What are the immediate management steps for acute stroke?

Immediate Management of Acute Stroke

The immediate management of acute stroke requires rapid assessment, neuroimaging, and time-sensitive interventions including thrombolysis within 4.5 hours and endovascular thrombectomy within 6-24 hours for eligible patients to minimize brain damage and improve outcomes. 1

Initial Assessment and Stabilization

• Airway, Breathing, Circulation (ABC): Assess and stabilize immediately 2, 1
• Rapid neurological examination: Use standardized stroke scale (NIHSS) to assess stroke severity 2, 1
• Vital signs monitoring: Heart rate, rhythm, blood pressure, temperature, oxygen saturation 2
• Blood glucose: Check immediately (hypoglycemia can mimic stroke symptoms) 2

Emergency Diagnostic Imaging

• Non-contrast CT scan: Immediate priority to differentiate ischemic from hemorrhagic stroke 1
• CT angiography: To identify large vessel occlusions for potential endovascular therapy 1
• Advanced imaging: For patients presenting beyond 6 hours, additional imaging (CT perfusion or MRI with diffusion-weighted imaging) to identify salvageable tissue 2, 1

Acute Interventions for Ischemic Stroke

Thrombolysis with IV Alteplase

• Time window 0-4.5 hours from symptom onset or last known well 2, 1, 3
• Dosage: 0.9 mg/kg (maximum 90 mg) with 10% as bolus over 1 minute, remainder over 60 minutes 1
• Blood pressure requirements: Must be ≤185/110 mmHg before treatment 1
• Contraindications: Recent surgery, bleeding disorders, anticoagulant use with elevated INR, prior ICH, extensive infarct on imaging 1

Endovascular Thrombectomy (EVT)

• Standard time window: Within 6 hours of symptom onset 2, 1
• Extended time window: 6-24 hours for selected patients with salvageable tissue on advanced imaging 2, 1
• Eligibility criteria: Large vessel occlusion, disabling stroke symptoms, ASPECTS ≥6 2
• Blood pressure management: Maintain BP ≤180/105 mmHg during and for 24 hours after procedure 2

Blood Pressure Management

• For patients NOT receiving thrombolysis:

  • Withhold antihypertensive agents unless BP >220/120 mmHg 1
  • Use easily titrated agents like labetalol when treatment needed 1

• For patients receiving thrombolysis or EVT:

  • Maintain BP ≤180/105 mmHg during and for 24 hours after procedure 2, 1
  • After successful reperfusion with EVT, consider lower targets (BP <140/90 mmHg) 2

Antithrombotic Therapy

• Aspirin: Administer 160-325 mg within 24-48 hours after stroke onset 2, 1
• For patients receiving IV thrombolysis: Delay aspirin administration until 24 hours after thrombolysis 2, 1
• Do NOT administer anticoagulants or other antiplatelets within 24 hours of IV thrombolysis 1

Prevention of Complications

• DVT prophylaxis: Use intermittent pneumatic compression devices or prophylactic-dose LMWH for patients with restricted mobility 1
• Temperature management: Monitor and treat fever (>38°C) 1
• Glucose management: Monitor and maintain normal glucose levels 2
• Cardiac monitoring: For at least 24 hours to detect atrial fibrillation 1
• Seizure management: Treat new-onset seizures with short-acting medications if not self-limited 2

Hospital Admission and Monitoring

• Admit to dedicated stroke unit or ICU 1
• Neurological monitoring: Every 15 minutes during and after IV alteplase for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours 1
• Vital signs monitoring: Regular assessment of BP, heart rate, temperature, and oxygen saturation 2

Early Rehabilitation

• Begin rehabilitation: As early as possible, ideally within 24-48 hours for stable patients 1
• Multidisciplinary approach: Physical therapy, occupational therapy, speech therapy, and cognitive assessment 1

Common Pitfalls to Avoid

• Delaying imaging or treatment: "Time is brain" - every minute delay results in loss of approximately 1.9 million neurons 2
• Excessive BP lowering: May worsen ischemia in patients not receiving reperfusion therapy 2
• Missing the extended treatment window: Patients with wake-up stroke or unknown onset time may still be eligible for treatment with appropriate imaging selection 2
• Failure to recognize stroke mimics: Conditions such as hypoglycemia, seizures, or migraine can present with stroke-like symptoms 1
• Overlooking dysphagia: Screen for swallowing difficulties before oral intake to prevent aspiration pneumonia 1

The management of acute stroke has evolved significantly with evidence supporting extended time windows for intervention, but the fundamental principle remains that faster treatment leads to better outcomes 4. The approach has shifted from a strict time-based paradigm to a tissue-based approach, focusing on salvageable brain tissue identified through advanced imaging techniques 4.