What is the management and treatment plan for a patient with a cerebrovascular (cerebral vascular) stroke?

Management and Treatment of Cerebrovascular Stroke

Treat stroke as a life-threatening emergency requiring immediate action—admit all patients to a specialized stroke unit, administer IV alteplase (0.9 mg/kg, max 90 mg) within 4.5 hours if eligible, and initiate comprehensive interdisciplinary care to reduce mortality and disability. 1, 2

Immediate Emergency Response (Minutes Matter)

Time is brain tissue—every minute of delay results in irreversible neuronal loss. 3, 4

• Triage stroke with the same priority as acute myocardial infarction or major trauma, regardless of deficit severity 1, 5, 2
• Stabilize airway, breathing, and circulation immediately, particularly in patients with depressed consciousness or large territorial strokes 1, 2
• Document the precise time of symptom onset (or when patient was last at baseline)—this determines all treatment eligibility 1, 5, 2
• Perform rapid neurological assessment using the NIH Stroke Scale to quantify deficit severity 1, 2

Urgent Neuroimaging (Within 25 Minutes)

• Obtain non-contrast CT scan immediately as first-line diagnostic test to differentiate ischemic from hemorrhagic stroke 1, 5, 2
• CT must be completed within 25 minutes of order and interpreted within 20 minutes 6
• MRI with diffusion-weighted imaging is more sensitive for early ischemia but CT is faster and more widely available 1, 2

Acute Reperfusion Therapy

For patients presenting within 4.5 hours of symptom onset:

• Administer IV alteplase (rtPA) 0.9 mg/kg, maximum 90 mg immediately if no contraindications exist 6, 1, 2
• Blood pressure must be maintained strictly <180/105 mmHg during and for 24 hours after thrombolysis to prevent hemorrhagic transformation 1, 5, 2
• Safe use requires strict adherence to NINDS selection criteria and close observation 6

For patients presenting 6-24 hours with large vessel occlusion:

• Consider mechanical thrombectomy based on specific imaging criteria showing salvageable penumbra 5, 2

Blood Pressure Management

For patients NOT receiving thrombolysis:

• Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg in the acute phase 5, 2
• Elevated blood pressure should be lowered cautiously 6

For patients receiving thrombolysis:

• Maintain BP <180/105 mmHg strictly for at least 24 hours after rtPA 1, 5, 2

Hospital Admission and Specialized Care

All stroke patients must be admitted to the hospital in almost all circumstances. 6

• Admit to a geographically defined stroke unit with dedicated interdisciplinary staff trained in cerebrovascular disease 6, 1, 5, 2
• Stroke unit care reduces mortality and morbidity with benefits comparable to IV thrombolysis, with effects persisting for years 6, 2
• Nurse-to-patient ratios should be approximately 1:3 6
• Monitor neurological status and vital signs frequently during first 24-48 hours—approximately 25% of patients deteriorate during this period 6

Cardiac Monitoring and Evaluation

• Continuous cardiac monitoring for at least 24 hours to screen for atrial fibrillation and arrhythmias 1, 2
• Perform echocardiography (transthoracic or transesophageal) to evaluate for cardioembolic source 1, 2

Swallowing Assessment (Within 24 Hours)

• Perform swallowing screening within 24 hours using a validated tool before allowing ANY oral intake (food, fluids, or medications) 1, 5, 2
• Keep patient NPO until swallowing safety is confirmed 1
• Use nasogastric or nasoduodenal tube feeding for patients with impaired swallowing 2

Prevention of Acute Complications

Deep vein thrombosis prophylaxis:

• Apply intermittent pneumatic compression devices immediately for all immobilized patients 1, 2
• Administer subcutaneous anticoagulants (low molecular weight heparin or unfractionated heparin) for immobilized patients 2

Cerebral edema management (for large territorial strokes):

• Corticosteroids are NOT recommended 2
• Use osmotic therapy (mannitol or hypertonic saline) and hyperventilation for patients deteriorating from malignant edema 2
• Consider decompressive craniectomy with dural expansion for patients with large hemispheric infarcts who continue to deteriorate despite medical management 6, 2

Antiplatelet Therapy

• Administer aspirin 160-300 mg within 48 hours of stroke onset for reasonable safety and small benefit 6, 5, 2
• Delay aspirin until 24 hours after thrombolysis if rtPA was given 2
• Urgent anticoagulation is NOT recommended due to increased bleeding risk, especially in moderately severe strokes 6, 2

Seizure Management

• Do NOT administer prophylactic anticonvulsants to patients who have not had seizures 6

Neurosurgical Availability

• Neurosurgical care must be available within 2 hours when clinically necessary for procedures such as ventricular drainage, hematoma evacuation, or decompressive hemicraniectomy 6

Early Rehabilitation (Within 48 Hours)

• Begin rehabilitation assessment by specialized therapists within 48 hours of admission 1, 5, 2
• Physical therapy for motor deficits, occupational therapy for activities of daily living, and speech therapy for dysarthria 1, 2
• Early mobilization when medically stable reduces complications (pneumonia, DVT, pulmonary embolism, pressure sores) 2

Secondary Prevention Workup

Vascular imaging:

• Carotid duplex ultrasound if carotid territory symptoms and patient is a surgical candidate 1, 2
• Consider carotid endarterectomy for 70-99% ipsilateral stenosis within 6 months (ideally within 2 weeks) 5, 2

Laboratory evaluation:

• Lipid panel for statin therapy consideration 1
• Initiate high-intensity statin therapy regardless of baseline cholesterol levels 2

Long-term Secondary Prevention

• Antiplatelet therapy (aspirin, clopidogrel, or combination) 1
• Blood pressure control (target <140/90 mmHg after acute phase) 1
• Diabetes management if present 1
• Smoking cessation 1

Discharge Planning

• Early assessment and planning with family education about management, rehabilitation, causes, secondary prevention, and community resources 2
• Education on stroke warning signs (FAST mnemonic) and risk factor modification 2
• Regular follow-up to monitor neurological recovery and medication adherence 2

Key Pitfalls to Avoid

• Do not delay treatment waiting for "complete" workup—imaging and treatment decisions must occur within minutes 1, 2
• Do not give oral intake before swallowing screening—aspiration pneumonia is preventable 1, 5, 2
• Do not aggressively lower blood pressure in acute phase unless receiving thrombolysis or BP dangerously elevated 5, 2
• Do not use streptokinase or other thrombolytics—only rtPA is proven safe 6
• No neuroprotective medication has been shown useful for acute ischemic stroke 6