What is the management of a stroke?

Management of Stroke

Stroke management requires immediate intervention through a structured pathway that includes rapid assessment, imaging, reperfusion therapy when appropriate, and comprehensive care in a dedicated stroke unit to minimize brain injury and maximize recovery.

Initial Assessment and Diagnosis

• Rapid recognition and assessment using validated stroke screening tools 1
• Urgent brain imaging within 24 hours (CT or MRI) to differentiate between ischemic and hemorrhagic stroke 1, 2
• Laboratory investigations: Complete blood count, electrolytes, renal function, coagulation studies, fasting lipids, ESR/CRP, glucose, and ECG 1, 2
• Vascular imaging: Carotid duplex ultrasound for patients with carotid territory symptoms who are potential candidates for revascularization 1, 2

Acute Management

For Ischemic Stroke

1. Reperfusion therapy:

   • IV thrombolysis (alteplase 0.9 mg/kg, maximum 90 mg) within 4.5 hours of symptom onset for eligible patients 2
   • 10% given as initial bolus over 1 minute, followed by remainder over 60 minutes 2
   • Endovascular thrombectomy for selected patients, particularly for basilar artery occlusion 2

2. Blood pressure management:

   • For patients eligible for reperfusion: Treat if BP >185/110 mmHg using labetalol or nicardipine 2
   • For patients ineligible for reperfusion: Only treat if systolic >220 mmHg or diastolic >120 mmHg 2
   • For ICH patients with history of hypertension: Keep mean arterial pressure below 130 mmHg 1

3. Glucose management:

   • Maintain glucose between 140-180 mg/dL 2
   • Avoid hypoglycemia (<60 mg/dL) 2

For Hemorrhagic Stroke

1. Blood pressure control is critical
2. Reversal of anticoagulation should be done urgently for ICH due to anticoagulants 1
3. Surgical intervention:
   • Consider for cerebellar hemorrhage 1
   • May be considered for superficial ICH <1 cm from surface 1
   • Stereotactic surgery for deep ICH may be an option 1
   • Hemicraniectomy within 48 hours for extensive hemispheric infarcts in selected patients (18-60 years) 1

Stroke Unit Care

All stroke patients should be managed in a dedicated stroke unit with:

• Multidisciplinary team including stroke physician, nursing staff, occupational therapist, physiotherapist, speech pathologist, dietician, and social worker 1
• Regular scheduled ward rounds attended by the full multidisciplinary team 1
• Established protocols for acute and post-acute management 1
• Early mobilization and rehabilitation 1, 2
• Skilled nursing care with frequent monitoring 1, 2
• Early assessment of swallowing, nutrition, cognition, perception, and communication 1

Monitoring and Complications Prevention

• Vital signs monitoring: Every 15 minutes during initial assessment 2
• Neurological assessments: Every 15 minutes during and after IV rtPA for 2 hours, every 30 minutes for 6 hours, then hourly until 24 hours 2
• Prevention of complications:
  • Deep vein thrombosis prophylaxis
  • Fever management
  • Pressure ulcer prevention
  • Fall prevention
  • Pain management 1
• Seizure management: Treat with appropriate anticonvulsants (levetiracetam preferred) 2

Rehabilitation and Discharge Planning

• Begin rehabilitation as early as possible (within 24-48 hours for stable patients) 2
• Comprehensive rehabilitation including physical, occupational, and speech therapy 2
• Predischarge needs assessment to identify physical, emotional, social, and financial needs 1
• Home assessment when needed to ensure safety and community access 1
• Carer training in personal care techniques, communication strategies, physical handling, and safe swallowing 1
• Development of care plans involving the patient, carers, GP, and community care providers 1

Secondary Prevention

• Carotid endarterectomy for symptomatic carotid stenosis:
  • 70-99% stenosis: Strong recommendation 1
  • 50-69% stenosis: Consider in select patients 1
  • Ideally performed within 2 weeks of event 1
• Antiplatelet therapy for non-cardioembolic ischemic stroke
• Anticoagulation for cardioembolic stroke (e.g., atrial fibrillation)
• Risk factor management: Hypertension, diabetes, hyperlipidemia, smoking cessation

Special Considerations

• Basilar artery occlusion requires urgent treatment due to high mortality rate 2
• Posterior circulation strokes may have similar benefits from reperfusion therapy with lower hemorrhage risks compared to anterior circulation strokes 2
• Young stroke patients may have different etiologies requiring specific investigations 3

The implementation of organized stroke care through dedicated stroke units has been shown to significantly improve outcomes, reducing mortality and disability even in resource-constrained settings 1.