What is the management approach for stroke in a flowchart?

Management of Stroke: A Comprehensive Flowchart Approach

The management of stroke requires a systematic approach following a clear flowchart that begins with rapid recognition and extends through acute treatment to rehabilitation, with time being the most critical factor affecting outcomes. 1

Initial Recognition and Pre-hospital Management

• Immediate recognition of stroke symptoms using validated tools such as FAST (Face, Arms, Speech, Time) 1
• Immediate activation of Emergency Medical Services (911) 1
• EMS should use validated stroke assessment tools and implement a "recognize and mobilize" approach to minimize on-scene time 1
• Pre-notification of the receiving hospital by EMS to activate stroke protocols and prepare the stroke team, imaging, and other necessary resources 1, 2

Emergency Department Triage and Assessment

• Immediate triage with the same priority as patients with acute myocardial infarction or serious trauma 3
• Initial assessment following the ABCs (Airway, Breathing, Circulation) 3
• Urgent vital signs monitoring with temperature checks every 4 hours for the first 48 hours 1
• Determine time of symptom onset - the most important piece of historical information 3
• Perform standardized stroke severity assessment using the National Institutes of Health Stroke Scale (NIHSS) 4
• Initial laboratory tests: complete blood count, electrolytes, renal function, glucose, lipids, and coagulation studies 1

Immediate Imaging

• Urgent brain CT or MRI within 24 hours of symptom onset, but ideally as soon as possible 1
• Non-enhanced CT (NECT) to exclude hemorrhage and assess for early signs of ischemia 3
• For patients eligible for thrombolysis or endovascular therapy, imaging should be performed without delay 1
• Additional vascular imaging (CT angiography or MR angiography) to identify large vessel occlusions in patients presenting within 24 hours 4

Acute Treatment Decision Pathway

For Ischemic Stroke:

• If within 3 hours of symptom onset (or up to 4.5 hours in selected patients):
  • Consider intravenous rtPA (0.9 mg/kg, maximum 90 mg) if no contraindications 1
  • Ensure blood pressure <185/110 mmHg before administering rtPA 1
• For large vessel occlusions within 6-24 hours (depending on clinical/imaging criteria):
  • Consider endovascular thrombectomy 1
• If not eligible for thrombolysis or thrombectomy:
  • Administer aspirin within 48 hours 5

For Hemorrhagic Stroke:

• Reverse anticoagulation urgently if applicable 5
• Lower blood pressure to keep mean arterial pressure below 130 mmHg in patients with a history of hypertension 5
• Consider surgical intervention for:
  • Cerebellar hemorrhages causing brainstem compression 5
  • Superficial ICH less than 1 cm from surface 5
  • Deep ICH amenable to stereotactic surgery 5

Management of Physiological Parameters

• Blood pressure management:
  • For ischemic stroke: Avoid treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg 1
  • For patients receiving thrombolysis: Maintain BP <185/110 mmHg 1
• Glucose management:
  • Monitor blood glucose regularly 1
  • Treat hyperglycemia to maintain levels <300 mg/dL (<16.63 mmol/L) 1
• Temperature management:
  • Treat sources of fever and use antipyretics for elevated temperatures 1
  • For temperatures >37.5°C, increase monitoring frequency and investigate possible infections 1

Management of Complications

Cerebral Edema and Increased Intracranial Pressure:

• Osmotherapy and hyperventilation for deteriorating patients 1
• Consider surgical decompression for large cerebellar infarctions causing brainstem compression 1
• Hemicraniectomy within 48 hours for extensive hemispheric infarcts in selected patients (18-60 years old) 5

Seizures:

• Treat new-onset seizures with appropriate short-acting medications (e.g., lorazepam IV) if not self-limiting 1
• Prophylactic anticonvulsants are not recommended 1

Agitation:

• Identify and treat potential underlying causes (hypoxia, increased intracranial pressure, seizures, hypoglycemia) 6
• For mild to moderate agitation: lorazepam (1-2 mg IV/IM) 6
• For moderate to severe agitation: haloperidol (5-10 mg IV/IM) 6
• Avoid rapid or excessive sedation as it may mask neurological symptoms 6

Stroke Unit Care

• All stroke patients should be admitted to a geographically defined stroke unit with specialized staff 5
• The multidisciplinary team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 5

Early Rehabilitation and Supportive Care

• Initial assessment by rehabilitation professionals within 48 hours of admission 1
• Begin rehabilitation therapy as early as possible once the patient is medically stable 1
• Start frequent, brief, out-of-bed activity within 24 hours if no contraindications exist 1
• Screen swallowing, nutritional, and hydration status as early as possible, ideally on admission day 1
• Provide appropriate feeding (nasogastric, nasoduodenal, or PEG) for patients who cannot take food and fluids orally 1

Secondary Prevention

• Identify stroke etiology to guide secondary prevention strategies 1
• Initiate appropriate antithrombotic therapy before discharge 1
• Address modifiable risk factors: hypertension, diabetes, hyperlipidemia, and smoking 1
• Consider carotid imaging for patients with carotid territory symptoms who might be candidates for revascularization 1

Common Pitfalls and Caveats

• Delays in recognition and treatment significantly worsen outcomes - every 30-minute delay in recanalization decreases the chance of good functional outcome by 8-14% 1
• Overly selective treatment criteria may exclude patients who could benefit from therapy 1
• Inadequate blood pressure control before thrombolysis increases hemorrhagic risk 1
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) can worsen outcomes 1
• Overlooking the need for early rehabilitation can delay recovery 1