What is the management approach for a stroke patient?

Management of Stroke Patients

The most effective approach to stroke management involves rapid recognition, immediate activation of emergency medical services, and treatment in a specialized stroke unit with a multidisciplinary team to reduce mortality and improve outcomes. 1

Initial Assessment and Stabilization

• Triage stroke patients with the same priority as patients with acute myocardial infarction or serious trauma, regardless of deficit severity 2
• Immediately stabilize airway, breathing, and circulation (ABCs) followed by assessment of neurological deficits 2
• Determine time of symptom onset - defined as when the patient was last at baseline or symptom-free state 2
• Implement stroke pathways and notify stroke team early in parallel with ED evaluation 2
• Perform neuroimaging urgently (CT or MRI) within 24 hours to rule out hemorrhage and determine eligibility for reperfusion therapies 1

Acute Treatment

• For eligible patients with ischemic stroke, administer intravenous alteplase within 4.5 hours of symptom onset 1
• Consider mechanical thrombectomy for patients with large vessel occlusion within 6-24 hours based on specific imaging criteria 1
• Blood pressure management:
  • For patients not receiving thrombolysis, avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg 1
  • For patients receiving thrombolysis, maintain BP <180/105 mmHg 1

Stroke Unit Care

• Admit all stroke patients to a geographically defined stroke unit with specialized staff 1
• Provide care through an interdisciplinary team with expertise in stroke management 1
• Monitor neurological status and vital signs frequently during the first 24 hours 1
• Implement standardized stroke orders or integrated stroke pathways to improve adherence to best practices 1

Management of Complications

Dysphagia and Aspiration Prevention

• Perform swallowing screening within 24 hours of admission using a validated tool before giving food, fluids, or oral medications 1, 2
• Implement appropriate dietary modifications based on swallowing assessment results 2
• Consider techniques such as chin tuck, small sips, multiple swallows, and upright positioning for patients with dysphagia 2

Neurological Complications

• Monitor closely for signs of neurological deterioration 2
• For cerebral edema and increased intracranial pressure:
  • Avoid corticosteroids 1
  • Consider osmotic therapy and hyperventilation for patients who deteriorate 1
  • Consider decompressive craniectomy or ventriculostomy for malignant MCA syndrome 2
• Monitor for and treat seizures with antiseizure medications when documented (prophylactic seizure medication is not recommended) 2

Other Complications

• Actively monitor and manage fever and hyperglycemia 1
• Implement early mobilization to prevent complications such as pneumonia, deep vein thrombosis, and pressure sores 1
• Implement frequent turning, use alternating pressure mattresses, and closely monitor skin to prevent pressure sores 1
• Ensure proper hydration and nutrition to prevent dehydration, which can slow recovery and increase risk of deep vein thrombosis 1

Rehabilitation

• Begin rehabilitation assessment by specialized professionals within 48 hours of admission 1
• Start rehabilitation therapy as soon as the patient is medically stable 1
• Implement a comprehensive approach including physical, occupational, and speech therapy 3
• Consider community-based rehabilitation options which can be as effective as hospital-based programs 1

Secondary Prevention

• Start aspirin 160-300 mg/day within 48 hours of onset for ischemic stroke patients not receiving thrombolysis 1
• Consider carotid endarterectomy for patients with recent carotid artery territory ischemic stroke with ipsilateral stenosis of 70-99% (ideally within 2 weeks) 1
• Identify and manage modifiable risk factors including hypertension, diabetes, hyperlipidemia, and smoking 1

Public Education and Prevention

• Promote awareness of stroke warning symptoms and the importance of calling emergency services immediately 4, 5
• Use the FAST mnemonic (Face, Arm, Speech, Time to call emergency services) to increase public recognition of stroke symptoms 1
• Emphasize that "time is brain" - any delay in starting therapy after acute stroke results in progressive, irreversible loss of brain tissue 5

Healthcare System Organization

• Develop efficient processes and pathways to manage stroke patients in ED and inpatient settings 2
• Implement local protocols for early notification by paramedics, high-priority transportation, and rapid access to imaging 1
• Participate in quality improvement programs like Get With The Guidelines-Stroke to improve care processes and adherence to stroke performance measures 1