What is the most appropriate initial step and management for a patient diagnosed with ischemic stroke and potential dysphasia (difficulty speaking) due to stroke?

Acute Management of Ischemic Stroke with Dysphasia

For this 72-year-old woman presenting within 6 hours of symptom onset, the most appropriate initial step is urgent non-contrast CT brain imaging to rule out hemorrhage, followed by immediate consideration for IV thrombolysis with rtPA (0.9 mg/kg, maximum 90 mg) if she presents within the 3-4.5 hour window and has no contraindications. 1, 2

Immediate Initial Assessment and Stabilization

The first priority is rapid evaluation to confirm ischemic stroke and exclude hemorrhage:

• Perform urgent non-contrast CT brain imaging immediately to rule out intracranial hemorrhage and assess for early ischemic changes 3, 1, 2
• Obtain vital signs and stabilize airway, breathing, and circulation 2
• Determine exact time of symptom onset (critical for thrombolysis eligibility) 1, 2
• Perform focused neurological examination to assess stroke severity and localization 3, 1

Essential Laboratory Testing

Draw blood tests immediately but do not delay rtPA administration while waiting for coagulation results unless there is clinical suspicion of bleeding abnormality or uncertain anticoagulant use:

• Complete blood count with platelets, electrolytes, renal function (creatinine, eGFR), glucose, prothrombin time/INR, aPTT, and troponin 3
• Blood glucose determination is particularly important as hypoglycemia can mimic stroke 3

Thrombolytic Therapy Decision

If the patient presents within 3 hours of symptom onset, strongly consider IV rtPA (0.9 mg/kg, maximum 90 mg) 1, 4. The window may extend to 4.5 hours in carefully selected patients 2.

Critical Pre-Treatment Requirements:

• Blood pressure must be <185/110 mmHg before rtPA administration 5, 1, 2
• If BP is elevated, use labetalol 10-20 mg IV over 1-2 minutes (may repeat) or nicardipine 5 mg/hr IV infusion to achieve target 3, 1
• Do not administer rtPA if BP cannot be controlled below 185/110 mmHg 3

Post-Thrombolysis Monitoring:

• Maintain BP <180/105 mmHg for 24 hours after rtPA 5, 1
• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 3

Blood Pressure Management (If NOT Receiving Thrombolysis)

For patients not receiving reperfusion therapy, withhold antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg 3, 1. Elevated BP may represent a physiological response to maintain cerebral perfusion 3.

Management of Dysphasia and Swallowing

Screen swallowing function as early as possible, ideally on the day of admission, before allowing any oral intake 1. This is critical because:

• Dysphagia occurs in approximately 23% of acute ischemic stroke patients 6
• Dysphagic patients have significantly higher rates of respiratory tract infections and pneumonia 7
• Patients who are "nil by mouth" at 2 days post-stroke are significantly more likely to develop pneumonia (OR=1.45) 7

Swallowing Assessment Protocol:

• Perform formal swallowing screening within 48 hours of admission 1, 8
• If dysphagia is suspected, conduct standardized swallowing assessment 6
• Keep patient NPO (nothing by mouth) until swallowing is formally assessed 1
• If unable to take oral intake safely, initiate alternative feeding (nasogastric, nasoduodenal, or PEG) to maintain hydration and nutrition 1

Predictors of Dysphagia to Monitor:

• Presence of facial palsy (associated with initial dysphagia) 8
• Stroke severity (strongest predictor of dysphagia, dysarthria, and aphasia) 6
• Aphasia presence (predicts poor swallowing recovery at 1 month) 8

Additional Supportive Care

• Monitor temperature every 4 hours for first 48 hours; treat fever aggressively with antipyretics as hyperthermia worsens neurological outcomes 3, 1
• Monitor blood glucose regularly and treat to maintain 140-180 mg/dL (avoid both hyperglycemia and hypoglycemia) 1
• Initiate cardiac monitoring for at least 24 hours to detect arrhythmias, particularly atrial fibrillation 3, 1, 2
• Obtain 12-lead ECG to assess for cardiac complications and atrial fibrillation 3

Early Rehabilitation

• Begin rehabilitation assessment within 48 hours of admission 1
• Initiate early mobilization within 24 hours if medically stable with frequent, brief out-of-bed activities 1
• Arrange speech-language pathology consultation for formal aphasia and dysphagia assessment 9, 6

Common Pitfalls to Avoid

• Do not delay imaging or treatment - every 30-minute delay in recanalization decreases good functional outcome by 8-14% 1
• Do not give oral medications, food, or fluids before swallowing assessment - this significantly increases pneumonia risk 7
• Do not aggressively lower blood pressure in non-thrombolysis candidates unless severely elevated (>220/120 mmHg) 3, 1
• Do not overlook the need for alternative feeding routes in dysphagic patients to prevent aspiration and maintain nutrition 1

Stroke Unit Admission

Admit to a geographically defined stroke unit with specialized staff as soon as possible, ideally within 24 hours 1. Stroke unit care significantly reduces mortality (OR 0.76) and dependency (OR 0.80) compared to general ward care 1.