What is the timeline for managing a suspected stroke?

Timeline for Managing a Suspected Stroke

Immediate recognition and rapid management of suspected stroke is critical, with time-sensitive interventions required within specific timeframes to reduce morbidity and mortality.

Initial Recognition and Pre-Hospital Management

Highest Risk Patients (Within 48 Hours of Symptom Onset)

• Patients with unilateral weakness (face, arm, leg) or speech disturbance:
  • Must be immediately transported to an emergency department with advanced stroke care capabilities 1
  • EMS should use validated stroke screening tools (like FAST - Face, Arm, Speech, Time) 1
  • Hospital pre-notification by EMS is essential to mobilize stroke teams 1

Emergency Medical Services Response

• Immediate contact with EMS (911) is strongly recommended upon recognition of stroke symptoms 1
• EMS should prioritize rapid transport to appropriate stroke-capable facilities, bypassing hospitals without stroke resources 1
• On-scene goal is to "recognize and mobilize" - minimize time spent at the scene 1

Emergency Department Evaluation (Time-Critical)

Immediate Assessment (First Minutes)

• Rapid evaluation of airway, breathing, and circulation 1
• Neurological examination using standardized scales (NIHSS or Canadian Neurological Scale) 1
• Assessment of vital signs: heart rate, blood pressure, temperature, oxygen saturation 1

Urgent Diagnostic Imaging (Target: Within 24 Hours, Ideally Much Sooner)

• Brain imaging (CT or MRI) must be completed urgently to rule out hemorrhage 1
• For patients eligible for thrombolysis, CT should be performed immediately 1
• Vascular imaging (CTA or MRA from aortic arch to vertex) should be completed without delay 1

Laboratory Testing

• Initial blood work: electrolytes, glucose, CBC, coagulation studies (INR, aPTT), creatinine, eGFR, troponin 1
• ECG should be completed but should not delay thrombolysis decisions 1

Treatment Decision Timeline

Thrombolytic Therapy Window

• IV tPA must be administered within 4.5 hours of symptom onset 2
• Decision-making should be expedited, with a goal of treatment within 60 minutes of hospital arrival 3
• Benefit of thrombolysis is time-dependent, with greatest benefit when given early 4

Endovascular Therapy Window

• May be considered within 24 hours of symptom onset with evidence of salvageable brain tissue 2
• Most beneficial for patients with large vessel occlusion 2

Risk Stratification for TIA and Minor Stroke

Risk Categories and Management Timeframes

1. Highest Risk (Symptoms within 48 hours):

   • Immediate ED evaluation and imaging 1

2. Increased Risk (Symptoms between 48 hours and 2 weeks):

   • Comprehensive evaluation within 24 hours for motor/speech symptoms 1
   • Evaluation within 2 weeks for non-motor/speech symptoms 1

3. Lower Risk (Symptoms >2 weeks ago):

   • Neurologist evaluation within 1 month 1

Post-Acute Management

Early Secondary Prevention

• Aspirin (160-300mg) should be started within 48 hours of ischemic stroke onset 1
• Carotid revascularization benefit diminishes significantly beyond 2 weeks after symptom onset 1
• After 4 weeks in women and 12 weeks in men, the benefit of carotid surgery is reduced to that observed in asymptomatic patients 1

Common Pitfalls to Avoid

1. Delayed Recognition:

   • Public awareness of stroke symptoms remains low, with only 16.4% of people recognizing all symptoms and the need to call 911 5
   • Failure to distinguish between symptom onset and symptom recognition can lead to treatment delays 6

2. Stroke Mimics:

   • Up to 36.6% of suspected stroke patients may have non-neurological conditions 6
   • Common mimics include seizures, hypoglycemia, migraine, and hypertensive encephalopathy 1

3. Neglecting General Care:

   • Failure to manage blood glucose (target <8 mmol/L), blood pressure, temperature, and oxygen saturation can worsen outcomes 7
   • Homeostasis maintenance is associated with better outcomes 7

4. Missing the Treatment Window:

   • Delays in seeking medical attention or in-hospital delays can result in missed opportunities for thrombolysis 4
   • Only about 3-7% of eligible stroke patients receive thrombolytic therapy, often due to delays 1

Remember that "time is brain" - each minute delay in stroke treatment results in the loss of approximately 1.9 million neurons, emphasizing the critical importance of rapid assessment and management.