What is the management plan for a patient suspected of having a stroke?

Management of Suspected Stroke: A Comprehensive Approach

Immediate activation of emergency medical services (911) is the first and most critical step in the management of a patient suspected of having a stroke, as time is brain tissue and rapid intervention significantly impacts morbidity and mortality outcomes.

Initial Prehospital Management

Recognition and Assessment

• Use standardized stroke screening tools that include FAST (Face, Arm, Speech, Time) components 1
• For positive FAST screens, perform a second validated stroke severity assessment to identify possible endovascular treatment candidates 1
• Document critical information:
  • Time of symptom onset or last known well 1
  • Current medications (especially anticoagulants) 1
  • Comorbid conditions 1
  • Obtain capillary blood glucose measurement 1

On-Scene Management

• Keep on-scene time as short as possible (target median ≤20 minutes) for patients within treatment window 1
• Optimize out-of-hospital care by:
  • Maintaining airway, breathing, and circulation 1
  • Providing supplemental oxygen if saturation <94% 1
  • Placing patients with hypotension flat and administering isotonic saline 1
  • Avoiding routine blood pressure intervention for hypertensive patients 1

Transport Decisions

• EMS should bypass hospitals that cannot treat stroke and transport to the closest facility capable of providing appropriate stroke care 1
• Direct transport protocols should consider:
  • Patient medical stability 1
  • Eligibility for thrombolysis (within 4.5 hours of symptom onset) 1
  • Potential for endovascular treatment (up to 24 hours in selected patients) 1
  • Hospital's ability to provide stroke services with target door-to-needle time of ≤60 minutes 1

Emergency Department Management

Immediate Assessment

• Triage suspected stroke patients as high priority (CTAS Level 2 in most cases, Level 1 if compromised ABCs) 1
• Perform rapid assessment of:
  • Vital signs with special attention to blood pressure 2
  • Neurological status using standardized tools like NIHSS 2
  • Blood glucose level 1

Diagnostic Imaging

• Urgent non-contrast CT scan within 25 minutes of arrival to distinguish between ischemic and hemorrhagic stroke 2
• CT angiography from aortic arch to vertex to identify large vessel occlusions 2
• Vascular imaging to identify significant symptomatic extracranial carotid artery stenosis 2

Laboratory Testing

• Order critical laboratory tests:
  • Complete blood count
  • Coagulation studies (aPTT, INR) 1
  • Renal function tests 1
  • Electrocardiogram (ECG) 1, 2

Acute Interventions

Thrombolytic Therapy

• IV thrombolysis (alteplase) for eligible patients within 4.5 hours of symptom onset 2
  • Dose: 0.9 mg/kg (maximum 90 mg)
  • Ensure BP <185/110 mmHg before administration

Endovascular Treatment

• Consider endovascular thrombectomy for large vessel occlusion 2
  • Can be considered up to 24 hours with evidence of salvageable brain tissue

Blood Pressure Management

• For patients receiving thrombolysis: maintain BP <185/110 mmHg 2
• For patients not receiving thrombolysis: individualized BP management based on stroke type and comorbidities

Antiplatelet Therapy

• Administer aspirin (160-325 mg) within 48 hours of ischemic stroke onset, but only after hemorrhage is ruled out by imaging 2

In-Hospital Management

Specialized Care

• Transfer patients to a specialized stroke unit as soon as possible 2
• Implement continuous monitoring of vital signs and neurological status 2
• Initiate early mobilization by rehabilitation professionals within 48 hours of admission 2

Secondary Prevention

• For patients with atrial fibrillation:
  • Initiate anticoagulation therapy (warfarin with target INR 2.0-3.0 or direct oral anticoagulants) 3
• Implement statin therapy for lipid management 2
• Control hypertension with appropriate medications 2

Management of Complications

• Treat seizures with short-acting medications if not self-limiting 2
• Manage fever with temperature reduction measures and investigate for possible infection 2
• Consider neurosurgical consultation for extensive MCA territory ischemic stroke 2

Common Pitfalls to Avoid

• Delaying activation of emergency services - remember "time is brain tissue" 4
• Failing to document the time of symptom onset or last known well, which is critical for treatment eligibility 1
• Missing stroke mimics such as hypoglycemia, seizures, migraines, or toxic-metabolic disorders 1
• Inadequate blood pressure management before thrombolytic therapy
• Delaying transfer to specialized stroke centers, which can improve mortality and morbidity by up to 20% 5

By following this comprehensive, time-sensitive approach to stroke management, healthcare providers can significantly improve patient outcomes by reducing mortality, minimizing disability, and enhancing quality of life for stroke survivors.