What is the proper assessment and management of a patient with suspected stroke?

Assessment of Suspected Stroke

Patients with suspected stroke must be treated as a medical emergency with the same priority as acute myocardial infarction or major trauma, regardless of symptom severity, and should undergo immediate evaluation with a goal of assessment within 10 minutes of arrival. 1, 2

Prehospital Recognition and Transport

EMS Dispatch and Assessment

• Emergency dispatch personnel should use stroke recognition tools (FAST - Face, Arms, Speech, Time) to identify probable stroke and trigger priority response 1
• EMS personnel must use a validated standardized stroke screening tool on scene, such as the Cincinnati Prehospital Stroke Scale or Los Angeles Prehospital Stroke Screen 1
• The critical on-scene goal is "recognize and mobilize" - minimize scene time and transport rapidly 1

Transport Decisions

• EMS should bypass hospitals without stroke treatment capability and transport directly to the closest stroke center 1, 2
• Prehospital notification to the receiving hospital is mandatory while en route, as this significantly reduces door-to-imaging time (26 vs 31 minutes) and door-to-needle time (78 vs 80 minutes) 1
• Transport a witness or family member when possible to verify time of symptom onset 1

Emergency Department Initial Assessment (Within 10 Minutes)

Immediate Stabilization

• Assess and support airway, breathing, and circulation (ABCs) first 1, 2
• Administer supplemental oxygen only if oxygen saturation <94% 1
• Establish IV access immediately 1
• Check capillary glucose at bedside - hypoglycemia is a critical stroke mimic that requires immediate treatment 1, 3

Critical Time Determination

• The single most important piece of information is determining the exact time of symptom onset, defined as when the patient was last known to be at baseline 1, 2, 3
• If the patient awoke with symptoms, use the time they went to sleep as "last known well" 3

Rapid Neurological Assessment

• Perform focused neurological examination using a standardized tool (National Institutes of Health Stroke Scale recommended) 1, 3
• Document specific deficits: facial droop, arm/leg weakness, speech disturbance, visual field defects, ataxia, sensory loss 1

Immediate Diagnostic Studies

Neuroimaging (Highest Priority)

• Brain CT without contrast must be performed immediately to differentiate ischemic stroke from hemorrhage 1, 2
• Imaging should be completed within 25 minutes of arrival for thrombolysis candidates 1
• CT angiography from aortic arch to vertex should be performed simultaneously with initial CT when possible to identify large vessel occlusion 1
• MRI is an acceptable alternative if immediately available, but should not delay treatment 1

Laboratory Studies (Obtain Immediately)

The following blood tests should be drawn upon IV access 1, 2:

• Complete blood count 1
• Coagulation studies (aPTT, INR) 1, 2
• Electrolytes 1
• Renal function (creatinine, eGFR) 1, 2
• Glucose (if not already done by fingerstick) 1, 2
• Troponin 1, 2

Cardiac Assessment

• Obtain 12-lead ECG to identify atrial fibrillation, acute MI, or structural heart disease 1
• The ECG should not delay CT imaging 1
• Initiate continuous cardiac monitoring for at least 24 hours to detect paroxysmal atrial fibrillation and life-threatening arrhythmias 1, 2

Risk Stratification for TIA/Minor Stroke

Highest Risk (Requires Immediate Admission)

Patients presenting within 48 hours with unilateral weakness (face, arm, leg) or speech disturbance should receive comprehensive evaluation within 24 hours 1

Moderate Risk

Patients presenting within 48 hours to 2 weeks with non-motor symptoms (sensory changes, monocular vision loss, diplopia, hemianopia, ataxia) should be evaluated within 2 weeks 1

Lower Risk

Patients presenting >2 weeks after symptom onset should be seen by a stroke specialist within one month 1

Blood Pressure Management

For Thrombolysis Candidates

• Blood pressure must be <185/110 mmHg before administering thrombolytic therapy 1
• Use labetalol 10-20 mg IV over 1-2 minutes (may repeat once) or nicardipine IV 5 mg/hr titrated up as needed 1
• Maintain BP <180/105 mmHg for at least 24 hours after thrombolysis 2

For Non-Thrombolysis Patients

• Avoid aggressive BP lowering in acute ischemic stroke unless systolic BP >220 mmHg or diastolic >120 mmHg 1
• For intracerebral hemorrhage presenting within 6 hours, reduce systolic BP to target of 140 mmHg (avoid <110 mmHg) 1, 2

Critical Pitfalls to Avoid

• Do not delay imaging for laboratory results - CT should be performed while awaiting blood work 1
• Do not assume symptoms are "too mild" to be stroke - minor strokes can progress and benefit from treatment 1
• Do not miss stroke mimics: hypoglycemia, seizure with Todd's paralysis, complicated migraine, conversion disorder 1, 3, 4
• Do not forget to ask about anticoagulation use - this critically affects hemorrhage reversal decisions 1, 2
• Do not initiate antihypertensive therapy in the prehospital setting unless patient is hypotensive (systolic <90 mmHg) 1

Time Targets for Stroke Centers

• Door-to-physician assessment: ≤10 minutes 1
• Door-to-CT completion: ≤25 minutes 1
• Door-to-needle time (for thrombolysis): ≤60 minutes in ≥50% of patients, with aspirational goal of ≤45 minutes 1