From the Guidelines
If a patient admitted for stroke shows worsening symptoms, immediate medical attention is crucial, and the healthcare team should consider interventions such as thrombolysis with intravenous alteplase or mechanical thrombectomy for large vessel occlusions, as recommended by recent guidelines 1. Worsening symptoms may include increasing weakness or numbness, worsening speech difficulties, visual changes, altered consciousness, or severe headache. Time is critical in stroke management as "time is brain" - every minute delay can result in significant neuronal loss. The healthcare team will likely perform a rapid neurological assessment, obtain urgent brain imaging (CT or MRI), and consider the patient's eligibility for thrombolysis or mechanical thrombectomy, taking into account the time window from symptom onset and other factors such as blood pressure and anticoagulation status, as outlined in guidelines for the management of acute ischemic stroke 1. Key considerations in the management of worsening stroke symptoms include:
- Rapid assessment and diagnosis to determine the cause of worsening symptoms
- Urgent brain imaging to guide treatment decisions
- Consideration of thrombolysis or mechanical thrombectomy for eligible patients
- Blood pressure management, with permissive hypertension allowed initially in ischemic stroke unless thrombolysis is planned, and more aggressive control in hemorrhagic stroke
- Continuous neurological monitoring to track changes in the patient's condition. Early recognition and rapid response to worsening stroke symptoms significantly improve outcomes by limiting brain tissue damage, as emphasized in recent guidelines for the safe transfer of brain-injured patients, including those with stroke 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Worsening Stroke Symptoms
If a patient admitted for stroke shows worsening symptoms, it is essential to swiftly identify the cause and provide appropriate treatment. The causes of clinical worsening are diverse and can include:
- Collateral failure
- Brain edema
- Seizures
- Reocclusion after successful initial therapeutic recanalization
- Systemic medical complications 2
Diagnostic Approaches
To evaluate the deteriorating stroke patient, the following diagnostic approaches can be used:
- History
- Physical examination
- Screening blood work
- Emergent reassessment of the cervical and cerebral vasculatures, regional hypoperfusion, and infarct core 2
- Multimodal computed tomography and magnetic resonance imaging can also be used to transform the evaluation of the deteriorating stroke patient 2
Treatment Options
The therapeutic armamentarium for the worsening stroke patient has expanded greatly and now includes:
- Rescue late endovascular recanalization therapy
- Pressor collateral enhancement therapy
- Hemicraniectomy
- Additional novel interventions in addition to enhanced supportive care 2
- Tissue plasminogen activator (t-PA) for acute ischemic stroke, which has been shown to improve clinical outcome at three months, despite an increased incidence of symptomatic intracerebral hemorrhage 3
- Combining statins with t-PA treatment, which has been found to be safe and does not increase the risk of hemorrhagic transformation 4
Emergency Care
In the emergency care of patients with acute ischemic stroke, it is crucial to manage blood pressure before thrombolytic therapy. Elevated blood pressure can lead to a delay in thrombolytic therapy, which is associated with increased morbidity. The use of antihypertensive agents such as labetalol, nicardipine, or hydralazine can help control blood pressure before alteplase administration 5 The initial evaluation and management of acute ischemic stroke, including prehospital considerations, initial evaluation, and treatment options, such as thrombolysis and endovascular therapy, are critical to patient outcomes 6