What are the treatment and prevention options for a patient with a stroke?

Treatment and Prevention Options for Stroke

The management of stroke requires a comprehensive, organized approach that includes urgent evaluation, specific treatments based on stroke type, and prevention of complications to improve mortality, morbidity, and quality of life outcomes.

Acute Management of Ischemic Stroke

Initial Management

• Urgent evaluation to determine if ischemic stroke is the cause and whether the patient can receive thrombolytic therapy 1
• Protect airway, breathing, and circulation, especially in seriously ill or comatose patients 1
• Intravenous rtPA (0.9 mg/kg; maximum 90 mg) is strongly recommended for carefully selected patients who can receive the medication within 3 hours of stroke onset 1
• For patients outside the 3-hour window, intra-arterial thrombolysis may be considered, though selection criteria are not fully established 1

Blood Pressure Management

• Elevated blood pressure should be lowered cautiously in the acute setting 1
• For most patients, target blood pressure <130/80 mmHg; for intracranial stenosis, maintain systolic BP <140 mmHg 2

Prevention of Complications

Respiratory and Infectious Complications

• Early assessment of swallowing ability before allowing oral intake to prevent aspiration 1
• Pneumonia is a leading cause of death after stroke; prompt evaluation of fever and early antibiotic therapy are essential 1
• Urinary tract infections are common (15-60% of patients) and independently predict worse outcomes 1
• Avoid indwelling catheters when possible; consider intermittent catheterization 1

Venous Thromboembolism Prevention

• Deep vein thrombosis (DVT) and pulmonary embolism (PE) are significant risks, with PE accounting for 10% of post-stroke deaths 1
• Early mobilization is crucial 1
• Subcutaneous anticoagulants (LMWH preferred over UFH) or intermittent external compression stockings are strongly recommended for immobilized patients 1
• The PREVAIL trial showed that 40-mg enoxaparin once daily was more effective than 5000 IU UFH twice daily 1

Other Acute Complications

• Monitor and treat cerebral edema and increased intracranial pressure, seizures, and hemorrhagic transformation 1
• Maintain adequate nutrition; consider nasogastric or nasoduodenal tube if swallowing is impaired 1

Secondary Prevention

Antithrombotic Therapy

• For noncardioembolic ischemic stroke/TIA:
  • Short-term dual antiplatelet therapy (aspirin plus clopidogrel) should be initiated within 12-24 hours and continued for 21-90 days 2
  • Follow with long-term single antiplatelet therapy 2
• For cardioembolic stroke with atrial fibrillation:
  • Warfarin is the drug of choice (INR 2-3) 1, 2
  • For patients unable to take warfarin, aspirin is an appropriate alternative 1

Risk Factor Management

• Aggressive management of modifiable risk factors is essential:
  • Hypertension (most important modifiable risk factor) 2, 3
  • Diabetes mellitus 2, 3
  • Dyslipidemia (high-intensity statin therapy recommended for all stroke patients) 2
  • Smoking cessation 2
  • Physical activity (at least 30 minutes of moderate-intensity activity 1-3 times/week) 2
  • Diet (low in fat and sodium, high in fruits and vegetables) 2
  • Alcohol moderation (≤2 drinks/day for men, ≤1 drink/day for women) 2

Surgical Interventions

• Carotid endarterectomy is recommended for symptomatic patients with 70-99% stenosis 2
• May be considered for select patients with 50-69% stenosis or highly select asymptomatic patients with 60-99% stenosis 2

Rehabilitation and Long-term Care

• Use of comprehensive specialized stroke care units incorporating rehabilitation is strongly recommended 1
• Early mobilization to prevent complications 1
• Multidisciplinary approach involving physicians, nurses, and rehabilitation personnel 1
• Smooth transition from inpatient to outpatient care with timely transfer of discharge information 1

Patient Education

• Ensure patients and families receive education about:
  • Stroke risk factors
  • Warning signs
  • Availability of time-sensitive therapy
  • Method for activating emergency medical services 1
• Teaching self-management skills or using behavioral change theory improves medication adherence 2

Common Pitfalls and Caveats

1. Delayed treatment: "Time is brain" - every minute counts in acute stroke management 4, 5
2. Inadequate swallowing assessment: A preserved gag reflex does not guarantee safety from aspiration 1
3. Poor blood pressure management: Both hypertension and hypotension can worsen outcomes 4
4. Overlooking fever: Hyperthermia worsens stroke outcomes; early treatment is essential 4
5. Insufficient secondary prevention: Risk factors often remain poorly controlled among stroke survivors 2
6. Inappropriate anticoagulation: Routine urgent anticoagulation has not been shown to improve outcomes and may increase bleeding risk 1
7. Inadequate DVT prophylaxis: DVT is common and preventable with appropriate measures 1

By implementing these evidence-based strategies for acute management, complication prevention, and secondary prevention, outcomes for stroke patients can be significantly improved.