What is the immediate treatment for a patient who has suffered a stroke?

Immediate Treatment for Acute Stroke

For a patient presenting with acute stroke, immediately assess airway, breathing, and circulation, perform rapid neurological examination with NIHSS, obtain urgent brain imaging (CT or MRI) to rule out hemorrhage, and initiate reperfusion therapy (IV thrombolysis or mechanical thrombectomy) as soon as possible if eligible—do not delay imaging or treatment for ECG, chest X-ray, or blood work results unless the patient is hemodynamically unstable. 1, 2

Critical First Steps (Within Minutes)

ABC Assessment and Vital Signs

• Airway, breathing, and circulation must be rapidly evaluated first 1, 3
• Assess oxygen saturation and provide supplemental oxygen if <92% 3, 4
• Monitor heart rate and rhythm, blood pressure, temperature, hydration status, and seizure activity 1
• Use a standardized stroke scale (NIHSS or Canadian Neurological Scale) to quantify neurological deficits and stroke severity 1, 2

Immediate Brain Imaging

• Obtain urgent brain CT or MRI to differentiate ischemic from hemorrhagic stroke and determine reperfusion therapy eligibility 1, 2
• Do not delay imaging for ECG, chest X-ray, or awaiting blood work results unless there is hemodynamic instability 1
• Imaging should occur as soon as possible, certainly within 24 hours, but ideally within minutes for thrombolysis candidates 1

Reperfusion Therapies (Time-Critical)

Intravenous Thrombolysis

• Administer IV rtPA (0.9 mg/kg, maximum 90 mg) to eligible patients within 3 hours of symptom onset 2
• Blood pressure must be <185/110 mmHg before rtPA administration 2
• Do not await blood work results unless there is specific clinical concern (e.g., INR for patients on warfarin) 1

Mechanical Thrombectomy

• Perform endovascular thrombectomy for large vessel occlusion within 6-24 hours based on advanced imaging showing salvageable tissue 2
• The treatment window can be extended in select patients with appropriate imaging criteria 1

Initial Laboratory and Diagnostic Work

Blood Work (Do Not Delay Treatment)

• Order electrolytes, glucose, CBC, coagulation studies (INR, aPTT), creatinine, eGFR, and troponin 1
• Awaiting results should not delay acute stroke treatment unless clinically indicated (e.g., warfarin patients require INR) 1
• For patients with disabling symptoms, prioritize "neurons over nephrons"—do not delay CTA for renal function results in most cases 1

ECG and Chest X-Ray

• Complete ECG but defer until after thrombolysis decision if patient is hemodynamically stable 1
• Obtain chest X-ray only if evidence of acute heart or pulmonary disease; otherwise defer until after acute treatment 1

Blood Pressure Management

For Patients NOT Receiving Thrombolysis

• Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg 2
• Overly aggressive blood pressure lowering can worsen outcomes by reducing cerebral perfusion 2, 4
• For watershed stroke specifically, maintain cerebral perfusion pressure—avoid aggressive lowering 3

For Patients Receiving Thrombolysis

• Lower blood pressure to <185/110 mmHg before rtPA and maintain <180/105 mmHg for 24 hours post-treatment 2

For Intracerebral Hemorrhage

• Keep mean arterial pressure below 130 mmHg in patients with hypertension history 1

Physiological Parameter Management

Temperature Control

• Monitor temperature every 4 hours for first 48 hours 3
• Treat fever >37.5°C with antipyretics and investigate source 3, 2, 4
• Hyperthermia worsens stroke outcomes and must be controlled early 4

Glucose Management

• Monitor blood glucose regularly and treat hyperglycemia to maintain levels <300 mg/dL 2
• Glucose levels >8 mmol/L predict poor prognosis; insulin therapy in critically ill stroke patients is safe and reduces mortality 4

Seizure Management (If Present)

• Administer IV lorazepam for active, non-self-limiting seizures occurring at onset or within 24 hours 3
• Do not delay brain imaging due to seizure activity 3
• A single self-limiting seizure within 24 hours should not be treated with long-term anticonvulsants 3

Early Supportive Care

Aspirin Administration

• Start aspirin 160-300 mg/day within 48 hours of ischemic stroke onset (not before or during thrombolysis) 1

DVT Prophylaxis

• Initiate subcutaneous heparin or low molecular weight heparin for immobile patients 2
• Enoxaparin 40 mg once daily is more effective than unfractionated heparin 5000 IU twice daily 2

Swallowing Assessment

• Assess swallowing function before allowing oral intake due to elevated aspiration risk 3

Early Mobilization

• Begin early mobilization within 24 hours once medically stable if no contraindications 3
• Rehabilitation assessment should occur within 48 hours of admission 2

Critical Pitfalls to Avoid

• Every 30 minutes of delay decreases probability of good functional outcome by 8-14%—time is brain tissue 2, 5
• Do not perform ECG, chest X-ray, or await non-essential blood work before imaging or thrombolysis decisions 1
• Do not aggressively lower blood pressure in patients not receiving thrombolysis, as this can worsen cerebral perfusion 2, 4
• Do not discharge patients from ED without diagnostic evaluation, functional assessment, secondary prevention initiation, and ongoing management plan 1