What are the management strategies for stroke?

Management of Stroke

Immediate Recognition and Emergency Response

Stroke is a medical emergency requiring immediate activation of emergency medical services (911) and rapid transport to a stroke-capable hospital, as time-critical interventions directly correlate with brain tissue salvage and patient outcomes. 1, 2

Prehospital Management

• Emergency medical services personnel should use standardized stroke screening tools (such as FAST: Face, Arms, Speech, Time) during on-scene assessment to rapidly identify stroke patients 1, 2
• Paramedics should obtain critical information including symptom onset time (or time last known well), current medications, and comorbid conditions while minimizing on-scene time 1
• EMS communications centers should implement priority dispatch protocols and provide pre-arrival instructions to expedite care 1
• In rural settings, consider air transport and telestroke consultation to overcome geographic barriers to stroke-capable facilities 1

Emergency Department Assessment and Stabilization

Initial Evaluation (Within Minutes of Arrival)

• Perform immediate neurological evaluation using validated stroke severity scales (e.g., National Institutes of Health Stroke Scale) to assess prognosis and guide treatment decisions 2, 3
• Obtain urgent brain CT or MRI within 24 hours to distinguish ischemic from hemorrhagic stroke and determine eligibility for reperfusion therapies 4, 2, 3
• Assess and maintain airway, breathing, and circulation; intubate patients with compromised airway or respiratory failure 2
• Provide supplemental oxygen only if needed to maintain oxygen saturation >94% 2, 3

Essential Laboratory Investigations

• Obtain full blood count, electrocardiogram, electrolytes, renal function, fasting lipids, glucose, and coagulation profile 1, 3
• Perform urgent carotid duplex ultrasound for patients with carotid territory symptoms who are potential candidates for revascularization 3

Acute Reperfusion Therapy

Intravenous Thrombolysis

Administer intravenous alteplase within 4.5 hours of symptom onset for eligible ischemic stroke patients, as this represents the most time-sensitive intervention with proven mortality and morbidity benefit. 4, 2

• Maintain blood pressure <180/105 mmHg during and for 24 hours after thrombolytic administration 4, 2
• Monitor closely for bleeding complications, particularly hemorrhagic transformation 2, 5

Mechanical Thrombectomy

• Perform endovascular thrombectomy for patients with large vessel occlusion within 6-24 hours based on specific imaging criteria 2
• Combined stent-retriever and aspiration techniques achieve the most effective first-pass complete reperfusion 2

Blood Pressure Management

For ischemic stroke patients NOT receiving thrombolysis, avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg, as premature BP reduction may worsen cerebral perfusion. 4, 2, 3

• For hemorrhagic stroke with hypertension, lower systolic BP to target of 140 mmHg (avoiding <110 mmHg) within 6 hours 4
• Monitor blood pressure closely during the first 48 hours after stroke onset 3

Stroke Unit Care

All stroke patients should be admitted to a geographically defined stroke unit with specialized interdisciplinary staff, as this intervention provides mortality and morbidity benefits comparable to thrombolytic therapy. 4, 2, 3

Multidisciplinary Team Composition

• The stroke unit team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 3
• Implement standardized clinical pathways to ensure consistent application of evidence-based interventions 3

Monitoring and Vital Signs Management

• Assess neurological status and vital signs frequently during the first 24-48 hours, as approximately 25% of patients deteriorate during this period 4, 2
• Monitor body temperature at least 4 times daily for 3 days; treat fever >37.5°C (99.5°F) with acetaminophen 3
• Measure blood glucose on admission and at least 4 times daily for 3 days; treat elevated glucose >180 mg/dL (10 mmol/L) with insulin 3

Prevention and Management of Complications

Swallowing and Aspiration Prevention

• Perform swallowing screening within 24 hours of admission using a validated tool before allowing any oral intake (food, fluids, or medications) 4, 2, 3
• Implement measures to prevent aspiration pneumonia including good pulmonary toileting and early mobility 3

Venous Thromboembolism Prevention

• Encourage early mobilization to prevent deep vein thrombosis and pulmonary embolism 2, 3
• Use frequent turning, alternating pressure mattresses, and close skin surveillance to prevent pressure sores 2

Urinary and Infection Management

• Avoid indwelling urinary catheters when possible to reduce urinary tract infection risk 3
• Assess for urinary retention in the first 72 hours using bladder scanning to obtain post-void residual volume 3

Cerebral Edema Management

• Do NOT use corticosteroids for cerebral edema and increased intracranial pressure 2
• Reserve osmotic therapy and hyperventilation for patients who deteriorate neurologically 2
• Consider decompressive craniectomy for malignant cerebral edema, particularly in younger patients 5, 6

Early Rehabilitation

Begin rehabilitation assessment within 48 hours of admission and initiate therapy as soon as the patient is medically stable, as early intervention improves functional outcomes. 2, 3

• Implement early, short, frequent exercise sessions to prevent complications and improve outcomes 3
• Perform daily stretching of hemiplegic limbs to prevent contractures 3
• Position the hemiplegic shoulder in maximum external rotation for 30 minutes daily to prevent shoulder contracture 3
• Provide rehabilitation through specialized stroke rehabilitation units or general rehabilitation units as needed 2

Secondary Prevention

Antithrombotic Therapy

• Commence aspirin 160-300 mg daily within 48 hours of acute ischemic stroke onset 2, 3
• Do NOT use anticoagulation (e.g., intravenous unfractionated heparin) as standard treatment due to increased bleeding risk 2, 3
• Prescribe appropriate long-term antithrombotic therapy based on stroke etiology 3

Carotid Revascularization

• Perform carotid endarterectomy for patients with recent (within 6 months) non-disabling carotid territory ischemic stroke or TIA with ipsilateral 70-99% stenosis 2
• Consider carotid endarterectomy for select patients with 50-69% stenosis 2
• Perform surgery as soon as possible after the event, ideally within 2 weeks 2

Risk Factor Management

• Address all modifiable risk factors including hypertension, dyslipidemia, diabetes, and atrial fibrillation 3, 7
• Initiate statin therapy for dyslipidemia management 7
• Provide anticoagulation for atrial fibrillation when appropriate 7

Special Considerations for Rural and Resource-Constrained Settings

• Implement telestroke networks to provide remote specialist access for thrombolysis decisions and ongoing consultation 1
• Support transition of hospitals to certified Acute Stroke Ready Hospital status to expand access to acute stroke care 1
• Develop coordinated systems of stroke care that include rural hospitals with enhanced data sharing and partnerships with hub stroke centers 1
• Consider home-based telerehabilitation interventions where inpatient rehabilitation facilities are unavailable 1

Discharge Planning and Transitions of Care

• Ensure smooth transition from inpatient to outpatient care with timely transfer of discharge information to subsequent treating physicians 3
• Establish clear follow-up methods and appointments before discharge 3
• Provide comprehensive patient and family education about stroke risk factors, warning signs, and prevention strategies 3

Quality Improvement

• Participate in stroke registries and quality improvement collaboratives (e.g., Get With The Guidelines-Stroke) to improve care processes and adherence to performance measures 1, 2
• Transport patients to Primary Stroke Centers when possible, as this leads to lower 30-day mortality rates and increased use of appropriate therapies compared to non-designated hospitals 2

Critical Pitfalls to Avoid

• Never delay brain imaging - failure to obtain urgent CT/MRI within 24 hours prevents timely reperfusion decisions 2, 3
• Never lower blood pressure prematurely in ischemic stroke patients not receiving thrombolysis, as this may worsen cerebral perfusion and outcomes 4, 2
• Never allow oral intake before swallowing screening - this substantially increases aspiration pneumonia risk 4, 2, 3
• Never use corticosteroids for stroke-related cerebral edema, as they are ineffective and potentially harmful 2
• Never delay aspirin administration beyond 48 hours in ischemic stroke patients 2, 3