What is the initial management protocol for stroke patients in the ICU (Intensive Care Unit)?

Stroke Protocol in ICU: Initial Management

All stroke patients admitted to the ICU require immediate stabilization of airway, breathing, and circulation, followed by urgent neuroimaging within minutes, continuous physiological monitoring, and rapid determination of reperfusion therapy eligibility—with the primary goal of minimizing door-to-needle time to under 60 minutes for eligible patients. 1

Immediate Triage and Stabilization (First 10 Minutes)

Airway and Breathing Management

• Administer supplemental oxygen immediately if oxygen saturation <94% to prevent hypoxemia-related secondary brain injury 1, 2
• Assess for airway protection, particularly in patients with depressed consciousness, as poor perfusion and hypoxemia will exacerbate ischemic injury 1, 3
• Intubation may be necessary for patients with severe stroke affecting consciousness or respiratory drive 3

Circulation and Vital Signs

• Establish IV access immediately and obtain blood samples for complete blood count, coagulation studies (PT/INR, aPTT), platelet count, electrolytes, renal function, glucose, and cardiac troponin 1
• Laboratory results must be available within 20 minutes of blood sampling for thrombolysis candidates 1
• Treat hypoglycemia immediately if identified 1

Continuous Physiological Monitoring (First 48 Hours)

Mandatory Monitoring Parameters

• Continuous automated monitoring of oxygen saturation, arterial blood pressure, heart rhythm (1-lead ECG), and body temperature 1, 2
• Cardiac monitoring for at least 24 hours to detect atrial fibrillation and potentially life-threatening arrhythmias 1
• Temperature monitoring every 4 hours for the first 48 hours, then per ward routine 1
• Intermittent blood glucose monitoring 1

Neurological Monitoring

• Frequent neurological assessments using the National Institutes of Health Stroke Scale (NIHSS) to rapidly detect complications or stroke progression 1, 2
• Close-meshed follow-up is necessary for detection of neurological or medical complications 1

Urgent Neuroimaging (Within 20-30 Minutes)

• Non-contrast CT scan is the priority imaging modality to definitively exclude hemorrhage and assess for early ischemic changes 1, 2
• Target: CT completion and analysis within 30 minutes of arrival 1
• MRI is more sensitive for early ischemic changes but may delay treatment due to access limitations 2
• Repeat imaging urgently if patient's condition deteriorates 1

Reperfusion Therapy Decision (Target Door-to-Needle <60 Minutes)

For Ischemic Stroke Within 4.5 Hours

• Intravenous alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) should be administered if eligibility criteria are met 1, 2
• Primary goal: Door-to-needle time ≤60 minutes in ≥50% of patients; secondary goal: ≤45 minutes 1
• Blood pressure must be controlled to <185/110 mmHg before thrombolysis and maintained <180/105 mmHg during and for 24 hours after treatment 1, 2

Blood Pressure Management Specifics

For thrombolysis candidates with BP >185/110 mmHg: 1

• Labetalol 10-20 mg IV over 1-2 minutes, may repeat once, OR
• Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5-15 minutes (maximum 15 mg/hr)

For intracerebral hemorrhage patients with hypertension history: 1

• Keep mean arterial pressure below 130 mmHg
• Systolic blood pressure target of 130-140 mmHg is associated with reduced hematoma growth 1

Temperature Management

• For temperature >37.5°C: increase monitoring frequency, initiate cooling measures, investigate for infection (pneumonia, UTI), and start antipyretic therapy 1
• Hyperthermia has a negative effect on stroke outcome and requires early aggressive treatment 4
• Fever control is associated with better prognosis in stroke unit patients 4

Prevention of Acute Complications

Venous Thromboembolism Prophylaxis

• Apply intermittent pneumatic compression (IPC) devices immediately for all immobilized patients 1, 2
• Continue IPC until patient becomes independently mobile, at discharge, or by 30 days (whichever comes first) 1
• Low-molecular-weight heparin (enoxaparin) for high-risk patients; unfractionated heparin for those with renal failure 1
• Anti-embolism stockings alone are NOT recommended 1
• Assess skin integrity daily during IPC use 1

Aspiration Prevention

• Perform swallowing screening within 24 hours using a validated tool before any oral intake 2
• Keep patient NPO until swallowing safety is confirmed 2
• Early screening prevents aspiration pneumonia, a common complication 1

Seizure Management

• Treat new-onset seizures with short-acting medications (e.g., lorazepam IV) if not self-limiting 1
• A single self-limiting seizure within 24 hours of ischemic stroke should NOT be treated with long-term anticonvulsants 1
• Monitor for recurrent seizure activity during routine vital sign checks 1
• Consider enhanced EEG monitoring in neonates, children, and adults with unexplained reduced consciousness 1

Early Mobilization and Rehabilitation

• Initial rehabilitation assessment by specialized therapists within 48 hours of admission 1, 2
• Begin frequent, brief out-of-bed activity (sitting, standing, walking) within 24 hours if no contraindications 1
• More intense early sessions are not of additional benefit; use clinical judgment 1
• All patients require assessment for swallowing, nutrition, cognition, perception, communication, mobility, and mood 1

Critical Pitfalls to Avoid

Common errors that worsen outcomes:

• Delaying thrombolysis for non-essential tests—chest X-ray and additional imaging should NOT delay rtPA unless specific concerns exist 1
• Treating single self-limiting seizures with long-term anticonvulsants 1
• Using anti-embolism stockings alone without IPC or pharmacological prophylaxis 1
• Allowing hyperthermia to persist untreated 1, 4
• Permitting hyperglycemia >8 mmol/L, which predicts poor prognosis 4
• Prolonged ED stays before ICU admission, which lead to worse outcomes 1

Specialized ICU Considerations

• Admission to a dedicated stroke unit or neuroscience ICU with trained interdisciplinary staff is mandatory 1, 2
• Access to neurosurgical consultation 24/7 for potential hemicraniectomy in malignant cerebral edema 1, 5
• Ventilatory and hemodynamic support capabilities must be immediately available 1, 3
• Initial stroke severity (NIHSS) and ventilator dependence are the strongest predictors of 3-month mortality in ICU-admitted stroke patients 6