What are the steps for acute stroke evaluation and management?

Acute Stroke Evaluation and Management

Immediate Assessment (First 10 Minutes)

All patients with suspected acute stroke require immediate evaluation of airway, breathing, and circulation, followed by rapid neurological examination using the NIHSS to determine stroke severity and eligibility for reperfusion therapy. 1

Primary Survey

• Assess ABCs immediately upon patient arrival, ensuring airway patency, adequate breathing, and circulatory stability 1, 2
• Perform neurological examination using a standardized stroke scale (NIHSS preferred) to determine focal deficits and stroke severity 1, 2
• Establish time of symptom onset - defined as when patient was last at previous baseline or symptom-free, which is critical for determining treatment eligibility 2

Vital Signs Monitoring

• Monitor heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and seizure activity 1, 2
• Maintain oxygen saturation ≥92% with supplemental oxygen if needed 1

Immediate Diagnostic Workup (Within 25 Minutes of Arrival)

Brain Imaging - Priority #1

Obtain non-contrast CT (NCCT) or MRI immediately to differentiate ischemic from hemorrhagic stroke and assess for stroke mimics 1, 2

• Perform CT angiography (CTA) from aortic arch to vertex at the time of initial brain CT when possible to assess both extracranial and intracranial circulation 2
• Do not delay imaging for any other tests - imaging takes absolute priority over ECG, chest X-ray, or awaiting blood work results 1

Laboratory Studies

Order initial blood work immediately but do not wait for results before imaging or treatment decisions 1

Essential labs include:

• Complete blood count (CBC) 1, 2
• Electrolytes and random glucose 1, 2
• Coagulation studies (INR, aPTT) - critical for patients on anticoagulants 1, 2
• Creatinine and eGFR - should not delay CTA in most patients with disabling symptoms ("neurons over nephrons") 1, 2

Deferred Studies (Unless Hemodynamically Unstable)

• ECG should be completed but can wait until after thrombolysis decision 1
• Chest X-ray only if evidence of acute cardiac or pulmonary disease - otherwise defer until after acute treatment decision 1

Blood Pressure Management

For Thrombolysis Candidates

Blood pressure must be reduced to <185/110 mmHg before administering tPA to avoid hemorrhagic complications 1, 2

For Non-Thrombolysis Candidates

Lower blood pressure only when systolic >220 mmHg or diastolic >120 mmHg 1, 2

The rationale: Aggressive blood pressure lowering may decrease cerebral perfusion pressure and worsen ischemia, while extremely high pressures risk cerebral edema or hemorrhagic transformation 1

Acute Reperfusion Therapy

Intravenous Thrombolysis

Administer IV tPA at 0.9 mg/kg (maximum 90 mg) to eligible patients within 3-4.5 hours of symptom onset 2

• Target door-to-needle time <60 minutes, though faster is always better 3, 4
• Strict adherence to inclusion/exclusion criteria is mandatory for safe administration 2

Endovascular Therapy

Consider mechanical thrombectomy for patients with large vessel occlusion, particularly proximal anterior circulation occlusions 2, 5, 4

• Can be performed up to 6 hours from symptom onset in appropriately selected patients 4
• Should be considered for patients ineligible for IV tPA who can begin treatment within 6 hours 4

Early Management Priorities

Swallowing Assessment

Complete swallowing screening as early as possible using a validated tool, ideally within 24 hours 1, 2

• Keep patient NPO (nil per os) until swallowing screen completed 1
• Do not administer oral medications until normal swallowing confirmed - use IV or rectal routes while NPO 1
• Refer patients with abnormal screening to swallowing specialist for comprehensive assessment 1

Seizure Management

Treat new-onset seizures at stroke onset with short-acting medications (e.g., lorazepam IV) if not self-limited 1, 2

Critical caveats:

• Do NOT treat single, self-limiting seizures with long-term anticonvulsants 1
• Do NOT use prophylactic anticonvulsants - no evidence of benefit and possible harm to neural recovery 1, 2
• Monitor for recurrent seizures during routine vital sign checks 1

Temperature Management

Monitor temperature every 4 hours for first 48 hours 2

• Initiate temperature-reducing measures if temperature exceeds 37.5°C 2
• Hyperthermia worsens stroke outcomes and should be treated aggressively 6

Glucose Management

Treat glucose levels >8 mmol/L (>144 mg/dL) as hyperglycemia predicts poor prognosis 6

• Insulin therapy in critically ill stroke patients is safe and associated with lower mortality 6

Prevention of Complications

Venous Thromboembolism Prophylaxis

Encourage early mobilization and adequate hydration 2

• Consider low-molecular-weight heparin (e.g., enoxaparin) for high-risk patients 2
• Do NOT use anti-embolism stockings alone - use intermittent pneumatic compression devices or pharmacological prophylaxis instead 2

Monitoring and Ongoing Care

Closely monitor neurological status as patient condition can change rapidly in first hours following stroke 1

• Repeat brain imaging urgently if patient deteriorates 1
• Maintain homeostasis of blood pressure, glucose, temperature, and oxygenation - this maintenance is associated with better outcomes 6

Common Pitfalls to Avoid

• Never delay imaging or treatment for ECG, chest X-ray, or blood work results unless patient is hemodynamically unstable 1
• Never aggressively lower blood pressure in non-thrombolysis candidates unless severely elevated (>220/120 mmHg) 1
• Never give oral medications before swallowing screen - aspiration risk is high 1
• Never use prophylactic anticonvulsants - evidence suggests possible harm 1, 2
• Never discharge TIA patients from ED without diagnostic evaluation and secondary prevention plan 1