, patients enter a subacute phase (weeks 1-4) characterized by early recovery as brain edema resolves. The chronic phase (beyond 1 month) involves continued but slower improvement through neuroplasticity. Most significant recovery occurs within 3-6 months, though improvements can continue for years. Complications may include pneumonia, deep vein thrombosis, depression, and seizures. Long-term outcomes vary widely based on stroke severity, location, age, comorbidities, and access to rehabilitation. About 25% of stroke survivors experience another stroke within 5 years, highlighting the importance of secondary prevention through risk factor management and appropriate medications.
Key factors that influence the clinical course of stroke include:
- Time of onset of symptoms and time to treatment
- Severity of the stroke
- Location of the stroke
- Presence of comorbidities, such as hypertension, diabetes, and atrial fibrillation
- Access to rehabilitation and secondary prevention measures
- Use of evidence-based treatments, such as antiplatelet therapy and thrombolytic agents.
Overall, the clinical course of stroke is a complex and dynamic process that requires a multidisciplinary approach to management, including emergency medical services, neurology, radiology, and rehabilitation medicine. By prioritizing rapid diagnosis and treatment, minimizing complications, and promoting secondary prevention, healthcare providers can improve outcomes and reduce morbidity and mortality in patients with stroke.
From the Research
Clinical Course of Stroke
The clinical course of stroke is a complex and time-dependent process that requires urgent attention and coordinated management to provide the best treatment as early as possible 2.
Key Aspects of Stroke Management
- Early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment is crucial 3
- General measures to ensure patient hemodynamic stability are essential in the acute phase of ischemic stroke 2
- Reperfusion therapies, including intravenous thrombolytics and mechanical thrombectomy, are critical in minimizing the impact of acute ischemic stroke 4, 5, 3
- Monitoring and controlling vascular risk factors, as well as antithrombotic treatment, are necessary to prevent early recurrences 2
Advances in Stroke Care
- Recent advances in stroke care have led to the development of new treatments, including tenecteplase, and the expansion of treatment eligibility for patients with acute ischemic stroke 4, 6
- The use of multimodal CT and MRI has improved the ability to individualize treatment and preserve cerebral blood flow 4
- Emerging therapies and protocols for management of patient physiologic parameters are being developed to minimize infarct volumes and improve outcomes 3