What is the pathway for acute stroke management in the emergency department?

Acute Stroke Management Pathway for Emergency Department

The emergency department management of acute stroke requires immediate recognition, rapid assessment, and time-sensitive interventions to minimize brain damage and improve patient outcomes. 1, 2

Initial Assessment and Triage (0-10 minutes)

• Immediate triage as high priority emergency (similar to acute MI or severe trauma)
• Use validated stroke screening tool with FAST components (Face, Arms, Speech, Time) 1
  • Face: Check for facial droop
  • Arms: Check for arm drift
  • Speech: Assess for slurred speech or language difficulties
  • Time: Document precise time of symptom onset or last known well
• For positive FAST signs, perform second screening for stroke severity to identify potential EVT candidates 1
• Obtain vital signs, capillary blood glucose, and oxygen saturation
• Activate "Code Stroke" protocol immediately

Rapid Diagnostic Evaluation (10-25 minutes)

• Urgent neuroimaging within 25 minutes of arrival 2
  • Non-contrast CT scan to distinguish ischemic from hemorrhagic stroke 1
  • CT angiography for patients within 24 hours to identify large vessel occlusions 2
• Apply standardized stroke severity scale (NIHSS) 2
• Essential laboratory tests (do not delay imaging or treatment) 2:
  • Complete blood count
  • Electrolytes, renal function
  • Coagulation studies (PT/INR, aPTT)
  • Blood glucose
  • Cardiac-specific troponin
• 12-lead ECG to identify atrial fibrillation or other cardiac abnormalities 2

Treatment Decision and Initiation (25-60 minutes)

For Ischemic Stroke:

• IV thrombolysis (alteplase) for eligible patients within 4.5 hours of symptom onset 2
  • Ensure BP <185/110 mmHg before administration
  • Dose: 0.9 mg/kg (maximum 90 mg), with 10% as bolus and remainder over 60 minutes
• Endovascular thrombectomy for large vessel occlusion 2
  • Can be considered up to 24 hours with evidence of salvageable brain tissue
  • Expedite transfer to thrombectomy-capable center if needed
• For patients ineligible for thrombolysis or thrombectomy:
  • Aspirin 160-325 mg after hemorrhage is ruled out 2

For Hemorrhagic Stroke:

• Immediate BP control for all ICH patients 1
  • Begin BP control immediately after ICH onset
• Reverse anticoagulation if applicable 2:
  • For VKA-related ICH: Withhold VKA, administer vitamin K and prothrombin complex concentrate
  • For severe coagulation factor deficiency or thrombocytopenia: Appropriate factor replacement or platelets 1
• Neurosurgical consultation for potential hemicraniectomy 1:
  • Consider for extensive (malignant) MCA territory ischemic stroke
  • Consider posterior fossa decompression for significant cerebellar stroke with mass effect/hydrocephalus

Ongoing Management and Monitoring (1-24 hours)

• Transfer to stroke unit or neuroscience ICU as soon as possible 2
• Continuous cardiac monitoring for arrhythmias 2
• Monitor vital signs and neurological status every 4 hours for first 48 hours 2
• Manage complications:
  • Seizures: Treat with short-acting medications (e.g., lorazepam IV) if not self-limiting 2
  • Fever: Increase monitoring frequency, implement temperature reduction measures, investigate for infection 2
  • Elevated intracranial pressure: Head elevation, osmotic therapy if indicated
• Early mobilization within 48 hours by rehabilitation professionals 2

Secondary Prevention and Disposition Planning

• Initiate statin therapy for lipid management 2
• Control hypertension with appropriate medications 2
• Implement smoking cessation counseling if applicable 2
• Arrange follow-up with neurologist or stroke specialist within one month 2

Special Considerations

• For patients with TIA: Complete evaluation within 24 hours due to high early recurrence risk (up to 13% in 90 days) 2
• For patients requiring transfer: Use established transfer protocols to ensure direct admission to appropriate level of care 2
• For patients with unknown time of onset: Advanced imaging (perfusion studies) may identify salvageable tissue for treatment decisions 3

Common Pitfalls to Avoid

• Delaying neuroimaging for laboratory results - brain imaging should be prioritized
• Missing the time window for thrombolysis or thrombectomy due to delayed recognition
• Failing to identify stroke mimics such as postictal states, hypoglycemia, or migraine 4
• Inadequate blood pressure management before thrombolysis or in hemorrhagic stroke
• Overlooking dysphagia screening before oral intake, which can lead to aspiration pneumonia

The pathway outlined above emphasizes rapid assessment, early intervention, and comprehensive care to maximize neurological recovery and minimize disability in acute stroke patients.