What is the step-wise management approach for stroke?

Step-wise Management Approach for Stroke

The management of acute stroke requires immediate recognition, rapid transport to a specialized stroke center, and prompt initiation of appropriate treatments to restore blood flow in ischemic stroke, with time being the most critical factor for improving outcomes. 1

Initial Recognition and Pre-hospital Management

• Emergency Medical Services (EMS) should be contacted immediately (e.g., 911) when signs of stroke are recognized, using validated tools such as FAST (Face, Arms, Speech, Time) 1
• EMS dispatchers should be trained to recognize stroke symptoms and prioritize rapid response 1
• Paramedics should use validated stroke assessment tools on scene and implement a "recognize and mobilize" approach to minimize on-scene time 1
• Pre-notification of the receiving hospital by EMS is essential to activate stroke protocols and prepare the stroke team, imaging, and other necessary resources 1

Emergency Department Triage and Assessment

• Emergency departments should use validated stroke screening tools and follow local protocols developed jointly with pre-hospital services 1
• Patients should be evaluated immediately by clinicians experienced in stroke assessment 1
• Urgent vital signs monitoring should be initiated, with temperature checks every 4 hours for the first 48 hours 1
• Initial laboratory tests should include complete blood count, electrolytes, renal function, glucose, lipids, and coagulation studies 1

Immediate Imaging

• All suspected stroke patients should undergo urgent brain CT or MRI within 24 hours of symptom onset, but ideally as soon as possible 1
• Imaging is crucial to:
  1. Rule out intracranial hemorrhage
  2. Identify vessel occlusion and its location
  3. Assess the risk/benefit ratio of potential treatments 1
• For patients eligible for thrombolysis or endovascular therapy, imaging should be performed without delay 1

Acute Treatment of Ischemic Stroke

Thrombolytic Therapy

• Intravenous rtPA (0.9 mg/kg, maximum 90 mg) is strongly recommended for carefully selected patients within 3 hours of stroke onset 1
• Extended window thrombolysis (3-4.5 hours) may be considered for eligible patients 2
• Blood pressure must be <185/110 mmHg before administering rtPA 1
• Recent evidence suggests potential benefit of thrombolysis up to 24 hours in selected patients with salvageable brain tissue identified by perfusion imaging 3

Endovascular Therapy

• For large vessel occlusions, endovascular thrombectomy should be considered, particularly within 6 hours of symptom onset 1
• Combined approaches using stent retrievers and aspiration techniques achieve the best reperfusion rates 1
• Transport decisions (direct to comprehensive stroke center vs. initial evaluation at primary stroke center) should be based on local geography and hospital capabilities 1

Antithrombotic Therapy

• Aspirin (160-300 mg) should be started within 48 hours of ischemic stroke onset if thrombolysis is not given 1
• Routine urgent anticoagulation is not recommended due to increased bleeding risk 1

Management of Physiological Parameters

• Blood pressure management:

  • Cautious approach to hypertension is recommended 1
  • Avoid treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg 1
  • Use short-acting agents with minimal effect on cerebral blood vessels 1
  • Avoid sublingual nifedipine or other agents causing precipitous BP reduction 1

• Glucose management:

  • Monitor blood glucose regularly 1
  • Treat hyperglycemia to maintain levels <300 mg/dL (<16.63 mmol/L) 1
  • Avoid glucose-containing IV solutions 1

• Temperature management:

  • Treat sources of fever and use antipyretics for elevated temperatures 1
  • For temperatures >37.5°C, increase monitoring frequency and investigate possible infections 1

Management of Complications

Cerebral Edema and Increased Intracranial Pressure

• Corticosteroids are not recommended 1
• Osmotherapy and hyperventilation are recommended for deteriorating patients 1
• Surgical decompression may be life-saving for large cerebellar infarctions causing brainstem compression 1

Seizures

• New-onset seizures should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limiting 1
• A single, self-limiting seizure within 24 hours of stroke onset does not require long-term anticonvulsant treatment 1
• Prophylactic anticonvulsants are not recommended 1

Venous Thromboembolism Prevention

• Early mobilization and adequate hydration should be encouraged 1
• Pharmacological prophylaxis with low molecular weight heparin or unfractionated heparin (for patients with renal failure) is recommended 1
• Anti-embolism stockings alone are not recommended 1

Early Rehabilitation and Supportive Care

• Initial assessment by rehabilitation professionals should be conducted within 48 hours of admission 1
• Rehabilitation therapy should begin as early as possible once the patient is medically stable 1
• Frequent, brief, out-of-bed activity involving active sitting, standing, and walking should begin within 24 hours if no contraindications exist 1
• Swallowing, nutritional, and hydration status should be screened as early as possible, ideally on the day of admission 1
• Patients who cannot take food and fluids orally should receive appropriate feeding (nasogastric, nasoduodenal, or PEG) to maintain hydration and nutrition 1

Secondary Prevention

• Identify stroke etiology to guide secondary prevention strategies 1
• Initiate appropriate antithrombotic therapy before discharge 1
• Address modifiable risk factors including hypertension, diabetes, hyperlipidemia, and smoking 1
• Consider carotid imaging for patients with carotid territory symptoms who might be candidates for revascularization 1

Common Pitfalls and Caveats

• Delays in recognition and treatment significantly worsen outcomes - every 30-minute delay in recanalization decreases the chance of good functional outcome by 8-14% 1
• Overly selective treatment criteria may exclude patients who could benefit from therapy 1
• Inadequate blood pressure control before thrombolysis increases hemorrhagic risk 1
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) can worsen outcomes 1
• Overlooking the need for early rehabilitation can delay recovery 1