What to do after the golden time for stroke treatment?

Post-Golden Time Stroke Management

After the golden time for stroke treatment has passed, comprehensive care should focus on preventing recurrent stroke, maximizing functional recovery, managing complications, and optimizing quality of life through a structured approach to patient care.

Establish Foundation for Post-Stroke Care

• Obtain and review hospital records to understand the stroke event, including pre-stroke risk factors, symptoms, diagnostic evaluation results, anatomic location, emergency therapy received, hospital course, and presumed pathogenesis 1
• Document a brief narrative of the patient's stroke to anchor stroke-specific care for future visits 1
• Solicit the patient's experience, including their understanding of the event, fears, and psychological consequences 1
• Confirm that the pathogenetic evaluation is complete and that specific treatment for the pathogenesis is in place 1
• Classify the stroke pathogenesis to guide secondary prevention strategies 1, 2

Screen for Complications and Unmet Needs

• Assess for common post-stroke complications including anxiety, cognitive impairment, depression, falling, fatigue, pain, spasticity, and thromboembolism 1
• Screen for depression, which affects up to 25% of patients at 2 years post-stroke 1
• Evaluate for cognitive impairment using validated screening tools 1
• Assess for unmet needs in physical rehabilitation, activities of daily living, mobility, pain control, and communication 1
• Monitor for neurological deterioration, which may occur in approximately 25% of patients during the first 24-48 hours after stroke 3

Implement Secondary Prevention Strategies

• Aggressively manage stroke risk factors to prevent recurrence 1:
  • Control hypertension with a target BP <140/90 mmHg for most patients 1
  • Prescribe high-intensity statin therapy for patients with ischemic stroke to reduce LDL-C by ≥50% 1
  • Target hemoglobin A1c ≤7% for most patients with diabetes 1
  • Facilitate weight management for patients with overweight or obesity 1
• Implement appropriate antithrombotic therapy based on stroke etiology 1:
  • For noncardioembolic ischemic stroke, prescribe aspirin 50-325 mg, clopidogrel 75 mg, or combination aspirin/dipyridamole 1
  • For patients with atrial fibrillation, prescribe oral anticoagulation unless contraindicated 1
• Address lifestyle modifications including regular physical activity, smoking cessation, healthy diet, and limited alcohol consumption 1

Facilitate Rehabilitation and Functional Recovery

• Initiate rehabilitation therapy as early as possible once the patient is medically stable 2
• Encourage frequent, brief, out-of-bed activity involving active sitting, standing, and walking within 24 hours if no contraindications exist 2
• Ensure patients have access to appropriate rehabilitation services including physical therapy, occupational therapy, and speech therapy based on individual needs 1
• Establish processes for stroke survivors to re-access rehabilitation services if functional decline occurs, even months or years post-stroke 1
• Assess patients' ability to adapt across all adaptive modes, focusing on physical mobility, communication abilities, and role changes 4

Support Patient and Caregiver Needs

• Foster patient-centered care by creating a welcoming environment where patients can express their values, aspirations, questions, fears, and needs 1
• Involve caregivers in the care plan with the patient's consent to help identify needs and improve satisfaction 1
• Provide education tailored to patients' cognitive abilities about medications, follow-up appointments, and warning signs requiring medical attention 4
• Assess caregivers' abilities and provide specific training for tasks they will need to perform at home 4
• Connect patients and caregivers with support groups and community resources for ongoing assistance 4

Coordinate Transitions of Care

• Schedule initial review with primary care provider within the first two to four weeks following hospital discharge 1
• Ensure primary care providers screen patients for ongoing physical issues, medication adherence, stroke prevention management, and need for follow-up 1
• Coordinate care beyond the inpatient setting with community support services to improve outcomes and satisfaction 4
• Implement early supported discharge programs with multidisciplinary teams when appropriate to facilitate better adaptation to home environments 4

Common Pitfalls to Avoid

• Delaying transfer to appropriate care settings, as earlier admission to stroke units (within 2 days) has been associated with fewer complications 3
• Failing to screen for and treat complications such as swallowing difficulties, infections, and venous thromboembolism, which can worsen outcomes 2
• Overlooking the need for early and ongoing rehabilitation, which can delay recovery 2
• Inadequate attention to secondary prevention strategies, which increases risk of recurrent stroke 1
• Insufficient support for caregivers, who play a crucial role in post-stroke recovery 4