From the Guidelines
The management of a patient with stroke requires immediate action following a "time is brain" approach, with the most recent and highest quality study 1 emphasizing the importance of admission to a stroke unit for monitoring, swallowing assessment, early mobilization, and prevention of complications.
Initial Assessment and Treatment
Initial assessment should include rapid neurological evaluation using the NIH Stroke Scale, urgent neuroimaging (CT or MRI), and determination of stroke type (ischemic vs. hemorrhagic).
- For ischemic stroke, if the patient presents within 4.5 hours of symptom onset and has no contraindications, intravenous recombinant tissue plasminogen activator (rtPA, alteplase) should be administered at 0.9 mg/kg (maximum 90 mg), with 10% given as a bolus and the remainder over 60 minutes, as recommended by 1 and 1.
- For eligible patients presenting within 24 hours, endovascular thrombectomy may be considered, as suggested by 1 and 1.
Secondary Prevention and Long-term Management
Secondary prevention includes addressing modifiable risk factors, such as hypertension, diabetes, hyperlipidemia, and smoking cessation, as emphasized by 1.
- Long-term management involves rehabilitation services tailored to individual deficits, including physical, occupational, and speech therapy, which should begin as soon as the patient is medically stable to maximize functional recovery, as recommended by 1 and 1.
Blood Pressure Management and Antiplatelet Therapy
Blood pressure management is crucial, maintaining systolic BP below 180 mmHg for patients receiving thrombolysis, as recommended by 1 and 1.
- Antiplatelet therapy with aspirin (325 mg initially, then 81 mg daily) should be started within 24-48 hours after ischemic stroke, as suggested by 1 and 1.
Admission to a Stroke Unit
All stroke patients require admission to a stroke unit for monitoring, swallowing assessment before oral intake, early mobilization, and prevention of complications like deep vein thrombosis, as emphasized by 1 and 1.
- The core interdisciplinary team on the stroke unit should consist of healthcare professionals with stroke expertise, including physicians, nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers, and clinical nutritionists, as recommended by 1.
From the Research
Approach to the Patient with Stroke
The approach to managing a patient with stroke involves several key steps, including:
- Diagnosis of the type of stroke, which can be categorized as ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage 2
- Identification of the common presenting symptoms of ischemic stroke, such as speech disturbance and weakness on one-half of the body 2
- Exclusion of stroke mimics, such as seizure, conversion disorder, migraine headache, and hypoglycemia, through patient history and diagnostic studies 2
- Use of neuroimaging to differentiate ischemic stroke from intracerebral hemorrhage and to diagnose other entities 2
Diagnostic Studies
Diagnostic studies, such as noncontrast head computed tomography, are essential in diagnosing subarachnoid hemorrhage and excluding other conditions 2
- Cerebrospinal fluid inspection for bilirubin is recommended if subarachnoid hemorrhage is suspected in a patient with a normal computed tomography result 2
Treatment Options
Treatment options for acute ischemic stroke include:
- Thrombolysis, which has been shown to improve functional outcome in stroke patients 3
- Mechanical thrombectomy, which has been demonstrated to improve functional outcome in stroke patients over intravenous thrombolysis alone 3
- Bridging therapy, which involves intravenous thrombolysis followed by endovascular therapy 4
- New thrombolytic strategies, such as tenecteplase, which have shown improved rates of recanalization compared to tissue-type plasminogen activator (alteplase) 3, 4
Emergency Care
Emergency care of patients with acute ischemic stroke is critical to patient outcomes, and management in the first hours is crucial 5