What is the management and treatment for a patient suspected of having a stroke?

Acute Stroke Management

All patients with suspected stroke require immediate emergency evaluation with rapid assessment of airway, breathing, and circulation, followed by urgent brain imaging (non-contrast CT or MRI) to differentiate ischemic from hemorrhagic stroke and determine eligibility for time-sensitive reperfusion therapies. 1

Prehospital Recognition and Transport

• Stroke screening tools (FAST: Face, Arm, Speech, Time) should be used by EMS personnel to identify stroke patients, followed by a second validated tool to assess stroke severity for potential endovascular therapy candidates 1
• Direct transport protocols must prioritize transfer to stroke-capable centers, with on-scene time ideally ≤20 minutes for patients within the 4.5-hour treatment window 1
• Prehospital notification to the receiving hospital enables stroke team activation and preparation, reducing door-to-treatment times 1, 2
• Obtain critical information including time last known well, current medications (especially anticoagulants), and capillary blood glucose measurement 1

Emergency Department Initial Evaluation

Immediate Assessment (Within Minutes)

• Triage as CTAS Level 2 (or Level 1 if airway/breathing/circulation compromised) for immediate physician evaluation 1
• Rapid ABC assessment: Evaluate airway patency, breathing adequacy, and circulatory status, particularly in seriously ill or comatose patients 1
• Neurological examination using a standardized stroke scale (NIHSS or Canadian Neurological Scale) to determine focal deficits and stroke severity 1
• Vital signs monitoring: Heart rate/rhythm, blood pressure, temperature, oxygen saturation, hydration status, and seizure activity 1

Essential Laboratory Tests (Do Not Delay Imaging)

• Immediate blood work: Electrolytes, random glucose, complete blood count, coagulation status (INR, aPTT), creatinine, and troponin 1
• Electrocardiogram should be completed but should not delay thrombolysis assessment 1
• Capillary glucose must be checked immediately to rule out hypoglycemia as a stroke mimic 1
• Results should not delay imaging or treatment decisions unless clinically necessary (e.g., INR for warfarin patients) 1

Urgent Neuroimaging

Ischemic Stroke Candidates (Within 4.5 Hours)

• Non-contrast CT (NCCT) immediately for all patients presenting within 4.5 hours to determine thrombolysis eligibility 1
• A physician skilled in CT interpretation must be available 24/7 to assess for hemorrhage and early infarct signs 1
• Early infarct signs on CT do not preclude rtPA treatment if onset time is well-established and <3 hours 1

Large Vessel Occlusion Candidates (Within 6-24 Hours)

• NCCT plus CT angiography (CTA) from arch-to-vertex for patients presenting within 6 hours to identify large vessel occlusions eligible for endovascular thrombectomy (EVT) 1
• Validated triage tools (such as ASPECTS) should rapidly identify EVT candidates who may require transfer 1
• Advanced imaging (CT perfusion or multiphase CTA) can aid patient selection but must not delay thrombolysis or EVT decisions 1
• Treatment window for highly selected patients may extend to 24 hours from symptom onset based on neurovascular imaging 1, 3

Blood Pressure Management

For Non-Thrombolysis Candidates

• Conservative approach: Lower blood pressure only when systolic >220 mmHg or diastolic >120 mmHg 1
• Aggressive blood pressure reduction may decrease perfusion pressure and worsen ischemia 1

For Thrombolysis Candidates

• Strict control required: Blood pressure must be reduced to <185/110 mmHg before rtPA administration to avoid hemorrhagic complications 1
• Maintain BP <180/105 mmHg for at least 24 hours after thrombolytic therapy 4, 5

For Intracerebral Hemorrhage

• Acute reduction: For spontaneous ICH presenting within 6 hours, reduce systolic BP to target of 140 mmHg (strictly avoid <110 mmHg) 4

Acute Treatment Decisions

Intravenous Thrombolysis (rtPA/Tenecteplase)

• Administer rtPA (0.9 mg/kg; maximum 90 mg) to carefully selected patients within 3 hours of symptom onset 1
• Tenecteplase is now a safe and effective alternative to alteplase 3
• Safe use requires strict adherence to NINDS selection criteria, close observation, and careful ancillary care 1
• Do not substitute streptokinase or other thrombolytic agents for rtPA 1

Antiplatelet Therapy

• Aspirin 160-300 mg/day should be administered within 48 hours of ischemic stroke onset, but generally after 24 hours if thrombolysis was given 1, 4, 5
• Aspirin provides reasonable safety and small benefit in acute ischemic stroke 1

Anticoagulation

• Not recommended for routine acute ischemic stroke treatment due to increased bleeding risk without proven benefit for preventing early recurrent stroke 1, 5
• For ICH with anticoagulants: Immediately discontinue and reverse anticoagulation as soon as possible 4

Seizure Management

• Treat active seizures at stroke onset or within 24 hours with short-acting medications (e.g., lorazepam IV) if not self-limited 1
• Do not treat single, self-limiting seizures with long-term anticonvulsants 1
• Prophylactic anticonvulsants are not recommended and may negatively affect neural recovery 1
• Monitor for recurrent seizure activity during routine vital sign checks 1

Hemorrhagic Stroke Specific Management

• Immediate anticoagulation reversal for anticoagulant-associated ICH 4
• External ventricular drainage recommended for hydrocephalus with decreased level of consciousness 4
• Refer to hemorrhagic stroke guidelines for comprehensive management 1

Critical Monitoring and Supportive Care

• Swallowing screen within 24 hours using validated tool before oral intake to prevent aspiration pneumonia 1, 5
• Temperature monitoring at least 4 times daily for 3 days; treat fever >37.5°C (99.5°F) with acetaminophen 5
• Glucose monitoring at least 4 times daily for 3 days; treat hyperglycemia >180 mg/dL with insulin 5
• Oxygen supplementation only if saturation <94% 5
• Cardiac monitoring for at least 24 hours to detect atrial fibrillation and serious arrhythmias 4

Stroke Unit Care

• All stroke patients should be admitted to a geographically defined stroke unit with specialized interdisciplinary staff 1, 5
• Comprehensive stroke unit care improves outcomes across a broad spectrum of patients 1
• Early mobilization should begin promptly to prevent complications like venous thromboembolism 4, 5

Common Pitfalls to Avoid

• Delaying imaging for laboratory results: Blood work should not delay CT or treatment decisions unless clinically essential 1
• Aggressive blood pressure lowering in non-thrombolysis candidates: May worsen ischemia by decreasing perfusion pressure 1
• Missing the treatment window: Time is brain tissue—every minute of delay results in irreversible neuronal loss 6, 3
• Failing to screen swallowing: Increases aspiration pneumonia risk; must be done within 24 hours 1, 5
• Discharging TIA patients without evaluation: High-risk TIA patients (ABCD2 >4) require admission or evaluation within 24-48 hours due to 13% stroke risk in 90 days 4