What are the guidelines for managing a stroke?

Guidelines for Stroke Management

Patients with suspected stroke should be urgently transported to the nearest stroke-capable hospital, where they should receive immediate brain imaging and be admitted to a specialized stroke unit for comprehensive care. 1

Prehospital Management

• Use validated stroke assessment tools like FAST (Face, Arm, Speech, Time) for initial screening 1
• Designate suspected stroke cases as high priority with target on-scene time of ≤20 minutes 1
• Transport patients rapidly to the closest appropriate stroke-capable hospital 1
• Provide prehospital notification to the receiving hospital to mobilize resources 1
• Consider direct transport to comprehensive stroke centers for suspected large vessel occlusion 1
• For rural areas, consider air medical transport when ground transport exceeds 1 hour 1

Emergency Department Evaluation

• Complete initial evaluation within 30 minutes of hospital arrival, including:
  • Non-contrast CT head to differentiate between ischemic and hemorrhagic stroke 1, 2
  • CT angiography of head and neck for eligible patients 1
  • Basic laboratory tests (complete blood count, electrolytes, glucose, coagulation studies, renal function) 1
• Determine exact time of symptom onset or "last known well" time 1
• Perform standardized stroke scale assessment (NIHSS preferred) 1
• Assess for stroke risk factors and obtain medication history 1

Acute Treatment

Ischemic Stroke

• Administer intravenous alteplase (tPA) to eligible patients with target door-to-needle time <60 minutes (ideally <30 minutes) 1
• Standard dose: alteplase 0.9 mg/kg (maximum 90 mg) 1
• Consider endovascular thrombectomy for patients with:
  • Large vessel occlusion
  • Clinical severity (typically NIHSS ≥6)
  • Time window up to 24 hours in select patients
  • ASPECTS score ≥6 1

Hemorrhagic Stroke

• Implement blood pressure control protocols 1
• It is suggested that blood pressure lowering in ICH patients with hypertension is indicated only to keep mean arterial blood pressure below 130 mmHg 2
• Surgery may be considered in specific situations (e.g., craniotomy for superficial ICH <1 cm from surface or stereotactic surgery for deep ICH) 2
• ICH due to anticoagulation should be urgently reversed 2

Hospital Care

• Admit patients to a specialized stroke unit whenever possible 1, 2
  • Stroke units have been shown to lessen rates of mortality and morbidity with benefits persisting for years 2
  • The benefits from treatment in a stroke unit are comparable to the effects achieved with intravenous rtPA 2
• Monitor vital signs, neurological status, and oxygen saturation regularly 1
• Implement dysphagia screening before oral intake 1
• Provide DVT prophylaxis with intermittent pneumatic compression devices 1
• Begin early mobilization within 24 hours if no contraindications 1
• Monitor temperature every 4 hours for first 48 hours and treat fever >37.5°C 1
• Evaluate for stroke etiology to guide secondary prevention strategies 1

Rehabilitation and Discharge Planning

• Complete standardized assessments of stroke-related impairments and functional status 1
• Conduct formal assessment for rehabilitation needs within 72 hours post-stroke 1
• If ongoing inpatient rehabilitation is needed, care should be provided in either a stroke rehabilitation unit or a general rehabilitation unit 2
• Rehabilitation in the community is equally effective if delivered in the hospital via outpatients, day hospital, or in the community 2
• Before discharge, assess patients to determine the need for a home visit 2
• Provide specific training for carers before discharge, including personal care techniques, communication strategies, and physical handling techniques 2

Carotid Intervention for Secondary Prevention

• Carotid endarterectomy should be undertaken in patients with non-disabling carotid artery territory ischemic stroke or TIA with ipsilateral carotid stenosis measured at 70-99% (NASCET criteria) 2
• Eligible patients should undergo carotid endarterectomy as soon as possible after event (ideally within 2 weeks) 2
• Carotid endarterectomy should only be performed by a specialist surgeon at centers where outcomes of carotid surgery are routinely audited 2

Common Pitfalls to Avoid

• Overlooking stroke mimics such as seizures, migraines, or hypoglycemia 1
• Delaying imaging or treatment decisions due to laboratory tests 1
• Failing to stabilize airway, breathing, and circulation in patients with suspected stroke 1
• Inadequate blood pressure management, which is crucial for patient outcomes 3
• Prolonged immobility, which may lead to complications such as pneumonia, DVT, PE, and pressure sores 2

The implementation of comprehensive stroke care protocols and adherence to evidence-based guidelines significantly improves patient outcomes and reduces mortality and disability from stroke.