What are the management options for stroke?

Stroke Management

Stroke management requires a coordinated system of care with rapid evaluation and treatment, including intravenous thrombolysis with alteplase for eligible patients within 4.5 hours of symptom onset and endovascular thrombectomy for large vessel occlusions. 1, 2

Acute Phase Management

Initial Assessment and Diagnosis

• Urgent neuroimaging with CT or MRI to differentiate between ischemic and hemorrhagic stroke 2
• CT or MRI angiography to evaluate for large vessel occlusions 2
• Rapid clinical assessment using validated stroke scales

Reperfusion Therapy for Ischemic Stroke

Intravenous Thrombolysis

• Administer intravenous alteplase at 0.9 mg/kg (maximum 90 mg) with 10% as bolus and 90% as infusion over 60 minutes 1
• Target door-to-needle time of <60 minutes in 90% of patients, with median time of 30 minutes 1
• Treatment window:
  • 0-3 hours: Standard eligibility criteria 2
  • 3-4.5 hours: Extended window with additional exclusion criteria 3
• Blood pressure must be <185/110 mmHg before, during, and after treatment 2

Endovascular Thrombectomy (EVT)

• Indicated for large vessel occlusions 1
• Should be offered within a coordinated system of care 1
• Transport considerations:
  • "Mothership" model: Direct transport to EVT-capable center
  • "Drip-and-ship" model: Initial transport to nearest stroke center for alteplase, then transfer to EVT center
  • Decision depends on geography, transport times, and hospital efficiency 1

Management of Complications from Thrombolysis

• For angioedema: Staged response with antihistamines, glucocorticoids, and airway management 1
• For bleeding: Individual case-based decisions regarding use of cryoprecipitate, fresh frozen plasma, prothrombin complex concentrates, or other agents 1

General Supportive Care

Airway and Breathing

• Ensure adequate oxygenation and ventilation
• Monitor for aspiration risk, especially in patients with:
  • Brain stem infarctions
  • Multiple strokes
  • Large hemispheric lesions
  • Depressed consciousness 1

Blood Pressure Management

• For patients receiving thrombolysis: Maintain BP <185/110 mmHg 2
• For patients not receiving thrombolysis: Cautious reduction with short-acting agents 2

Swallowing Assessment

• Perform before allowing oral intake 1
• Risk factors for aspiration:
  • Abnormal gag reflex
  • Impaired voluntary cough
  • Dysphonia
  • Cranial nerve palsies
  • Wet voice after swallowing
  • Incomplete oral-labial closure
  • High NIHSS score 1

Nutrition

• Nasogastric or nasoduodenal tube feeding when necessary 1
• Consider percutaneous endoscopic gastrostomy for prolonged feeding needs 1

Management of Neurological Complications

Cerebral Edema and Increased Intracranial Pressure

• Peaks 3-5 days after stroke 1
• Management options:
  • Osmotherapy and hyperventilation for deteriorating patients 1
  • Surgical decompression for large cerebellar infarctions causing brain stem compression 1
  • CSF drainage for hydrocephalus 1
  • Note: Corticosteroids are not recommended 1

Seizures

• Treat recurrent seizures as with any other acute neurological condition 1
• Prophylactic anticonvulsants are not recommended 1

Hemorrhagic Transformation

• Occurs in approximately 5% of infarctions 1
• Risk increased with anticoagulants and thrombolytic agents 1
• Management depends on amount of bleeding and symptoms 1

Prevention of Complications

Venous Thromboembolism

• Subcutaneous anticoagulants for immobilized patients 1
• Alternative: Intermittent external compression stockings or aspirin 1

Infections

• Monitor for pneumonia, especially in immobile patients or those unable to cough 1
• Prompt antibiotic therapy for suspected infections 1
• Avoid indwelling bladder catheters when possible 1

Early Mobilization

• Encourage gradual early mobilization 2
• Use intermittent pneumatic compression devices for patients with limited mobility 2

Rehabilitation and Secondary Prevention

Early Rehabilitation

• Initiate 24-48 hours after stroke onset 2
• Care by multidisciplinary team with regular meetings 2

Secondary Prevention

• Aspirin administration within 24-48 hours after stroke onset 2
• For patients treated with IV thrombolysis, delay aspirin administration until >24 hours 2

Transport and System Considerations

• Transport decision-making depends on:
  • Likely diagnosis (LVO screening tool accuracy)
  • System geography (hospital locations relative to patient)
  • Treatment efficiency at hospitals (door-to-needle, door-in-door-out times) 1
• Mobile Stroke Units can reduce onset-to-treatment times but require further outcome data 1

Pitfalls and Caveats

• Alteplase dosing for stroke (0.9 mg/kg) differs from myocardial infarction dosing 1
• Low-dose alteplase (0.6 mg/kg) showed fewer hemorrhagic complications but did not meet non-inferiority criteria for efficacy compared to standard dose 4
• Thrombolysis beyond 4.5 hours is not supported by evidence 5
• Consent for thrombolysis follows emergency consent procedures 1
• Special populations (pediatric, pregnant) require urgent consultation with stroke experts 1