What is the management approach for an acute stroke?

Acute Stroke Management

The management of acute stroke requires immediate recognition, rapid transport to a stroke-capable facility, urgent neuroimaging, and timely administration of appropriate reperfusion therapies such as intravenous thrombolysis and/or endovascular thrombectomy for eligible patients. 1

Initial Recognition and Pre-hospital Management

• Contact Emergency Medical Services (EMS) immediately when stroke symptoms are recognized using validated tools such as FAST (Face, Arms, Speech, Time) 1
• EMS dispatchers should prioritize stroke calls and implement rapid response protocols 2
• Paramedics should use validated stroke assessment tools and minimize on-scene time with a "recognize and mobilize" approach 2
• Pre-notification of the receiving hospital by EMS is essential to activate stroke protocols and prepare the stroke team and resources 2, 1

Emergency Department Assessment

• Patients should be evaluated immediately by clinicians experienced in stroke assessment 1
• Initial assessment should include:
  • Vital signs monitoring (especially blood pressure) 2, 1
  • Temperature checks every 4 hours for the first 48 hours 1
  • Blood glucose measurement (hypoglycemia can mimic stroke symptoms) 2
  • Laboratory tests including complete blood count, electrolytes, renal function, coagulation studies 1

Immediate Neuroimaging

• All suspected stroke patients should undergo urgent brain CT or MRI, ideally within minutes of arrival 2, 1
• Imaging is crucial to:
  • Rule out intracranial hemorrhage 2
  • Identify vessel occlusion and its location 2
  • Assess eligibility for reperfusion therapies 1

Acute Treatment of Ischemic Stroke

• Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA, 0.9 mg/kg, maximum 90 mg) is strongly recommended for eligible patients within 4.5 hours of symptom onset 2
• Blood pressure must be <185/110 mmHg before administering rtPA 1
• For patients with large vessel occlusion, endovascular thrombectomy should be considered:
  • Within 6 hours of symptom onset for most patients 1
  • Extended time window up to 24 hours for selected patients with favorable imaging 2
• Combined approaches using stent retrievers and aspiration techniques achieve the best reperfusion rates 2, 1

Management of Physiological Parameters

Blood Pressure Management

• Take a cautious approach to hypertension in acute stroke 2, 1
• For patients NOT receiving thrombolysis:
  • Avoid treating hypertension unless systolic BP >220 mmHg or diastolic BP >120 mmHg 2, 3
  • If treatment is necessary, lower BP by approximately 15% during the first 24 hours 3
• For patients receiving thrombolysis:
  • Maintain BP <185/110 mmHg before treatment and <180/105 mmHg for the first 24 hours after treatment 1, 3
• Preferred antihypertensive agents include labetalol and nicardipine (short-acting agents with minimal effect on cerebral blood vessels) 2, 3

Glucose Management

• Check blood glucose levels regularly 2, 1
• Treat hypoglycemia immediately as it can mimic stroke symptoms 2
• Maintain glucose levels <300 mg/dL (<16.63 mmol/L) 1
• Hyperglycemia is associated with poor outcomes and should be treated 2

Temperature Management

• Monitor temperature regularly and treat fever promptly 2, 1
• For temperatures >37.5°C, use antipyretics and investigate possible infections 1
• Hyperthermia worsens stroke outcomes and should be actively treated 2, 4

Management of Complications

Cerebral Edema and Increased Intracranial Pressure

• Monitor for neurological deterioration that may indicate developing cerebral edema 1
• For large hemispheric infarctions with significant edema:
  • Consider hemicraniectomy within 48 hours for selected patients (particularly those 18-60 years old) 2
  • Urgent neurosurgical consultation is recommended for patients with "malignant" middle cerebral artery occlusion 2
• For cerebellar infarctions causing brainstem compression, surgical decompression may be life-saving 1

Seizures

• Treat new-onset seizures with appropriate short-acting medications if not self-limiting 1
• Prophylactic anticonvulsants are not recommended 1

Early Rehabilitation and Supportive Care

• Initial assessment by rehabilitation professionals should occur within 48 hours of admission 1
• Begin rehabilitation therapy as early as possible once the patient is medically stable 1
• Implement early mobilization with frequent, brief, out-of-bed activity within 24 hours if no contraindications exist 1
• Screen swallowing function before allowing oral intake to prevent aspiration pneumonia 1

Secondary Prevention

• Begin appropriate antithrombotic therapy before discharge 2, 1
  • Aspirin (150-300 mg) should be given within 48 hours of stroke onset if CT/MRI excludes hemorrhage 2
  • The routine use of anticoagulation (e.g., intravenous heparin) in unselected patients is not recommended 2
• Address modifiable risk factors including hypertension, diabetes, hyperlipidemia, and smoking 1

Common Pitfalls to Avoid

• Delayed recognition and treatment - Every 30-minute delay in recanalization decreases the chance of good functional outcome by 8-14% 2, 1
• Overly selective treatment criteria - This 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