What is the treatment for a suspected stroke?

Treatment for Suspected Stroke

Immediate brain imaging with non-contrast CT or MRI is the first essential step in treating suspected stroke, followed by appropriate reperfusion therapy (intravenous thrombolysis and/or endovascular thrombectomy) for eligible patients within their respective time windows. 1

Initial Emergency Assessment

• Perform rapid initial evaluation of airway, breathing, and circulation 1
• Conduct neurological examination using a standardized stroke scale (such as NIHSS) to determine focal deficits and assess stroke severity 1
• Assess vital signs including heart rate, rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity 1
• Provide supplemental oxygen to maintain oxygen saturation ≥94% 1
• Correct hypotension and hypovolemia to maintain adequate systemic perfusion 1

Immediate Diagnostic Studies

• Perform immediate brain imaging with non-contrast CT or MRI to differentiate between ischemic and hemorrhagic stroke 1
  • Ideally, CT should be completed within 25 minutes of ED arrival and interpreted within 45 minutes 1
• Conduct CT angiography (CTA) from arch-to-vertex for patients potentially eligible for endovascular therapy 1
• Obtain essential blood work without delaying treatment 1:
  • Blood glucose (must precede thrombolysis)
  • Complete blood count including platelet count
  • Coagulation studies (INR, aPTT)
  • Serum electrolytes and renal function
  • Cardiac markers

Acute Treatment for Ischemic Stroke

Intravenous Thrombolysis (tPA/Alteplase)

• Administer IV alteplase (0.9 mg/kg, maximum 90 mg over 60 minutes with initial 10% as bolus) to eligible patients within 4.5 hours of symptom onset 1

• Key eligibility criteria for IV thrombolysis within 3 hours 1:

  • Measurable neurological deficit
  • No evidence of intracranial hemorrhage on imaging
  • Blood pressure <185/110 mmHg
  • No recent trauma, surgery, or bleeding
  • No use of anticoagulants with elevated INR >1.7

• For patients between 3-4.5 hours, additional exclusion criteria apply 1:

  • Age >80 years
  • Severe stroke (NIHSS >25)
  • Taking oral anticoagulants regardless of INR
  • History of both diabetes and prior stroke

Endovascular Thrombectomy (EVT)

• Consider EVT for patients with large vessel occlusion in the anterior circulation within 6 hours of symptom onset 1
• Selected patients may be eligible for EVT up to 24 hours based on advanced imaging 1
• Transfer patients from primary stroke centers to comprehensive stroke centers if EVT is indicated but unavailable 1

Blood Pressure Management

• For patients eligible for thrombolysis 1:

  • Lower blood pressure to <185/110 mmHg before thrombolysis
  • Maintain BP <180/105 mmHg for 24 hours after thrombolysis

• For patients not eligible for thrombolysis 1:

  • Consider lowering blood pressure only if systolic BP >220 mmHg or diastolic BP >120 mmHg
  • Target 15-25% reduction within the first day

Seizure Management

• Treat new-onset seizures at the time of stroke with short-acting medications (e.g., lorazepam IV) if not self-limited 1
• A single, self-limiting seizure within 24 hours of stroke onset does not require long-term anticonvulsant medication 1
• Prophylactic use of anticonvulsants is not recommended 1

Common Pitfalls to Avoid

• Delaying brain imaging for other tests like ECG or chest X-ray 1
• Waiting for all laboratory results before initiating thrombolysis (only glucose must be checked before treatment) 1
• Aggressive blood pressure reduction in patients not receiving thrombolysis, which may worsen ischemia 1
• Evaluating response to IV thrombolysis before proceeding with EVT assessment 1
• Exceeding the 60-minute door-to-needle time target for thrombolysis, which is associated with poorer outcomes 2

Time-Critical Considerations

• "Time is Brain" - rapid assessment and treatment are essential 1
• Target door-to-needle time for IV thrombolysis should be under 60 minutes 2
• Scene time during pre-hospital care should be minimized; treatments not immediately required should be performed en route 1
• Do not delay emergency treatment to obtain advanced imaging studies 1