What is the assessment and plan for a patient with subacute stroke?

Assessment and Management of Subacute Stroke

The assessment and management of subacute stroke requires a standardized, multidisciplinary approach focused on early identification of complications, prevention of secondary stroke, and rehabilitation to improve long-term outcomes.

Initial Assessment

• All patients with suspected subacute stroke should undergo urgent brain CT or MRI within 24 hours of symptom onset to confirm diagnosis and rule out hemorrhage 1, 2
• A standardized stroke severity evaluation using validated tools (e.g., National Institutes of Health Stroke Scale) should be performed to assess prognosis and rehabilitation potential 3, 2
• Emergency department staff should use validated stroke screening tools to assist in rapid and accurate assessment 1
• Essential laboratory investigations should include full blood picture, electrocardiogram, electrolytes, renal function, fasting lipids, erythrocyte sedimentation rate and/or C-reactive protein, and glucose 1, 3
• Patients with carotid territory symptoms who would potentially be candidates for carotid revascularization should have urgent carotid duplex ultrasound 1, 2

Vital Signs Monitoring and Management

• Blood pressure should be closely monitored in the first 48 hours after stroke onset 1
• For patients not receiving thrombolysis, blood pressure should only be lowered if systolic BP exceeds 220 mmHg or diastolic exceeds 120 mmHg 1
• For patients who received thrombolysis, maintain BP below 180/105 mmHg in the first 24 hours 1
• Body temperature should be monitored at least 4 times per day for 3 days with treatment of temperature >37.5°C (99.5°F) with acetaminophen 1
• Oxygen saturation should be monitored, with supplemental oxygen provided only to maintain oxygen saturation >94% 1

Prevention and Management of Complications

• Fever, hyperglycemia, and swallowing dysfunction (FeSS) should be actively monitored and managed 1
• Swallowing screening should be performed within 24 hours of admission using a validated tool before giving food, fluids, or oral medications 1
• Blood glucose should be measured on admission and at least 4 times per day for 3 days, with elevated glucose >180 mg/dL (10 mmol/L) treated with insulin 1
• Measures to prevent pneumonia should be implemented, including good pulmonary toileting and early mobility 1
• Indwelling urinary catheters should be avoided when possible to reduce risk of urinary tract infections 1
• Assess for urinary retention in the first 72 hours after stroke using bladder scanning to obtain post-void residual volume 1
• Implement fall prevention protocols, especially during transfers and toileting 1

Medication Management

• Aspirin 160-300 mg/day should be commenced within 48 hours of onset of acute ischemic stroke 1, 4
• For patients with mild ischemic stroke or high-risk TIA of presumed atherosclerotic cause, dual antiplatelet therapy with clopidogrel plus aspirin initiated within 72 hours after stroke onset can reduce the risk of recurrent stroke but carries a higher risk of bleeding 5
• Pre-existing statin and aspirin use is associated with lower neurological deterioration and platelet activity in patients with acute ischemic stroke 6
• Anticoagulation (e.g., intravenous unfractionated heparin) is not recommended as standard treatment due to increased bleeding risk 1, 2

Rehabilitation Assessment and Early Intervention

• All stroke patients should receive a standardized screening evaluation during initial hospitalization to identify those with residual impairments requiring rehabilitation 1
• Early, short, frequent exercise sessions should be implemented to prevent complications and improve outcomes 1
• Daily stretching of hemiplegic limbs should be performed to prevent contractures 1
• Positioning of the hemiplegic shoulder in maximum external rotation for 30 minutes daily can help prevent shoulder contracture 1
• Early mobilization should be encouraged to help prevent venous thromboembolism 3

Stroke Unit Care

• All stroke patients should be admitted to a geographically defined stroke unit with specialized staff 1, 2
• Stroke unit care should be provided by an interdisciplinary team with expertise in stroke management 1, 2
• The multidisciplinary team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 2
• Clinical pathways should be used consistently to ensure organized application of interventions to prevent stroke progression or secondary complications 1

Secondary Prevention

• All modifiable risk factors should be addressed as part of secondary prevention 2, 7
• Appropriate antithrombotic therapy should be prescribed based on stroke etiology 2
• Blood pressure and cholesterol should be managed appropriately 2, 7
• Carotid endarterectomy should be considered for patients with symptomatic carotid obstruction of 70% or greater 7

Discharge Planning and Follow-up

• A stroke system should ensure a smooth transition from inpatient to outpatient care 1
• Timely transfer of hospital discharge information to the subsequent treating physician should be arranged 1
• A clear method of appropriate follow-up should be established 1
• Patient and family education about stroke risk factors, warning signs, and prevention strategies should be provided 1

Common Pitfalls and Caveats

• Failure to monitor for and treat fever can worsen outcomes; temperature should be actively monitored and treated if >37.5°C 1
• Delaying swallowing assessment increases risk of aspiration pneumonia; screening should be completed within 24 hours 1
• Inadequate blood pressure management can lead to complications; follow specific parameters based on whether the patient received thrombolysis 1
• Overlooking urinary retention, which occurs in 21-47% of patients in the first 72 hours after stroke 1
• Neglecting early mobilization and rehabilitation can lead to preventable complications like deep vein thrombosis and contractures 1, 3