What is the initial treatment for a suspected stroke?

Initial Treatment for Suspected Stroke

Patients with suspected stroke require immediate stabilization of airway, breathing, and circulation (ABCs), followed by rapid neurological assessment, urgent brain imaging to differentiate ischemic from hemorrhagic stroke, and expedited transport to a stroke-capable facility—all within minutes, treating this as a medical emergency equivalent to acute myocardial infarction. 1, 2

Immediate Stabilization (First Minutes)

Airway, Breathing, and Circulation

• Assess and secure airway patency, breathing adequacy, and circulatory status immediately upon patient contact 1
• Administer supplemental oxygen to maintain oxygen saturation ≥94% 1, 2
• Establish intravenous access and obtain blood samples for baseline studies (complete blood count, electrolytes, coagulation studies including INR and aPTT, creatinine, and glucose) 1
• Check capillary blood glucose immediately—if <60 mg/dL, administer intravenous dextrose to correct hypoglycemia, as this can mimic stroke symptoms 1, 2

Blood Pressure Management

• Do NOT routinely lower blood pressure in the prehospital or initial ED setting unless specific criteria are met 1, 2
• For suspected ischemic stroke NOT receiving thrombolysis: only lower BP if systolic >220 mmHg or diastolic >120 mmHg 1
• For suspected ischemic stroke who ARE candidates for thrombolysis: BP must be reduced if systolic ≥185 mmHg or diastolic ≥110 mmHg using labetalol 10-20 mg IV or nicardipine 5 mg/hr IV 1
• For suspected intracerebral hemorrhage with hypertension presenting within 6 hours: reduce systolic BP acutely to target of 140 mmHg (avoid <110 mmHg) 3, 2
• If hypotensive (systolic <90-120 mmHg): place patient flat and administer isotonic saline to improve cerebral perfusion 1, 2

Rapid Neurological Assessment

• Perform standardized neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to determine stroke severity and focal deficits 1, 2
• Establish the exact time of symptom onset—defined as when the patient was last known to be at baseline neurological status—this is the single most critical piece of information for treatment decisions 1, 3
• Use a validated stroke screening tool to confirm stroke suspicion 1, 2
• Assess for seizure activity: if new-onset seizure occurs at stroke onset and is not self-limited, treat with short-acting medication (e.g., lorazepam IV) 1, 2

Urgent Diagnostic Imaging

• Obtain brain CT or MRI immediately (within 10 minutes of ED arrival) to differentiate ischemic stroke from intracerebral hemorrhage—this is the most critical diagnostic step 1
• A physician trained in stroke imaging interpretation must be immediately available 1
• Obtain 12-lead ECG to identify atrial fibrillation or acute myocardial infarction, but do not delay CT scan for this 1, 2
• Initiate cardiac monitoring for at least 24 hours to detect arrhythmias 1, 3

Transport and Triage Priorities

• Transport by EMS directly to a stroke-capable center, bypassing non-stroke hospitals 1, 3, 2
• Prehospital notification by EMS to receiving hospital significantly increases thrombolysis rates—this should be standard practice 1
• Target scene time <15 minutes for EMS personnel 4
• Transport a witness or family member who can verify time of symptom onset 1
• Triage immediately to high-acuity area upon ED arrival 1

Initial Treatment Based on Stroke Type

For Ischemic Stroke (After CT Rules Out Hemorrhage)

• Intravenous thrombolysis with rt-PA (alteplase or tenecteplase) is highly effective if administered within 3-4.5 hours of symptom onset in eligible patients 1, 3, 5
• Maintain BP <180/105 mmHg for at least 24 hours after thrombolysis 3
• Administer aspirin 160-300 mg within 48 hours of ischemic stroke onset, but wait 24 hours if thrombolysis was given 1, 3
• Consider endovascular thrombectomy for large vessel occlusions within 24 hours of onset 5

For Intracerebral Hemorrhage (If CT Shows Blood)

• Immediately discontinue and reverse anticoagulation if patient is on anticoagulants 3, 2
• Target systolic BP of 140 mmHg if presenting within 6 hours and patient has hypertension 3
• Consider external ventricular drainage if hydrocephalus with decreased consciousness develops 3

Critical Pitfalls to Avoid

• Never administer aspirin or antiplatelet agents before brain imaging rules out hemorrhage 2
• Do not aggressively lower blood pressure in suspected ischemic stroke—this may worsen cerebral perfusion and extend ischemia 1, 2
• Do not delay transport for extensive diagnostic workup in primary care or prehospital settings 2
• Do not use routine dextrose-containing IV fluids in non-hypoglycemic patients—use normal saline instead 1
• Do not treat single self-limited seizures at stroke onset with long-term anticonvulsants 1

Additional Monitoring

• Monitor temperature and treat fever >38°C 3
• Assess hydration status and maintain euvolemia 1
• Begin early gradual mobilization once stabilized 3

The overarching principle is "Time is Brain"—every 30-minute delay in treatment results in measurable neurological deterioration, making speed of assessment, imaging, and definitive therapy the primary determinant of outcomes. 1