What is the management plan for acute stroke?

Management of Acute Stroke

Immediate recognition and rapid treatment are essential for optimal outcomes in acute stroke management, with patients requiring admission to specialized stroke units for comprehensive care.

Initial Recognition and Pre-hospital Management

• Emergency Medical Services should be contacted immediately when signs of stroke are recognized using validated tools such as FAST (Face, Arms, Speech, Time) 1
• EMS dispatchers should prioritize rapid response and paramedics should implement a "recognize and mobilize" approach to minimize on-scene time 1
• Pre-notification of the receiving hospital by EMS is essential to activate stroke protocols and prepare the stroke team and imaging resources 1, 2

Emergency Department Assessment and Imaging

• All suspected stroke patients should undergo urgent brain CT or MRI within 24 hours of symptom onset, but ideally as soon as possible to rule out hemorrhage and determine eligibility for reperfusion therapies 1, 2
• Initial laboratory tests should include complete blood count, electrolytes, renal function, glucose, lipids, and coagulation studies 1
• Neurological status and vital signs should be assessed frequently during the first 24 hours after admission 2

Acute Treatment of Ischemic Stroke

Intravenous Thrombolysis

• Intravenous rtPA (0.9 mg/kg, maximum 90 mg) is strongly recommended for carefully selected patients within 4.5 hours of stroke onset 1, 3
• Blood pressure must be <185/110 mmHg before administering rtPA 4, 1
• For patients with blood pressure >185/110 mmHg who are candidates for acute reperfusion therapy, the following medications can be used 4:
  • Labetalol 10–20 mg IV over 1–2 min (may repeat once)
  • Nicardipine 5 mg/h IV, titrated up by 2.5 mg/h every 5–15 min (maximum 15 mg/h)
  • Clevidipine 1–2 mg/h IV, titrated by doubling the dose every 2–5 min (maximum 21 mg/h)

Endovascular Therapy

• For large vessel occlusions, endovascular thrombectomy should be considered, particularly within 6 hours of symptom onset 1, 2
• Combined approaches using stent retrievers and aspiration techniques achieve the best reperfusion rates 1, 2

Management of Physiological Parameters

Blood Pressure Management

• For patients not receiving thrombolysis, antihypertensive treatment should be avoided unless systolic BP >220 mmHg or diastolic BP >120 mmHg 2
• For patients receiving thrombolysis, maintain BP ≤180/105 mmHg during and after treatment 4
• The usefulness of drug-induced hypertension in patients with acute ischemic stroke is not well established 4

Temperature Management

• Sources of hyperthermia (temperature >38°C) should be identified and treated, and antipyretic medications should be administered to lower temperature in hyperthermic patients 4
• For temperatures >37.5°C, increase monitoring frequency and investigate possible infections 1
• Hypothermia should be offered only in the context of ongoing clinical trials 4

Blood Glucose Management

• Monitor blood glucose regularly and treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL 4, 1
• Close monitoring is essential to prevent hypoglycemia 4

Management of Complications

Cerebral Edema

• Corticosteroids are not recommended for cerebral edema and increased intracranial pressure 1, 2
• Osmotherapy and hyperventilation are recommended for deteriorating patients 1, 2
• Surgical decompression may be life-saving for large cerebellar infarctions causing brainstem compression 1
• For patients selected for decompressive hemicraniectomy, proceed urgently to surgery prior to significant decline in GCS or pupillary change, ideally within 48 hours from stroke onset 4

Seizures

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

Stroke Unit Care

• All stroke patients should be admitted to a geographically defined stroke unit with specialized staff as soon as possible, ideally within 24 hours of hospital arrival 4, 2
• Stroke unit care is characterized by an interdisciplinary stroke team with expertise in stroke management 4, 2
• Stroke unit care significantly reduces mortality (OR = 0.76) and dependency (OR = 0.80) compared to general ward care 4

Early Rehabilitation and Supportive Care

• Initial assessment by rehabilitation professionals should be conducted within 48 hours of admission 1, 2
• Rehabilitation therapy should begin as early as possible once the patient is medically stable 1, 2
• Frequent, brief, out-of-bed activity involving active sitting, standing, and walking should begin within 24 hours if no contraindications exist 1
• Swallowing screening should be performed within 24 hours of admission using a validated tool before giving food, fluids, or oral medications 1, 2

Secondary Prevention

• Aspirin 160-300 mg/day should be commenced within 48 hours of onset of acute ischemic stroke 2
• Identify stroke etiology to guide secondary prevention strategies 1
• Address modifiable risk factors including hypertension, diabetes, hyperlipidemia, and smoking 1
• Consider carotid imaging for patients with carotid territory symptoms who might be candidates for revascularization 1, 2

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 4, 1
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) can worsen outcomes 1
• Treatment with rtPA beyond 3 hours after symptom onset increases the risk of symptomatic intracerebral hemorrhage without clear benefit 5