What is the management plan for a patient with a recent stroke?

Management Plan for Recent Multivessel Territory Stroke

This patient with acute bilateral cortical infarcts (right frontal, parietal, occipital, and left motor cortex) requires immediate admission to a dedicated stroke unit, initiation of antiplatelet therapy, aggressive risk factor management, and early rehabilitation while investigating the likely cardioembolic source. 1, 2

Immediate Acute Management

Stroke Unit Admission

• All stroke patients must be admitted to a geographically defined stroke unit with specialized interdisciplinary staff (neurologists, nurses, physiotherapists, occupational therapists, speech-language pathologists) as soon as possible, ideally within 24 hours of hospital arrival. 1, 2
• Stroke unit care significantly reduces mortality (odds ratio 0.76) and dependency (odds ratio 0.80) compared to general ward care. 1
• This patient requires close monitoring given the bilateral nature and multivessel distribution suggesting cardioembolic etiology. 1, 2

Cardiovascular Monitoring

• Continuous cardiac monitoring for at least the first 24-48 hours is essential to detect intermittent atrial fibrillation and potentially lethal arrhythmias, particularly given the multivessel distribution suggesting cardioembolic source. 3
• Extended monitoring with 24-hour Holter or event-loop recording for several days may be required to detect occult arrhythmias. 3
• Patients with large deficits and right hemispheric strokes are at particular risk for myocardial ischemia, congestive heart failure, and significant arrhythmias. 3

Blood Pressure Management

• Adopt a cautious approach to hypertension—avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg. 1, 2
• Sublingual nifedipine and agents causing precipitous BP reductions must be avoided as they can compromise cerebral perfusion. 2
• The window for acute thrombolysis has passed for this patient (beyond 3-6 hours), so aggressive BP lowering is not indicated. 1

Glucose Management

• Monitor blood glucose regularly and treat hyperglycemia to maintain levels between 140-180 mg/dL (7.8-10 mmol/L). 1
• Close monitoring is essential to prevent hypoglycemia, which can mimic stroke symptoms and worsen outcomes. 1, 2

Temperature Control

• Check temperature every 4 hours for the first 48 hours. 1
• For temperatures >37.5°C, increase monitoring frequency and investigate possible infections. 1
• Treat sources of fever and use antipyretics for elevated temperatures. 1

Antiplatelet Therapy

Immediate Initiation

• Aspirin 160-300 mg should be administered immediately (within 48 hours of stroke onset) if not already given, as it prevents approximately 10 deaths and early recurrent strokes per 1,000 patients treated. 4
• This dose range achieves rapid inhibition of thromboxane biosynthesis. 4
• Aspirin can be given orally if swallowing is safe, or per rectum as a suppository if not. 4

Long-term Antiplatelet Strategy

• If the workup confirms cardioembolic source (atrial fibrillation), transition to oral anticoagulation with a direct oral anticoagulant (DOAC) such as apixaban, rivaroxaban, dabigatran, or edoxaban rather than continuing antiplatelet therapy. 5
• DOACs are preferred over warfarin due to decreased bleeding risks (including intracranial hemorrhage), no need for INR monitoring, no dietary restrictions, and limited drug-drug interactions. 5
• If no cardioembolic source is identified, continue with single antiplatelet therapy (aspirin or clopidogrel) for long-term secondary prevention. 6, 5

Critical Pitfall: The bilateral, multivessel distribution strongly suggests cardioembolic mechanism—antiplatelet therapy alone would be inadequate if atrial fibrillation or other cardiac source is confirmed. 5

Swallowing and Nutrition Assessment

Immediate Swallowing Screen

• Swallowing assessment must be performed before allowing any oral intake, ideally on the day of admission, to prevent aspiration pneumonia. 3, 1, 2
• Given the left motor cortex involvement (pre- and post-central gyri), this patient is at high risk for dysphagia. 3

Nutritional Support

• If the patient cannot take food and fluids orally safely, initiate nasogastric or nasoduodenal feeding immediately to maintain hydration and nutrition. 3
• If prolonged feeding support is anticipated (>2-3 weeks), percutaneous endoscopic gastrostomy (PEG) tube placement is superior to nasogastric tube feeding. 2
• Malnutrition interferes with stroke recovery and must be prevented. 2

Prevention of Complications

Deep Vein Thrombosis Prophylaxis

• Initiate subcutaneous low-molecular-weight heparin (e.g., enoxaparin 40 mg once daily) immediately for DVT prophylaxis, as this patient has significant motor deficits and will be immobilized. 3
• Enoxaparin 40 mg once daily is more effective than unfractionated heparin 5000 IU twice daily for DVT prevention in ischemic stroke patients. 3
• If anticoagulation is contraindicated, use intermittent external compression devices on the lower extremities. 3
• The risk of DVT is highest among immobilized patients with severe stroke and slows recovery and rehabilitation. 3

Monitoring for Neurological Deterioration

• Close observation is required as approximately 25-33% of patients deteriorate after initial assessment—one-third from progressive stroke, one-third from brain edema, 10% from hemorrhage, and 11% from recurrent ischemia. 3, 1
• Given the bilateral involvement and multiple territories, this patient is at elevated risk for malignant edema. 3
• Perform urgent repeat brain CT or MRI if the patient's condition deteriorates. 2

Cerebral Edema Management

• Corticosteroids are NOT recommended for cerebral edema. 1
• If deterioration occurs from edema, osmotherapy (mannitol or hypertonic saline) and hyperventilation are recommended. 3, 1
• For malignant edema with significant mass effect, decompressive hemicraniectomy should be considered urgently (ideally within 48 hours) before significant decline in Glasgow Coma Scale or pupillary changes. 1

Seizure Management

• If new-onset seizures occur, treat with short-acting medications (e.g., lorazepam IV) if not self-limiting. 1
• Prophylactic anticonvulsants are NOT recommended. 1
• Cortical involvement increases seizure risk in this patient. 1

Infection Prevention

• Avoid indwelling bladder catheters when possible due to infection risk. 2
• Monitor for and promptly treat pneumonia, which is an important cause of death following stroke. 2
• Actively prevent pressure ulcers, particularly given the bilateral motor involvement. 2

Early Rehabilitation

Immediate Assessment and Mobilization

• Initial assessment by rehabilitation professionals (physiotherapy, occupational therapy, speech-language pathology) must be conducted within 48 hours of admission. 1
• Begin frequent, brief, out-of-bed activity involving active sitting, standing, and walking within 24 hours if no contraindications exist (e.g., unstable medical condition, severe orthostatic hypotension). 1
• Early mobilization prevents complications and is strongly recommended. 2

Multidisciplinary Rehabilitation

• Given the left motor cortex involvement (hand bulb region), expect significant right upper extremity weakness requiring intensive occupational therapy. 1, 2
• Speech-language pathologists should evaluate for dysphagia and communication difficulties. 2
• Assessment of mobility, activities of daily living, cognition, perception, incontinence, and mood should be undertaken early. 2

Etiological Workup and Secondary Prevention

Cardiac Evaluation

• Given the bilateral, multivessel distribution, aggressive cardiac workup is mandatory to identify cardioembolic source, particularly atrial fibrillation. 3, 2
• Obtain 12-lead ECG, transthoracic echocardiogram (consider transesophageal if transthoracic is non-diagnostic), and extended cardiac monitoring. 2
• If atrial fibrillation is detected, anticoagulation with a DOAC is indicated rather than antiplatelet therapy. 5

Vascular Imaging

• Although the distribution suggests cardioembolic source, carotid duplex ultrasound should be performed to evaluate for large vessel stenosis. 2
• Consider CT or MR angiography of the head and neck to assess for vessel occlusions or stenosis. 2

Risk Factor Management

• Initiate statin therapy (high-intensity, e.g., atorvastatin 80 mg daily) for intensive lipid-lowering effect, which is highly recommended for secondary stroke prevention. 6, 7
• If the patient was already on a statin, continue it during the acute period. 2
• Obtain fasting lipid panel, HbA1c for diabetes screening, and assess for other modifiable risk factors. 2
• Address hypertension management for long-term secondary prevention (target <140/90 mmHg after acute phase). 6, 7
• Counsel on lifestyle modifications including smoking cessation, dietary changes, and physical activity. 3

Before Discharge

• Ensure appropriate antithrombotic therapy (anticoagulation if cardioembolic, antiplatelet if not) is prescribed before discharge—this is a quality-of-care indicator. 3
• Provide patient and family education regarding stroke warning signs, risk factor modification, and medication adherence. 3

Key Pitfalls to Avoid

• Failure to identify cardioembolic source: The bilateral, multivessel distribution strongly suggests cardioembolic mechanism—extended cardiac monitoring is essential as initial ECG may miss paroxysmal atrial fibrillation. 3, 5
• Inadequate DVT prophylaxis: This patient has significant motor deficits bilaterally and will be immobilized—DVT prophylaxis with LMWH is mandatory unless contraindicated. 3
• Allowing oral intake before swallowing assessment: Left motor cortex involvement increases aspiration risk—formal swallowing evaluation must precede any oral intake. 3, 1, 2
• Overly aggressive blood pressure lowering: In the subacute phase without indication for thrombolysis, aggressive BP reduction can worsen cerebral perfusion—treat only if >220/120 mmHg. 1, 2
• Delayed rehabilitation: Early mobilization and rehabilitation within 24-48 hours significantly improves outcomes—do not wait for "medical stability" beyond the first day unless contraindicated. 1, 2
• Using antiplatelet therapy if atrial fibrillation is found: If cardioembolic source is confirmed, anticoagulation with a DOAC is superior to antiplatelet therapy for secondary prevention. 5