What is the management and treatment approach for a patient who has suffered a stroke?

Management and Treatment of Stroke

The management of stroke requires immediate assessment, rapid intervention with reperfusion therapies when appropriate, and comprehensive care in a specialized stroke unit to reduce mortality and improve functional outcomes. 1, 2

Initial Assessment and Diagnosis

• Immediate Clinical Evaluation:

  • Rapid assessment of airway, breathing, and circulation
  • Detailed neurological examination focusing on mental status, cranial nerves, motor function, sensory function, reflexes, coordination, and gait 2
  • Use validated stroke scales like NIHSS to document severity
  • Document precise time of symptom onset (critical for treatment decisions) 2

• Urgent Imaging:

  • Non-contrast CT brain immediately to exclude hemorrhage 2, 1
  • CT angiography from aortic arch to vertex to assess extracranial and intracranial circulation 2
  • MRI with diffusion-weighted imaging is particularly valuable for posterior circulation strokes 2

• Laboratory Tests:

  • Complete blood count, electrolytes, coagulation studies (aPTT, INR), renal function, and glucose 2
  • 12-lead ECG to identify atrial fibrillation or evidence of structural heart disease 2

Acute Treatment

Reperfusion Therapy

• Intravenous Thrombolysis:

  • Administer IV alteplase (0.9 mg/kg, maximum 90 mg) within 4.5 hours of symptom onset in eligible patients 2
  • 10% given as initial bolus over 1 minute, followed by remainder over 60 minutes 2

• Endovascular Thrombectomy:

  • Consider for large vessel occlusions, particularly basilar artery occlusion 2
  • Especially important for patients with high mortality risk without treatment 2

Blood Pressure Management

• For patients eligible for reperfusion therapy:

  • Lower BP if >185/110 mmHg using labetalol or nicardipine 2
  • Maintain normovolemia using crystalloids 2

• For patients not eligible for thrombolysis:

  • Only treat blood pressure if systolic >220 mmHg or diastolic >120 mmHg 2
  • Avoid aggressive blood pressure reduction which may worsen ischemia 2

Management of Cerebral Edema

• Medical Management:

  • Restrict free water to avoid hypo-osmolar fluid
  • Avoid excess glucose administration
  • Minimize hypoxemia and hypercarbia
  • Treat hyperthermia 1

• Surgical Management:

  • Consider decompressive hemicraniectomy for malignant middle cerebral artery infarction within 48 hours of onset 1
  • Proceed urgently before significant decline in GCS or pupillary change 1
  • Transfer to ICU or neuro step-down unit for close monitoring prior to surgery 1

Stroke Unit Care

• All patients should be admitted to a specialized stroke unit within 24 hours of hospital arrival 1
• Stroke unit care is associated with reduced mortality, institutionalization, and dependency 1
• Characterized by interdisciplinary teams with expertise in stroke management 1

Prevention and Management of Complications

Dysphagia and Aspiration Prevention

• Keep patients NPO until dysphagia screening completed within 4-24 hours by trained personnel 1
• If patient fails screening, consult speech-language pathologist for formal assessment 1
• Implement appropriate feeding strategies based on assessment:
  • Dietary texture modification
  • Head positioning techniques
  • Small sips and no straws
  • Multiple swallows
  • Sitting upright during feeding 1

Deep Vein Thrombosis Prevention

• Low molecular weight heparin (enoxaparin 40 mg once daily) is more effective than unfractionated heparin (5000 IU twice daily) 1
• Risk of serious bleeding complications is relatively low 1

Cardiovascular Monitoring

• Continue cardiac monitoring for at least 24 hours after stroke 1
• Longer monitoring (24-hour Holter or event-looped recording) may be required to detect occult arrhythmias 1
• Treat clinically significant arrhythmias that may compromise cerebral perfusion 1

Other Complications

• Monitor for and treat:
  • Seizures (with levetiracetam preferred) 2
  • Hyperthermia (maintain normothermia) 2
  • Hyperglycemia (maintain glucose between 140-180 mg/dL) 2
  • Hypoxemia (maintain O₂ saturation >92%) 2

Rehabilitation

• Begin rehabilitation as early as possible, ideally within 24-48 hours for stable patients 2
• Include physical therapy, occupational therapy, speech therapy, and cognitive assessment 2
• Screen for and address depression, which is common after stroke 2

Secondary Prevention

• For patients with atrial fibrillation:

  • Oral anticoagulation with warfarin (target INR 2.0-3.0) 3 or direct oral anticoagulants like rivaroxaban 4
  • For patients with mechanical heart valves, warfarin remains the anticoagulant of choice 3

• For patients without atrial fibrillation:

  • Antiplatelet therapy
  • Management of modifiable risk factors (hypertension, diabetes, smoking, hyperlipidemia)

Common Pitfalls and Caveats

1. Delayed Recognition: Public awareness of stroke symptoms remains low, with only 16.4% of people recognizing all symptoms and the need to call 911 5. Educate patients about recognizing stroke symptoms.

2. Overlooking Posterior Circulation Strokes: CT may miss early posterior fossa infarcts; consider MRI when available 2.

3. Inadequate Blood Pressure Management: Both high and low blood pressure can worsen outcomes; careful titration is essential 6.

4. Neglecting Glucose Control: Hyperglycemia (>8 mmol/L) predicts poor outcomes; treat elevated glucose levels 6.

5. Failing to Treat Hyperthermia: Elevated body temperature negatively affects outcomes; early treatment is crucial 6.

6. Delayed Mobilization: Early rehabilitation improves outcomes but must be balanced with adequate cerebral perfusion in the acute phase 2.