What is the initial management of acute stroke?

Initial Management of Acute Stroke

The initial management of acute stroke requires rapid assessment of airway, breathing, and circulation, followed by immediate neurological examination, vital sign monitoring, and urgent brain imaging to determine stroke type and guide treatment decisions. 1

Immediate Assessment and Stabilization

• Patients with suspected acute stroke should have a rapid initial evaluation of airway, breathing, and circulation to ensure physiological stability 1, 2
• A standardized neurological examination using a validated stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) should be performed to determine focal deficits and assess stroke severity 1, 2
• Initial vital sign assessment should include heart rate, rhythm, blood pressure, temperature, oxygen saturation, and hydration status 1
• Supplemental oxygen should be provided to maintain oxygen saturation >94% 1
• Sources of hyperthermia (temperature >38°C) should be identified and treated with antipyretic medications 1, 2

Emergency Imaging

• Emergency brain imaging (typically non-contrast CT) must be performed before initiating any specific therapy for acute ischemic stroke 1, 2
• Brain imaging should be interpreted within 45 minutes of patient arrival in the emergency department by a physician with expertise in reading CT and MRI studies 1
• For patients who are candidates for thrombolytic therapy, imaging should be performed without delay to exclude intracranial hemorrhage (absolute contraindication) 1, 3
• A noninvasive intracranial vascular study is strongly recommended during initial imaging evaluation if intra-arterial fibrinolysis or mechanical thrombectomy is contemplated, but should not delay intravenous rtPA if indicated 1

Blood Pressure Management

• For patients not receiving thrombolytic therapy, medications should be withheld unless systolic blood pressure is >220 mmHg or diastolic blood pressure is >120 mmHg 1
• If treatment is needed, a reasonable goal is to lower blood pressure by 15% during the first 24 hours after stroke onset 1
• For patients eligible for thrombolytic therapy, blood pressure must be <185/110 mmHg before administering rtPA and maintained below 180/105 mmHg for at least the first 24 hours after treatment 1, 2
• Appropriate medications for blood pressure control include labetalol 10-20 mg IV over 1-2 minutes (may repeat once) or nicardipine 5 mg/h IV, titrated up by 2.5 mg/h every 5-15 minutes to a maximum of 15 mg/h 1

Laboratory Testing

• Initial blood work should include electrolytes, random glucose, complete blood count, coagulation status (INR, aPTT), and creatinine 1
• These tests should not delay imaging or treatment decisions for intravenous thrombolysis and endovascular therapy 1
• Hypoglycemia (blood glucose <60 mg/dL) should be treated promptly to achieve normoglycemia 1
• For hyperglycemia, it is reasonable to treat to achieve blood glucose levels in a range of 140 to 180 mg/dL while closely monitoring to prevent hypoglycemia 1

Reperfusion Therapy

• Intravenous rtPA (0.9 mg/kg, maximum 90 mg) is recommended for eligible patients within 3 hours of stroke onset 1, 4, 3
• For patients between 3-4.5 hours from symptom onset, intravenous rtPA may be beneficial in carefully selected patients, though this remains controversial 1, 4
• The ECASS III trial demonstrated benefit of intravenous rtPA in the 3-4.5 hour window with a higher rate of excellent outcomes (mRS 0-1) at 90 days (52.4% vs 45.2%) 1
• For patients with large vessel occlusions, mechanical thrombectomy should be considered, particularly within 6 hours of symptom onset 2, 3

Antithrombotic Therapy

• Oral administration of aspirin (initial dose 325 mg) within 24-48 hours after stroke onset is recommended for most patients with ischemic stroke 1
• Aspirin is not recommended as a substitute for other acute interventions, including intravenous rtPA 1
• Administration of aspirin or other antiplatelet agents within 24 hours of intravenous fibrinolysis is not recommended 1
• The usefulness of clopidogrel for acute ischemic stroke treatment is not well established 1

Management of Complications

• New-onset seizures occurring at the time of acute stroke should be treated with appropriate short-acting medications (e.g., lorazepam IV) if they are not self-limited 1
• A single, self-limiting seizure at stroke onset should not be treated with long-term anticonvulsant medications 1
• Patients should be monitored for recurrent seizure activity during routine monitoring of vital signs and neurological status 1

Common Pitfalls and Considerations

• Delays in recognition and treatment significantly worsen outcomes - every 30-minute delay in recanalization decreases the chance of good functional outcome 2
• Inadequate blood pressure control before thrombolysis increases hemorrhagic risk 1, 2
• Frank hypodensity on non-contrast CT involving more than one-third of the MCA territory is associated with increased risk of hemorrhagic transformation with fibrinolysis 1
• A history of cerebral hemorrhage is not an absolute contraindication for thrombolytic therapy, though it may increase the risk of symptomatic intracerebral hemorrhage 5
• Advanced imaging techniques like MRI perfusion/diffusion may help identify patients who could benefit from reperfusion therapy beyond conventional time windows 6