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

Comprehensive Management of Acute Stroke

The management of stroke requires immediate treatment in a dedicated stroke unit with a multidisciplinary team, focusing on early reperfusion therapy, prevention of complications, and early rehabilitation to optimize mortality, morbidity, and quality of life outcomes. 1

Initial Management and Acute Treatment

Reperfusion Therapy

• For ischemic stroke patients presenting within 4.5 hours of symptom onset:

  • Administer IV rtPA (alteplase) 0.9 mg/kg (maximum 90 mg), with 10% as initial bolus over 1 minute and remainder over 60 minutes 1
  • Patient eligibility criteria include:
    • Measurable neurological deficit
    • No spontaneous clearing of symptoms
    • No signs of intracranial hemorrhage on CT
    • Blood pressure <185/110 mmHg
    • No anticoagulant use or INR <1.5
    • Platelet count >100,000/mm³

• For eligible patients with large vessel occlusion:

  • Consider endovascular thrombectomy, particularly beneficial for basilar artery occlusions 1

Blood Pressure Management

• For patients eligible for reperfusion: maintain BP <185/110 mmHg
• For patients ineligible for reperfusion: treat only if systolic >220 mmHg or diastolic >120 mmHg
• Preferred agents: labetalol or nicardipine 1

Diagnostic Imaging

• Immediate non-contrast CT brain to exclude hemorrhage
• CT angiography from aortic arch to vertex to assess extracranial and intracranial circulation
• Consider MRI with diffusion-weighted imaging, particularly for posterior circulation strokes 1

Stroke Unit Care

Admission Criteria

• All stroke patients should be admitted to a dedicated stroke unit as soon as possible, ideally within 24 hours of hospital arrival 2
• Stroke unit care is associated with significant reductions in death (OR=0.76), death or institutionalization (OR=0.76), and death or dependency (OR=0.80) 2

Monitoring and Assessment

• Close neurological monitoring with assessments of:
  • Level of consciousness (e.g., Canadian Neurological Scale)
  • Worsening symptom severity
  • Blood pressure (at least hourly) 2
• Repeat CT scans for patients with neurological deterioration 2

Management of Complications

Neurological Complications

• Cerebral Edema Management:

  • Peaks 3-4 days after injury; can accelerate within 24 hours with early reperfusion
  • Medical management includes restriction of free water, avoidance of excess glucose, minimization of hypoxemia and hypercarbia, and treatment of hyperthermia 2
  • For malignant edema, consider decompressive hemicraniectomy within 48 hours from stroke onset for selected patients 2

• Hemorrhagic Transformation:

  • Occurs in approximately 1.5% of patients without reperfusion therapy
  • Monitor for neurological worsening, decreased level of consciousness, worsening deficits, pupil changes, and respiratory status changes 2

• Seizures:

  • Occur in 5-12% of acute ischemic stroke patients
  • EEG for changes in mental status
  • Antiseizure medication only for documented seizures (prophylactic treatment not recommended) 2

Dysphagia and Aspiration Prevention

• Keep patients NPO until dysphagia screening completed within 4-24 hours by trained personnel 2
• If screening fails, consult speech-language pathologist for comprehensive assessment
• Interventions may include:
  • Dietary texture modification of liquids and solid foods
  • Head positioning techniques
  • Small sips and bites
  • Avoidance of straws
  • Multiple swallows
  • Sitting upright during meals 2

Cardiovascular Monitoring

• Cardiac monitoring for at least 24 hours after stroke, particularly for patients with large deficits and right hemispheric strokes
• Consider longer monitoring (24-hour Holter or event-looped recording) to detect occult arrhythmias 2
• Treat clinically significant arrhythmias that may compromise cerebral perfusion 2

Venous Thromboembolism Prevention

• Enoxaparin 40 mg once daily is more effective than unfractionated heparin 5000 IU twice daily for DVT prevention
• Risk of serious bleeding complications is relatively low 2

Early Rehabilitation and Secondary Prevention

Early Mobilization and Rehabilitation

• Begin rehabilitation as early as possible, ideally within 24-48 hours for stable patients 1
• Include physical therapy, occupational therapy, speech therapy, and cognitive assessment 1

Secondary Prevention

• For non-cardioembolic stroke: antiplatelet therapy
• For cardioembolic stroke (e.g., atrial fibrillation): anticoagulation 1
• Risk factor management: hypertension, diabetes, hyperlipidemia, smoking cessation 1

Common Pitfalls and Caveats

1. Delayed Treatment: "Time is brain" - every minute delay in treatment results in loss of approximately 1.9 million neurons. Ensure rapid triage and treatment 3

2. Inadequate Monitoring: Deterioration occurs in 25% of patients after initial assessment (one-third due to stroke progression, one-third due to brain edema) 2

3. Missing Posterior Circulation Strokes: CT may miss early ischemic changes in the posterior fossa; consider MRI with diffusion-weighted imaging 1

4. Overlooking Dysphagia: Up to 78% of stroke patients have dysphagia; failure to screen can lead to aspiration pneumonia 2

5. Inadequate Blood Pressure Management: Both hypertension and hypotension can worsen outcomes; target appropriate BP ranges based on reperfusion eligibility 1

The comprehensive management of stroke patients requires a coordinated approach across the continuum of care, from emergency services through rehabilitation, with attention to both acute treatment and prevention of complications to optimize outcomes.