What is the management and treatment for a patient suspected of having a stroke?

Management and Treatment for Suspected Stroke Patients

Stroke is a medical emergency requiring immediate evaluation and treatment to minimize brain damage and improve outcomes. Patients with suspected stroke should be rapidly assessed, transported to appropriate stroke centers, and receive time-sensitive interventions based on stroke type and eligibility criteria.

Prehospital Management

Recognition and Activation of Emergency Services

• Immediate contact with emergency medical services (EMS) is strongly recommended when stroke symptoms are recognized 1
• The public should be educated to recognize stroke symptoms using tools such as FAST (Face, Arms, Speech, and Time) 1
• EMS dispatch centers should implement protocols to recognize stroke symptoms and prioritize response 1

Paramedic On-Scene Management

• Paramedics should use validated stroke screening tools that include FAST components 1
• A second screening tool to assess stroke severity should be used to identify potential endovascular thrombectomy (EVT) candidates 1
• On-scene time should be minimized to a median of 20 minutes or less for patients presenting within the treatment window 1
• Initial assessment should include capillary blood glucose measurement 1
• Information about symptom onset time, medications (especially anticoagulants), and comorbidities should be collected 1

Transport Considerations

• Direct transport protocols should facilitate transfer of suspected stroke patients to appropriate hospitals capable of providing acute stroke services 1
• Patients should be triaged as Canadian Triage Acuity Scale (CTAS) Level 2 in most cases, or Level 1 if airway, breathing, or cardiovascular function is compromised 1
• Pre-notification to the receiving hospital should be provided to allow preparation for rapid assessment and treatment 1

Emergency Department Evaluation and Management

Initial Assessment

• Rapid evaluation of airway, breathing, and circulation should be conducted immediately 1
• A neurological examination using a standardized stroke scale (such as NIHSS) should be performed to determine focal deficits and stroke severity 1
• Assessment should include heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity 1

Laboratory and Diagnostic 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 1
• An electrocardiogram (ECG) should be performed to assess cardiac rhythm and evidence of structural heart disease 1

Brain and Vascular Imaging

• All patients with suspected acute stroke must undergo immediate brain imaging with non-contrast CT (NCCT) or MRI to determine stroke type and treatment eligibility 1
• Patients arriving within 4.5 hours who are potential candidates for intravenous thrombolysis should have immediate NCCT 1
• Patients arriving within 6 hours who are potential candidates for endovascular thrombectomy (EVT) should have immediate NCCT and CT angiography (CTA) from arch-to-vertex 1
• Advanced imaging such as CT perfusion or multiphase CTA may be considered but should not delay treatment 1

Blood Pressure Management

• For patients eligible for thrombolytic therapy, blood pressure must be below 185/110 mmHg before treatment 1
• For patients not eligible for thrombolytic therapy, blood pressure should only be lowered if systolic pressure exceeds 220 mmHg or diastolic pressure exceeds 120 mmHg 1

Seizure Management

• New-onset seizures occurring at the time of stroke or within 24 hours should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limiting 1
• Single, self-limiting seizures should not be treated with long-term anticonvulsant medications 1
• Prophylactic use of anticonvulsant medications is not recommended 1

Acute Treatment Options

Intravenous Thrombolysis

• Eligible patients with acute ischemic stroke should be evaluated for intravenous thrombolytic therapy (alteplase) 1
• Treatment should begin within 4.5 hours of symptom onset 1
• Blood pressure must be controlled below 185/110 mmHg before treatment 1

Endovascular Thrombectomy (EVT)

• Patients with large vessel occlusions should be evaluated for EVT 1
• Some patients may be eligible for EVT up to 24 hours from symptom onset when selected by neurovascular imaging 1

Antiplatelet Therapy

• Aspirin (160-300 mg/day) should be started within 48 hours of ischemic stroke onset 1
• Clopidogrel may be considered for patients with recent stroke who are at high risk for recurrent ischemic events, but the combination with aspirin has been shown to increase major bleeding 2

Common Pitfalls and Caveats

• Failure to recognize stroke symptoms promptly can lead to delays in treatment and worse outcomes 3, 4
• Stroke mimics (such as seizures, hypoglycemia, migraine with aura) should be ruled out during evaluation 1
• Elevated blood pressure should not be aggressively lowered in acute stroke unless specific thresholds are exceeded, as this may decrease cerebral perfusion and worsen ischemia 1
• Prophylactic anticonvulsants should be avoided as they may have negative effects on neural recovery 1
• For patients on clopidogrel who require surgery, discontinue the medication five days prior to surgery due to increased bleeding risk 2
• Premature discontinuation of antiplatelet therapy may increase the risk of cardiovascular events 2
• Thrombotic thrombocytopenic purpura is a rare but serious complication of clopidogrel that requires urgent treatment 2