What is the approach to managing a stroke?

Approach to Managing Stroke

Stroke management requires a rapid, organized response through a structured stroke system of care to minimize brain injury and maximize patient recovery. 1

Immediate Recognition and Response

• Rapid recognition of stroke symptoms is the first critical step in the stroke chain of survival 1
• Emergency medical services (EMS) should be activated immediately by calling 911 when stroke symptoms are identified 1
• EMS should use validated stroke screening tools to assist in rapid and accurate assessment 1
• Prehospital notification by EMS to the receiving hospital significantly reduces delays in stroke evaluation and treatment 2
• Local protocols should include early notification by paramedic staff, high-priority transportation, rapid triage, and expedited access to imaging 1

Emergency Department Management

• All patients with suspected stroke should undergo urgent brain CT or MRI within 24 hours of symptom onset, but ideally as soon as possible 1
• A standardized stroke severity evaluation should be performed to assess prognosis and rehabilitation potential 3
• Written hospital protocols defining processes and responsibilities should be established according to AHA guidelines 1
• Emergency department staff should use validated stroke screening tools for rapid assessment 1
• Stroke teams should include members trained to homogeneously care for patients with stroke 1

Diagnostic Evaluation

• Essential investigations that should be obtained routinely in all patients include: full blood picture, electrocardiogram, electrolytes, renal function, fasting lipids, erythrocyte sedimentation rate and/or C-reactive protein, and glucose 1
• All patients with carotid territory symptoms who would potentially be candidates for carotid revascularization should have an urgent carotid duplex ultrasound 1
• Additional investigations may be required in selected patients: angiography, chest X-ray, syphilis serology, vasculitis screen, and prothrombotic screen 1
• A repeat brain CT or MRI should be performed urgently when a patient's condition deteriorates 1

Acute Treatment for Ischemic Stroke

• Intravenous recombinant tissue plasminogen activator (rtPA) is strongly recommended for carefully selected patients who can receive the medication within 3 hours of stroke onset 1
• Safe use of rtPA requires adherence to selection criteria, close observation, and careful ancillary care 1
• Aspirin can be administered within the first 48 hours due to its reasonable safety profile and modest benefit 1
• Anticoagulation (e.g., intravenous unfractionated heparin) is not recommended as standard treatment due to increased bleeding risk 1

Management of Intracerebral Hemorrhage (ICH)

• ICH due to anticoagulation should be urgently reversed 1
• Blood pressure lowering in ICH patients with a history of hypertension is indicated to keep mean arterial pressure below 130 mmHg 1
• Surgical intervention may be considered in specific situations, such as craniotomy for superficial ICH less than 1 cm from surface or stereotactic surgery for deep ICH 1
• Surgery is particularly beneficial for patients with cerebellar hemorrhages that are leading to brain stem compression and hydrocephalus 1

Stroke Unit Care

• All stroke patients should be admitted to a geographically defined stroke unit with specialized staff 1
• Stroke unit care is characterized by an interdisciplinary stroke team with expertise in stroke management 1
• The multidisciplinary team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 1
• Comprehensive stroke unit care combines acute management with early rehabilitation and secondary prevention 1

Prevention and Management of Complications

• Early screening and management of swallowing difficulties, nutrition, cognition, perception, and communication should be performed by appropriate members of the multidisciplinary team 1
• Complications such as deep venous thrombosis, pyrexia, pressure ulcers, falls, and pain should be actively prevented 1
• For patients with significant brain edema and increased intracranial pressure, osmotherapy and hyperventilation are recommended 1
• Hemicraniectomy within 48 hours has been shown to substantially reduce death and disability in selected patients (18-60 years old) with extensive hemispheric infarcts 1

Early Rehabilitation

• Early mobilization is strongly recommended to prevent complications 3
• Assessment and management of mobility, activities of daily living, incontinence, and mood should be undertaken early after stroke 1
• Speech and language pathologists should evaluate and treat all stroke patients for residual communication difficulties 3
• Touch discrimination training may be beneficial for patients with somatosensory loss 3

Secondary Prevention

• Appropriate antithrombotic therapy should be prescribed based on stroke etiology 3
• For non-cardioembolic ischemic stroke, antiplatelet therapy such as clopidogrel (75 mg once daily) is indicated to reduce the rate of recurrent stroke 4
• Blood pressure and cholesterol should be managed appropriately 3
• All modifiable risk factors should be addressed as part of secondary prevention 3

Quality Improvement

• In-hospital stroke performance and quality data should be examined specifically and used to drive focused quality improvement efforts 1
• Reviewing metrics such as the number of stroke alerts, true stroke rates with subtypes, response times, imaging acquisition times, treatment rates, treatment times, and outcomes will support quality improvement 1
• Reporting all stroke cases to a registry may help with monitoring the true incidence of stroke and provide data for future research 1