What is the clinical assessment and management approach for a patient presenting with symptoms of a stroke?

Clinical Assessment and Management of Acute Stroke

Immediate Triage and Emergency Response

Patients presenting with suspected stroke must be triaged with the same priority as acute myocardial infarction or serious trauma, regardless of deficit severity, and the stroke team should be activated immediately upon suspicion. 1

• Implement stroke pathways and notify the stroke team immediately upon suspicion, working closely with emergency department physicians and nurses 2, 1
• Perform initial stabilization focusing on airway, breathing, and circulation (ABCs), followed by rapid neurological assessment 1
• Monitor cardiac rhythm continuously as cardiac abnormalities frequently accompany stroke 1
• Check vital signs at minimum every 30 minutes while in the emergency department 2, 1

Critical Time-Sensitive Assessment Elements

The single most important piece of historical information is the time of symptom onset, defined as when the patient was last at baseline or symptom-free. 1

Essential History Components:

• Document exact time of symptom onset or last known well time if onset was unwitnessed 2, 1
• Identify specific symptoms to localize the lesion:
  • Anterior circulation: contralateral hemiparesis, hemisensory loss, aphasia, hemianopia 1
  • Posterior circulation: vertigo, ataxia, diplopia, dysarthria, dysphagia 1
• Note whether symptoms were preceded by similar transient symptoms (suggesting prior TIA) 1
• Obtain current medications, particularly anticoagulants and direct oral anticoagulants (DOACs) 2
• Document relevant comorbidities including diabetes, hypertension, atrial fibrillation 2

Immediate Diagnostic Workup

Brain Imaging (Priority #1):

• Non-contrast CT or MRI must be completed within 25 minutes of hospital arrival for potential thrombolysis candidates 2, 1
• CT scan interpretation should occur within 45 minutes of arrival 2
• For patients beyond 6 hours from symptom onset, CT or MR perfusion scanning can demonstrate perfusion mismatch and determine ischemic core extent 2

Vascular Imaging:

• CTA from aortic arch to vertex should be completed as soon as possible, ideally within 24 hours, and can be performed simultaneously with initial brain CT 2, 1
• CTA is recommended to identify proximal occlusions in anterior circulation for endovascular therapy eligibility 2
• Vascular imaging is essential to identify symptomatic extracranial carotid artery stenosis requiring possible revascularization 2

Laboratory Investigations:

• Order immediately but do not delay imaging: complete blood count, electrolytes, renal function (creatinine, eGFR), coagulation studies (aPTT, INR), random glucose, and troponin 2, 1
• Perform 12-lead ECG without delay 2
• Check fingerstick glucose immediately to exclude hypoglycemia as a stroke mimic 2, 1

Risk Stratification for TIA and Nondisabling Stroke

HIGHEST Risk (symptom onset <48 hours):

• Patients with transient or persistent unilateral weakness (face, arm, leg) or language/speech disturbance require comprehensive evaluation within 24 hours 2
• Brain imaging (CT or MRI) and vascular imaging (CTA or MRA) should be completed as soon as possible within 24 hours 2

HIGH Risk (symptom onset 48 hours to 2 weeks):

• Patients with unilateral motor weakness or language disturbance should receive comprehensive evaluation ideally within 24 hours of first healthcare contact 2

MODERATE Risk (symptom onset 48 hours to 2 weeks):

• Patients with hemibody sensory symptoms, monocular vision loss, binocular diplopia, hemifield vision loss, dysarthria, dysphagia, or ataxia without motor weakness should be evaluated ideally within 2 weeks 2

LOWER Risk (>2 weeks from symptom onset):

• Evaluation by neurologist or stroke specialist ideally within one month 2

Acute Inpatient Management

All patients admitted with acute stroke or TIA should be treated on a specialized, geographically defined inpatient stroke unit as soon as possible, ideally within 24 hours of hospital arrival. 2

Stroke Unit Requirements:

• Core interdisciplinary team must include physicians, nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers, and clinical nutritionists with stroke expertise 2
• Hospital pharmacists should be included to promote medication safety, reconciliation, and patient education 2
• The interdisciplinary team should assess patients within 48 hours of admission using standardized, valid assessment tools 2

Standardized Assessment Components:

• Dysphagia screening using validated tool before giving food, fluids, or oral medications 2, 3
• Mood and cognition evaluation 2
• Mobility and functional status assessment 2
• Temperature monitoring (treat fever >99.6°F as hyperthermia worsens outcomes) 1, 3
• Nutrition assessment 2
• Bowel and bladder function (assess for urinary retention in first 72 hours using bladder scanning) 3
• Skin breakdown risk 2
• Venous thromboembolism prophylaxis 2

Vital Signs Management:

• For patients NOT receiving thrombolysis: lower blood pressure only if systolic BP >220 mmHg or diastolic >120 mmHg 3
• For patients receiving thrombolysis: maintain BP <180/105 mmHg in first 24 hours, checking every 15 minutes during infusion 2, 3
• Monitor body temperature at least 4 times daily for 3 days, treating temperature >37.5°C (99.5°F) with acetaminophen 3
• Provide supplemental oxygen only to maintain oxygen saturation >94% 3

Management of In-Hospital Stroke

Hospital inpatients who experience new stroke while hospitalized should undergo immediate assessment by a physician with stroke expertise, undergo neurovascular imaging without delay, and be assessed for eligibility for intravenous alteplase and/or endovascular therapy. 2

• All hospitals should have protocols in place for management of acute inpatient stroke with all staff trained on these protocols, especially in high-risk units 2
• Implement rapid response teams with dedicated stroke training and immediate access to neurological expertise 2

Differentiating Stroke from Mimics

Common stroke mimics that must be excluded include:

• Hypoglycemia (identified rapidly by fingerstick glucose) 2, 1
• Seizures with postictal paralysis 1
• Migraine with aura 1
• Hypertensive encephalopathy 1
• Psychogenic disorders 1
• CNS abscess or tumor 1
• Wernicke's encephalopathy 1

Critical Pitfalls to Avoid

• Failure to establish accurate symptom onset time excludes patients from time-sensitive interventions - always document last known well time if onset was unwitnessed 1
• Posterior circulation strokes may present with atypical symptoms and require special attention to airway management due to risk of altered consciousness 2, 1
• Delaying swallowing assessment increases aspiration pneumonia risk - screening must be completed within 24 hours before oral intake 2, 3
• Inadequate blood pressure management - follow specific parameters based on thrombolysis status to avoid complications 3
• Missing urinary retention which occurs in 21-47% of patients in first 72 hours - use bladder scanning for post-void residual volume 3
• Neglecting early mobilization leads to preventable complications including deep vein thrombosis and contractures 3

Early Rehabilitation and Discharge Planning

• Formal individualized assessment to determine post-acute rehabilitation needs should occur within first 72 hours post-stroke using standardized protocols (such as alpha-FIM) 2
• Early, short, frequent exercise sessions should be implemented to prevent complications 3
• Daily stretching of hemiplegic limbs prevents contractures 3
• Ensure smooth transition from inpatient to outpatient care with timely transfer of discharge information to subsequent treating physician 3