What is the management approach for a patient presenting with stroke symptoms?

Management of Acute Stroke

Patients presenting with stroke symptoms require immediate emergency evaluation and treatment within the first few hours of symptom onset to reduce mortality and improve functional outcomes. 1

Initial Assessment and Stabilization

1. Immediate Triage and Assessment

   • Triage with same priority as acute myocardial infarction or serious trauma 2
   • Rapid neurological assessment using NIHSS scale 1
   • Determine exact time of symptom onset (defined as when patient was last known to be at baseline) 2

2. Stabilize ABCs

   • Ensure airway, breathing, and circulation 1
   • Monitor vital signs every 15 minutes during and after IV alteplase for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours 1

3. Immediate Diagnostic Imaging

   • Emergent non-contrast CT scan to rule out hemorrhage 1
   • CT angiography from aortic arch to vertex to identify large vessel occlusions 1
   • Complete imaging within 24 hours of symptom onset 2

Blood Pressure Management

• For patients not receiving thrombolysis: Withhold antihypertensive agents unless diastolic BP >120 mmHg or systolic BP >220 mmHg 1
• For patients receiving thrombolysis: Maintain BP ≤185/110 mmHg before treatment and ≤180/105 mmHg after treatment 1
• Long-term targets: <140/90 mmHg for most patients; <130/80 mmHg for patients with target-organ damage 1
• Preferred agent: Labetalol (easily titrated) when treatment is needed 1

Acute Reperfusion Therapies

Intravenous Thrombolysis

• IV alteplase (0.9 mg/kg, maximum 90 mg) administered over 60 minutes with 10% as initial bolus 1
• Time windows:
  • Strong recommendation within 3 hours of symptom onset 1
  • Consider between 3-4.5 hours with lower evidence 1
  • Not recommended beyond 4.5 hours 1

Endovascular Thrombectomy

• For large vessel occlusions:
  • Within 6 hours for standard cases 1
  • Extended window of 6-24 hours for selected patients with salvageable tissue 1
• Every 30-minute delay decreases good functional outcome chance by 8-14% 1
• Increases functional independence from 26.5% to 46% when performed within 6 hours 1, 3
• Preferred technique: Combined approach using stent-retrievers and aspiration 1

Antithrombotic Therapy

• For patients not receiving thrombolysis: Aspirin 325 mg initially within 24-48 hours 1
• For patients receiving thrombolysis: Delay aspirin until >24 hours after thrombolysis 1
• For high-risk TIA or minor stroke: Dual antiplatelet therapy (aspirin + clopidogrel) for 3 weeks followed by single antiplatelet therapy reduces stroke risk from 7.8% to 5.2% 3
• Long-term therapy:
  • Non-cardioembolic stroke: Antiplatelet therapy 1
  • Cardioembolic stroke (e.g., atrial fibrillation): Anticoagulation 1

Additional Management

1. DVT Prophylaxis

   • For patients with restricted mobility: Intermittent pneumatic compression devices or low molecular weight heparin 1
   • LMWH preferred over unfractionated heparin 1
   • Avoid elastic compression stockings 1

2. Temperature Management

   • Monitor body temperature and treat fever (>38°C) 1
   • Early treatment of hyperthermia is important 4

3. Glucose Management

   • Treat glucose levels >8 mmol/l (144 mg/dl) 4
   • Target fasting blood glucose levels less than 126 mg/dl (7 mmol/L) 1

4. Oxygen Therapy

   • Administer oxygen therapy if O₂ saturation <92% 4

Early Rehabilitation and Secondary Prevention

• Begin rehabilitation as early as possible, ideally within 24-48 hours for stable patients 1
• Implement comprehensive rehabilitation including physical, occupational, and speech therapy 1
• Manage modifiable risk factors (hypertension, diabetes, hyperlipidemia, smoking) 1
• Consider carotid endarterectomy for symptomatic carotid stenosis 1

Hospital Care

• Admit to dedicated stroke unit or ICU 1
• Perform cardiac monitoring for at least 24 hours to detect atrial fibrillation 1
• Consider telemedicine consultation if stroke expertise is not available on-site 1

Common Pitfalls to Avoid

1. Delayed recognition and treatment - Remember "time is brain tissue" 5
2. Failure to determine precise symptom onset time - Critical for thrombolysis eligibility 2
3. Inadequate blood pressure management - Both high and low BP levels relate to poor prognosis 4
4. Missing large vessel occlusions - Perform vascular imaging promptly 1
5. Overlooking fever or hyperglycemia - Both worsen outcomes and require prompt treatment 4

The management of stroke has evolved significantly with evidence showing that early intervention dramatically improves outcomes. Implementing these guidelines systematically can significantly reduce mortality and disability from stroke.