What is the management strategy for acute stroke symptoms?

Acute Stroke Management: A Time-Critical Approach

Immediate recognition and rapid treatment of acute stroke symptoms is critical for reducing morbidity and mortality, with organized protocols and systems of care being essential for optimal outcomes. 1

Initial Recognition and Response

Public and Patient Response

• Use the FAST (Face, Arms, Speech, Time) screening tool to identify stroke symptoms 1:
  • Facial drooping
  • Arm weakness
  • Speech difficulties
  • Time to call emergency services immediately
• Call 9-1-1 immediately upon recognition of stroke symptoms, even if symptoms resolve 2
• Never wait to see if symptoms resolve on their own, as time-sensitive treatments can prevent permanent brain damage 1

Prehospital Management

• EMS should use validated stroke screening tools in the field 1
• Minimize on-scene time (target median of 20 minutes or less) 1
• Pre-notify receiving hospital to mobilize stroke team 1
• Provide supplemental oxygen to maintain saturation >94% 2
• Establish intravenous access in the field to facilitate medication administration 2
• Position patients who are hypotensive with head flat and administer isotonic saline 2
• Check blood glucose levels; administer glucose for levels <60 mg/dL 2

Emergency Department Management

Immediate Assessment (First 10 Minutes)

• Perform rapid assessment of airway, breathing, and circulation 1
• Conduct standardized neurological examination using NIHSS 1
• Assess vital signs (heart rate, blood pressure, temperature, oxygen saturation) 1
• Obtain focused history including:
  • Time of symptom onset or last known well time
  • Current medications (especially anticoagulants)
  • Medical history
  • Description of symptoms and changes since onset 1

Urgent Diagnostic Workup (First 25 Minutes)

• Brain imaging (non-contrast CT or MRI) to rule out hemorrhage 1
• Vascular imaging (CTA or MRA from aortic arch to vertex) without delay 1
• Essential laboratory tests 1:
  • Complete blood count
  • Coagulation studies (INR, aPTT)
  • Electrolytes and renal function
  • Blood glucose
  • Cardiac biomarkers
• ECG to assess cardiac rhythm 1

Treatment Decision and Implementation (Within 60 Minutes of Arrival)

For Ischemic Stroke

1. Evaluate eligibility for intravenous thrombolysis (rtPA) if within 4.5 hours of symptom onset 1

   • Administer rtPA at 0.9 mg/kg (maximum 90 mg) if eligible
   • 10% of dose as bolus, remainder over 60 minutes

2. Blood pressure management 1:

   • For thrombolysis candidates: maintain BP <185/110 mmHg
   • For non-thrombolysis candidates: lower BP only if >220/120 mmHg

3. Antithrombotic therapy:

   • Initiate aspirin (160-300 mg) within 48 hours of ischemic stroke onset 1
   • Avoid urgent anticoagulation as it increases bleeding risk without improving outcomes 1

4. Evaluate eligibility for endovascular therapy:

   • Consider within 24 hours of symptom onset with evidence of salvageable brain tissue 1
   • Most beneficial for patients with large vessel occlusion 1

For Hemorrhagic Stroke

1. Urgent neurosurgical consultation for:

   • Cerebellar hemorrhage >3 cm 2
   • Rapidly deteriorating neurological status
   • Hydrocephalus

2. Blood pressure management:

   • Follow specific protocols based on hemorrhage type and severity

3. Reversal of anticoagulation if applicable 2

Ongoing Management

Stroke Unit Care

• Transfer to a dedicated stroke unit as soon as possible 2
• Monitor for and prevent complications:
  • Neurological deterioration
  • Aspiration pneumonia
  • Deep vein thrombosis
  • Pressure ulcers
  • Falls and pain 2

Early Secondary Prevention

• Initiate appropriate antithrombotic therapy based on stroke etiology 2
• Control hypertension with diet, exercise, and medication 2
• Initiate statin therapy for lipid management 2
• Provide lifestyle modification guidance (smoking cessation, diet, exercise) 2

Common Pitfalls to Avoid

• Delayed imaging: Brain imaging must be performed urgently to determine treatment options 1
• Inappropriate blood pressure management: Follow guideline-directed thresholds to prevent worsening ischemia 1
• Missing the treatment window: Systems should minimize delays at every step 1
• Waiting for laboratory results: Do not delay thrombolysis for non-critical lab results 2
• Overlooking stroke in young patients: Stroke can affect persons of any age 2
• Neglecting emotional changes: Post-stroke anxiety, depression, and emotional lability require treatment 1

The management of acute stroke symptoms requires a coordinated, time-sensitive approach with clear protocols at each stage. The phrase "Time is Brain" emphasizes that rapid assessment and treatment are essential to minimize brain injury and maximize patient recovery.