What are the symptoms and treatment options for a suspected stroke?

Stroke Symptoms and Management

Patients with suspected stroke require immediate emergency assessment and intervention to minimize morbidity and mortality, with recognition of key symptoms including facial droop, arm drift, and speech disturbance (FAST) being essential for prompt diagnosis and treatment. 1

Recognition of Stroke Symptoms

Primary Symptoms (FAST)

• Face: Facial droop or asymmetry when smiling
• Arms: Weakness or inability to raise one arm, or arm drift downward
• Speech: Slurred speech, inappropriate words, or inability to speak
• Time: Note when symptoms began - critical for treatment decisions 1, 2

Additional Symptoms

• Sudden onset of:
  • Numbness or weakness (especially on one side of the body)
  • Confusion or trouble understanding speech
  • Severe headache with no known cause
  • Vision problems in one or both eyes
  • Trouble walking, dizziness, loss of balance or coordination 2, 1

Initial Assessment and Management

Immediate Actions

1. Call emergency services (911) immediately upon recognition of stroke symptoms, even if symptoms resolve 1
2. Document time of symptom onset or last known well - critical for treatment eligibility 2
3. Rapid assessment of airway, breathing, and circulation 2
4. Check blood glucose to rule out hypoglycemia (which can mimic stroke) 2

Emergency Department Assessment

1. Neurological examination using standardized stroke scale (NIHSS or Canadian Neurological Scale) 2

2. Immediate brain imaging:

   • Non-contrast CT scan to rule out hemorrhage 2
   • CT angiography (CTA) for patients arriving within 6 hours to identify large vessel occlusions eligible for endovascular therapy 2

3. Essential laboratory tests (should not delay imaging or treatment):

   • Complete blood count
   • Electrolytes
   • Coagulation studies (INR, aPTT)
   • Blood glucose
   • Renal function (creatinine)
   • Troponin 2, 1

4. ECG to assess cardiac rhythm and identify atrial fibrillation 2, 1

Acute Treatment Options

Ischemic Stroke

1. Intravenous thrombolysis (alteplase):

   • For eligible patients within 4.5 hours of symptom onset
   • Dose: 0.9 mg/kg (maximum 90 mg), with 10% as bolus over 1 minute and remainder over 59 minutes 2, 1
   • Blood pressure must be <185/110 mmHg before administration 1

2. Endovascular thrombectomy:

   • For patients with large vessel occlusion
   • Can be considered up to 24 hours from symptom onset with evidence of salvageable brain tissue 1
   • Should not be delayed to evaluate response to thrombolysis 2

Hemorrhagic Stroke

• Reversal of anticoagulation when possible
• Neurosurgical consultation
• Blood pressure management
• Admission to stroke unit or specialized ICU 1

Blood Pressure Management

• For patients receiving thrombolysis: maintain BP <180/105 mmHg for 24 hours after administration
• For patients not eligible for thrombolysis: treat only when systolic >220 mmHg or diastolic >120 mmHg 1

Seizure Management in Acute Stroke

• New-onset seizures occurring at the time of stroke or within 24 hours should be treated with short-acting medications (e.g., lorazepam IV) if not self-limiting 2, 1
• A single, self-limiting seizure at stroke onset should not be treated with long-term anticonvulsants 2
• Prophylactic use of anticonvulsants is not recommended and may have negative effects on neural recovery 2
• Consider enhanced EEG monitoring in high-risk populations (neonates, children with stroke, adults with unexplained reduced consciousness) 2

Common Pitfalls to Avoid

1. Delayed recognition and response: Public awareness of stroke symptoms remains low, with only 16.4% of people recognizing all five correct symptoms and the need to call 911 3

2. Failure to document time of symptom onset: Treatment eligibility depends critically on time windows 2

3. Missing stroke in atypical presentations: Stroke can present differently in certain populations (e.g., posterior circulation strokes, young patients) 1

4. Inadequate blood pressure management: Both excessively high and low blood pressure can worsen outcomes 4

5. Failure to control glucose and temperature: Hyperglycemia and hyperthermia are associated with worse outcomes 4

The implementation of organized stroke protocols in emergency departments and prehospital settings has been shown to significantly reduce treatment times and improve outcomes. Medical dispatchers play a crucial role in early stroke recognition, with studies showing sensitivity rates of up to 66.2% in identifying stroke during emergency calls 5. Proper training of emergency medical services personnel can increase the correct identification of stroke patients and expedite their transport to appropriate stroke centers 6.