What is the management of stroke?

Comprehensive Management of Stroke

Definition and Recognition

• Stroke is a medical emergency requiring immediate recognition and treatment, as "time is brain tissue" - earlier reperfusion is associated with better clinical outcomes 1.
• The FAST mnemonic (Face, Arms, Speech, Time) is an effective tool for public recognition of stroke symptoms, which has been shown to increase awareness and prompt earlier medical attention 2.
• All patients with suspected stroke should undergo immediate neurological evaluation and brain imaging studies (CT or MRI) within 24 hours to rule out hemorrhage and determine eligibility for reperfusion therapies 3, 2.

Acute Management

Pre-hospital and Emergency Department Care

• Immediate activation of emergency medical services and rapid transport to a stroke-capable hospital is essential for optimal stroke outcomes 2.
• Local protocols should include early notification by paramedic staff, high-priority transportation, rapid referrals from ED staff to stroke specialists, and rapid access to imaging 2.
• Emergency department staff should use validated stroke screening tools for rapid assessment 2, 4.
• 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, 4.

Initial Assessment and Stabilization

• Airway, breathing, and circulation should be monitored and maintained, with tracheal intubation indicated for patients with compromised airway 3.
• Supplemental oxygen should be provided only to maintain oxygen saturation >94% 3, 4.
• Hypotension and hypovolemia should be corrected to maintain adequate systemic perfusion levels 3.
• Essential laboratory investigations include full blood picture, electrocardiogram, electrolytes, renal function, fasting lipids, erythrocyte sedimentation rate and/or C-reactive protein, and glucose 4.

Brain Imaging

• All patients with suspected stroke should have an urgent brain CT or MRI (within 24 hours) 2, 4.
• A repeat brain CT or MRI should be considered urgently when a patient's condition deteriorates 2.
• All patients with carotid territory symptoms who would potentially be candidates for carotid revascularization should have an urgent carotid duplex ultrasound 2, 4.

Reperfusion Therapies

Intravenous Thrombolysis

• Intravenous alteplase (0.9 mg/kg, maximum 90 mg) is recommended for selected patients within 4.5 hours of symptom onset 3, 1.
• For patients receiving thrombolysis, blood pressure should be maintained below 185/105 mmHg in the first 24 hours 4, 5.

Mechanical Thrombectomy

• Mechanical thrombectomy is recommended for patients with large vessel occlusion within 6-24 hours, according to specific imaging criteria 3.
• Mechanical thrombectomy is also recommended between 6-24 hours in patients with significant mismatch between the ischemic core and at-risk tissue based on advanced imaging criteria 3.

Blood Pressure Management

• For patients not receiving thrombolysis, antihypertensive treatment should be avoided unless systolic blood pressure is >220 mmHg or diastolic >120 mmHg 3, 5.
• For patients with marked elevation in blood pressure, a reasonable goal would be to lower blood pressure by 15% during the first 24 hours after onset of stroke 5.
• Emergency treatment of hypertension is recommended if there is concomitant acute myocardial infarction, aortic dissection, acute renal failure, acute pulmonary edema, or preeclampsia/eclampsia 3, 5.
• First-line drugs for lowering blood pressure include labetalol, nicardipine, and sodium nitroprusside 5.

Management of Complications

Cerebral Edema

• Cerebral edema will occur in all infarcts but is especially concerning in large-volume infarcts 2.
• Corticosteroids are not recommended for cerebral edema and increased intracranial pressure 3.
• Osmotic therapy and hyperventilation are recommended for patients who deteriorate 3.
• In swollen supratentorial hemispheric ischemic stroke, decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically 2.
• In swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically 2, 3.

Other Complications

• Fever, hyperglycemia, and swallowing dysfunction should be actively monitored and managed 4.
• Swallowing screening should be performed within 24 hours of admission using a validated tool before giving food, fluids, or oral medications 4.
• Blood glucose should be measured on admission and at least 4 times per day for 3 days, with elevated glucose >180 mg/dL treated with insulin 4, 6.
• Measures to prevent deep vein thrombosis include early mobilization and prophylactic anticoagulation 2, 4.

Stroke Unit Care

• All stroke patients should be admitted to a geographically defined stroke unit with specialized staff 2, 4.
• Stroke unit care should be provided by an interdisciplinary team with expertise in stroke management 4.
• The multidisciplinary team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 4.
• Essential components of a stroke unit include comprehensive assessment of medical problems, established pathways and management protocols, care coordinated by a multidisciplinary team, early mobilization, skilled nursing care, and early rehabilitation 2.

Rehabilitation and Recovery

• Initial assessment by rehabilitation professionals should be performed within 48 hours of admission 3.
• Rehabilitation therapy should begin as soon as possible once the patient is medically stable 3, 4.
• Early, short, frequent exercise sessions should be implemented to prevent complications and improve outcomes 4.
• Daily stretching of hemiplegic limbs should be performed to prevent contractures 4.

Secondary Prevention

• Aspirin 160-300 mg/day should be commenced within 48 hours of onset of acute ischemic stroke 4.
• Anticoagulation (e.g., intravenous unfractionated heparin) is not recommended as standard treatment due to increased bleeding risk 4.
• For patients with atrial fibrillation, anticoagulation therapy is effective for stroke prevention 7.
• Treatment of dyslipidemia with statins is effective for stroke prevention 7.
• Carotid endarterectomy in symptomatic high-grade carotid stenosis is effective for stroke prevention 7.

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 4, 6.
• Delaying swallowing assessment increases risk of aspiration pneumonia; screening should be completed within 24 hours 4.
• Inadequate blood pressure management can lead to complications; follow specific parameters based on whether the patient received thrombolysis 4, 5.
• Overlooking urinary retention, which occurs in 21-47% of patients in the first 72 hours after stroke 4.
• Neglecting early mobilization and rehabilitation can lead to preventable complications like deep vein thrombosis and contractures 4.