What is the management and treatment of a patient who has suffered a stroke?

Management and Treatment of Stroke

The management of stroke requires immediate evaluation and treatment, with patients being admitted to a geographically defined stroke unit with specialized staff to reduce mortality and improve outcomes. 1, 2

Immediate Assessment and Stabilization

• All patients with suspected stroke should undergo immediate neurological evaluation and brain imaging (CT or MRI) within 24 hours to rule out hemorrhage and determine eligibility for reperfusion therapies 1
• Airway, breathing, and circulation should be monitored and maintained, with supplemental oxygen provided only to maintain oxygen saturation >94% 2, 1
• Blood pressure should be closely monitored in the first 48 hours after stroke onset 2
• For patients not receiving thrombolysis, blood pressure should only be lowered if systolic BP exceeds 220 mmHg or diastolic exceeds 120 mmHg 1, 3
• For patients who received thrombolysis, maintain BP below 180/105 mmHg in the first 24 hours 3

Reperfusion Therapies

• Intravenous alteplase (0.9 mg/kg; maximum 90 mg) is strongly recommended for selected patients who can receive the medication within 3 hours of stroke onset 2
• Mechanical thrombectomy is recommended for patients with large vessel occlusion within 6-24 hours, according to specific imaging criteria 1
• The intra-arterial administration of thrombolytic agents holds promise for treating patients beyond 3 hours, though patient selection criteria and effectiveness are not fully established 2

Prevention and Management of Complications

Swallowing Assessment and Nutrition

• All patients should be kept NPO (nothing by mouth) until a formal swallowing assessment is completed within 4-24 hours by a trained professional 2
• Patients with brain stem infarctions, multiple strokes, large hemispheric lesions, or depressed consciousness are at greatest risk for aspiration 2
• A water swallow test performed at the bedside is a useful screening test, with videofluoroscopic modified barium swallow examination for those who fail initial screening 2
• When necessary, a nasogastric or nasoduodenal tube can be inserted to provide feedings and medications 2

Neurological Complications

• Monitor for cerebral edema and increased intracranial pressure, which usually peaks 3-5 days after stroke 2
• Seizures occur in 5-12% of patients with acute ischemic stroke; anticonvulsants should only be administered to patients who have had seizures, not prophylactically 2
• Monitor for hemorrhagic transformation, especially in patients receiving reperfusion therapy 2

Infectious Complications

• Pneumonia is an important cause of death following stroke; the appearance of fever should prompt a search for pneumonia and early antibiotic therapy 2
• Urinary tract infections are common; indwelling catheters should be avoided when possible due to infection risk 2, 3
• 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 3

Venous Thromboembolism Prevention

• The subcutaneous administration of anticoagulants or the use of intermittent external compression stockings is strongly recommended for immobilized patients 2
• For patients who cannot receive anticoagulants, aspirin can be used for deep vein thrombosis prevention 2

Rehabilitation and Recovery

• Initial assessment by rehabilitation professionals should be performed within 48 hours of admission 1
• Early mobilization and rehabilitation should begin as soon as the patient is medically stable 1, 3
• Daily stretching of hemiplegic limbs should be performed to prevent contractures 3
• Positioning of the hemiplegic shoulder in maximum external rotation for 30 minutes daily can help prevent shoulder contracture 3

Secondary Prevention

• Aspirin 160-300 mg/day should be commenced within 48 hours of onset of acute ischemic stroke 1, 3
• Anticoagulation with warfarin may be indicated for specific conditions such as atrial fibrillation, with target INR of 2.0-3.0 4
• All modifiable risk factors should be addressed as part of secondary prevention strategy 3

Common Pitfalls and Caveats

• Delaying brain imaging can prevent timely administration of reperfusion therapies 1, 5
• Failure to monitor for and treat fever can worsen outcomes; temperature should be actively monitored and treated if >37.5°C 3
• Delaying swallowing assessment increases risk of aspiration pneumonia; screening should be completed within 24 hours 2, 3
• Inadequate blood pressure management can lead to complications; follow specific parameters based on whether the patient received thrombolysis 2
• Prophylactic anticonvulsant administration is not recommended for patients who have not experienced seizures 2