What is the management approach for a patient with a suspected cerebrovascular (CV) stroke?

Management of Suspected Cerebrovascular Stroke

All patients with suspected acute stroke must be triaged with the same priority as acute myocardial infarction or serious trauma and undergo immediate brain imaging with non-contrast CT or MRI, followed by rapid assessment for thrombolytic therapy (within 4.5 hours) and endovascular thrombectomy (within 6-24 hours depending on imaging criteria). 1, 2, 3

Immediate Triage and Activation

• Activate the stroke team immediately upon suspicion - do not wait for confirmation, as time is critical for treatment eligibility 2, 3, 4
• Implement standardized stroke pathways with goal of completing evaluation and deciding treatment within 60 minutes of emergency department arrival 1, 3
• Patients should receive the same priority level as myocardial infarction or major trauma regardless of deficit severity 2, 3

Initial Stabilization (First 10-15 Minutes)

• Assess airway, breathing, and circulation (ABCs) with particular attention to airway management in posterior circulation strokes 1, 2, 5
• Check vital signs every 30 minutes minimum while in the emergency department 1, 2
• Monitor cardiac rhythm continuously as cardiac abnormalities frequently accompany stroke 2, 3
• Provide supplemental oxygen only if oxygen saturation is low (hypoxic patients) 2
• Position head of bed at 25-30 degrees unless contraindicated 2
• Treat fever >99.6°F as hyperthermia is associated with poor outcomes 2

Critical History Elements

The single most important piece of information is time of symptom onset, defined as when the patient was last at baseline or symptom-free (the "last known well" time) 2, 5, 6

Document specific symptoms to localize the lesion:

• Anterior circulation: contralateral hemiparesis, hemisensory loss, aphasia, visual field defects 2
• Posterior circulation: vertigo, ataxia, diplopia, crossed sensory/motor findings 2
• Note if preceded by similar symptoms that resolved (suggesting prior TIA) 2

Neurological Assessment

• Use a standardized stroke scale immediately - the National Institutes of Health Stroke Scale (NIHSS) is preferred over the Canadian Neurological Scale 1, 5
• The NIHSS provides stroke severity assessment, prognostic information, and influences acute treatment decisions 1, 6
• Assess for seizure activity, as seizure is a relative contraindication for thrombolytic therapy 1

Immediate Laboratory Testing

Order these tests immediately but do not delay imaging or treatment decisions while awaiting results 1:

• Electrolytes and random glucose 1
• Complete blood count 1
• Coagulation studies (INR, aPTT) - required before thrombolysis in patients on warfarin 1
• Creatinine and estimated glomerular filtration rate (eGFR) 1
• Troponin 1
• Electrocardiogram (can be deferred until after acute treatment decision unless patient is hemodynamically unstable) 1

Important caveat: For patients with known renal impairment, awaiting renal function results before CTA should be weighed against the benefit of immediate vessel imaging, with the principle of "neurons over nephrons" generally favoring immediate imaging in disabling strokes 1

Brain Imaging Protocol

Non-contrast CT or MRI must be completed within 25 minutes of hospital arrival for potential thrombolysis candidates 1, 3, 5:

For patients presenting within 4.5 hours:

• Immediate non-contrast CT (NCCT) without delay to exclude hemorrhage and determine thrombolysis eligibility 1
• CT interpretation should occur within 45 minutes of arrival 3
• The presence of early infarct signs on CT (even if involving >1/3 of middle cerebral artery territory) does not preclude IV tPA treatment in patients with well-established onset time <3 hours 1

For patients presenting within 6-24 hours:

• Immediate NCCT plus CT angiography (CTA) from aortic arch to vertex to identify large vessel occlusions eligible for endovascular thrombectomy 1, 2, 5
• Consider CT perfusion (CTP) or multiphase CTA to assess collateral vessels and aid patient selection, but this must not delay treatment decisions 1
• Use a validated triage tool such as ASPECTS to rapidly identify EVT candidates 1

Special considerations:

• MRI may be preferred for posterior circulation strokes but should not delay treatment if CT is immediately available 1
• If signs of hemorrhage appear on initial CT, proceed to CTA only based on clinical judgment of the treating physician 1

Blood Pressure Management

Blood pressure must be <185/110 mmHg before administering thrombolytic therapy 5:

• In patients NOT receiving thrombolysis: lower blood pressure only when systolic >220 mmHg or diastolic >120 mmHg 5
• This area remains controversial due to lack of strong evidence, so exercise caution and monitor closely 1

Acute Treatment Decision Points

Intravenous Thrombolysis (tPA):

• Administer 0.9 mg/kg (maximum 90 mg) within 3-4.5 hours of symptom onset to eligible patients 5
• During infusion, check vital signs every 15 minutes 2
• Refer to specific eligibility criteria (Box 4A in guidelines) 1

Endovascular Thrombectomy:

• Consider for large vessel occlusions within 6 hours (or up to 24 hours with appropriate imaging criteria) 1
• Primary stroke centers unable to perform CTA should complete NCCT, offer IV alteplase if appropriate, then rapidly transfer to comprehensive stroke center 1

Additional Early Management

• Swallowing screening within 24 hours using a validated tool by trained practitioner, but do not delay acute treatment decisions 1, 5
• Chest X-ray only if evidence of acute cardiac or pulmonary disease; otherwise defer until after acute treatment decision 1
• Do NOT routinely order chest X-ray - this is a change from older guidelines, as it alters management in only 3.8% of cases 1

Seizure Management

• Treat new-onset seizures at stroke onset or within 24 hours with short-acting medications (e.g., lorazepam IV) if not self-limited 1, 5
• Do NOT use prophylactic anticonvulsants - no evidence of benefit and possible harm to neural recovery 1, 5
• A single self-limiting seizure should not be treated with long-term anticonvulsants 1

Critical Pitfalls to Avoid

• Failure to establish accurate "last known well" time can inappropriately exclude patients from time-sensitive interventions 2
• Delaying imaging for laboratory results - only INR is required before treatment in anticoagulated patients 1
• Ordering unnecessary tests like routine chest X-ray or lumbar puncture that delay treatment 1
• Missing stroke mimics: Consider hypoglycemia, seizures, migraine with aura, hypertensive encephalopathy, or CNS abscess/tumor 2
• Inadequate attention to posterior circulation strokes which may present with atypical symptoms and require special airway management 2
• For patients with cerebellar symptoms, perform HINTS examination (head-impulse, nystagmus, test of skew) as it is more sensitive than early MRI for cerebellar stroke 2, 6

EMS and Prehospital Considerations

• EMS transport with hospital prenotification significantly reduces time to brain imaging completion and interpretation compared to private transport 7
• Patients arriving by EMS with prenotification are 3 times more likely to have brain imaging completed within 25 minutes and 2.7 times more likely to have it interpreted within 45 minutes 7