What is the management of stroke?

Management of Stroke

The most effective approach to stroke management involves rapid recognition, immediate transport to a stroke-capable hospital, and treatment in a dedicated stroke unit with specialized interdisciplinary care to minimize brain injury and maximize recovery.1, 2

Immediate Recognition and Response

• The "FAST" mnemonic (Face, Arm, Speech, Time) is an effective tool for public recognition of stroke symptoms, prompting earlier medical attention 1
• Emergency medical services should be activated immediately by calling 911 when stroke symptoms are identified 3
• Local protocols should include early notification by paramedic staff, high-priority transportation, rapid referrals from ED staff to stroke specialists, and rapid access to imaging 3, 2
• The "Stroke Chain of Survival" includes detection, dispatch, delivery, door, data, decision, drug, and disposition as key links in optimal stroke care 2

Emergency Department Management

• All patients with suspected stroke should undergo urgent brain CT or MRI within 24 hours of symptom onset, ideally as soon as possible, to rule out hemorrhage and determine eligibility for reperfusion therapies 1, 2
• Standardized stroke orders or integrated stroke pathways improve adherence to best practices for treatment of stroke patients 2
• Neurological status and vital signs should be assessed frequently during the first 24 hours after admission 2
• A standardized stroke severity evaluation should be performed to assess prognosis and rehabilitation potential 3

Acute Treatment for Ischemic Stroke

Intravenous Thrombolysis

• Intravenous recombinant tissue plasminogen activator (rtPA) is recommended for carefully selected patients who can receive the medication within 4.5 hours of stroke onset 1, 2
• Patients receiving thrombolytic therapy require close monitoring for bleeding complications 2

Mechanical Thrombectomy

• Mechanical thrombectomy is recommended for patients with large vessel occlusion within 6-24 hours according to specific imaging criteria 1, 2
• A combined endovascular therapy approach using stent-retrievers and aspiration is the most effective way to achieve fast first-pass complete reperfusion 2

Blood Pressure Management

• For patients not receiving thrombolysis, antihypertensive treatment should be avoided unless systolic blood pressure is >220 mmHg or diastolic >120 mmHg 1, 3
• Sublingual nifedipine and other agents causing precipitous reductions in blood pressure should be avoided 3

Stroke Unit Care

• All stroke patients should be admitted to a geographically defined stroke unit with specialized staff 1, 2
• Stroke unit care is characterized by an interdisciplinary team with expertise in stroke management, including physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 3, 2
• Stroke units significantly reduce mortality and morbidity after stroke, with positive effects persisting for years 2
• The benefits from treatment in a stroke unit are comparable to the effects achieved with intravenous administration of rtPA 2

Prevention and Management of Complications

• Early screening and management of swallowing difficulties is essential to prevent aspiration pneumonia 3, 2
• Impairments of swallowing are associated with a high risk of pneumonia, requiring swallowing assessment before allowing oral intake 3, 2
• Fever, hyperglycemia, and swallowing dysfunction should be actively monitored and managed 1
• Early mobilization is favored because it lessens the likelihood of complications such as pneumonia, deep vein thrombosis, pulmonary embolism, and pressure sores 2
• Frequent turning, use of alternating pressure mattresses, and close surveillance of the skin help prevent pressure sores 2

Nutrition and Hydration

• Sustaining nutrition is important as dehydration or malnutrition may slow recovery 2, 3
• Dehydration is a potential cause of deep vein thrombosis after stroke 2
• When necessary, nasogastric or nasoduodenal tubes can be inserted to provide feedings and medication administration 3
• Percutaneous endoscopic gastric tube placement is superior to nasogastric tube feeding if prolonged feeding support is anticipated 3

Early Rehabilitation

• Initial assessment by rehabilitation professionals should be performed within 48 hours of admission 1
• Rehabilitation therapy should begin as soon as possible once the patient is medically stable 1
• If ongoing inpatient rehabilitation is needed, care should be provided in either a stroke rehabilitation unit or a general rehabilitation unit 2
• Rehabilitation in the community is equally effective if delivered in the hospital via outpatients, day hospital, or in the community, and should be offered to all stroke patients as needed 2

Secondary Prevention

• Aspirin 160-300 mg/day should be commenced within 48 hours of onset of acute ischemic stroke 1
• Anticoagulation is not recommended as standard treatment due to increased bleeding risk 1, 3
• Carotid endarterectomy is recommended for patients with recent (within 6 months) non-disabling carotid artery territory ischemic stroke or TIA with ipsilateral carotid stenosis measured at 70-99% 2
• Carotid endarterectomy may be considered for select patients with stenosis of 50-69% 2
• Eligible patients should undergo carotid endarterectomy as soon as possible after the event, ideally within 2 weeks 2

Quality Improvement

• In-hospital stroke performance and quality data should be examined specifically and used to drive focused quality improvement efforts 3
• Participation in programs like Get With The Guidelines-Stroke has produced improved care processes and sustained increased adherence to stroke performance measures 2
• Transport and admission to a Primary Stroke Center compared with non-designated hospitals leads to lower overall 30-day mortality rates and increased use of fibrinolytic therapy 2