What is the management and treatment for a patient with a stroke?

Management and Treatment of Acute Stroke

Immediate Recognition and Emergency Response

Stroke must be treated as a life-threatening emergency requiring immediate activation of 9-1-1 and rapid transport to a stroke-capable hospital. 1

• Use the FAST mnemonic (Face weakness, Arm weakness, Speech difficulty, Time) to rapidly identify stroke symptoms—these three signs are present in 88% of all strokes and TIAs 1, 2
• Emergency Medical Services (EMS) transport reduces pre-hospital delays by 50% and shortens time to brain imaging compared to private transport 1, 3
• EMS should provide advance notification to the receiving hospital, which significantly reduces door-to-imaging and door-to-treatment times 1

Initial Emergency Department Assessment

All stroke patients require urgent brain CT or MRI within 24 hours to distinguish ischemic from hemorrhagic stroke and determine eligibility for reperfusion therapy. 2, 4

• Assess and stabilize airway, breathing, and circulation immediately—intubate patients with compromised airway 2, 5
• Provide supplemental oxygen only if oxygen saturation is <94% 2
• Determine exact time of symptom onset (defined as when patient was last at baseline/symptom-free) as this determines treatment eligibility 5
• Perform neurological evaluation using the National Institutes of Health Stroke Scale to assess severity and guide treatment decisions 4

Acute Reperfusion Therapy for Ischemic Stroke

Intravenous alteplase (0.9 mg/kg; maximum 90 mg) is the most critical time-sensitive intervention and should be administered within 3-4.5 hours of symptom onset for eligible patients. 1, 2, 4

Thrombolysis Management:

• Administer rtPA strictly following NINDS selection criteria with close observation 1
• Maintain blood pressure <180/105 mmHg during and for 24 hours after thrombolytic administration 4, 5
• Monitor closely for bleeding complications, particularly intracranial hemorrhage 1, 6
• Do NOT substitute streptokinase or other thrombolytic agents for rtPA—this is unsafe 1

Mechanical Thrombectomy:

• Consider for patients with large vessel occlusion within 6-24 hours based on specific imaging criteria 2, 5
• Combined stent-retriever and aspiration approach achieves the fastest 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. 2, 4, 5

• Elevated blood pressure should be lowered cautiously in all stroke patients 1
• Aggressive BP lowering can compromise perfusion to ischemic penumbra 7

Stroke Unit Admission

All stroke patients must be admitted to a geographically defined stroke unit with specialized interdisciplinary staff—this intervention provides mortality and morbidity benefits comparable to thrombolytic therapy. 1, 2, 4

• Stroke unit care reduces death and disability with effects persisting for years 1, 2
• The interdisciplinary team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 4, 5
• Monitor neurological status and vital signs frequently during the first 24 hours 1, 5
• Approximately 25% of patients deteriorate within 24-48 hours, making close observation essential 1

Prevention and Management of Complications

Swallowing Assessment:

• Perform swallowing screening within 24 hours using a validated tool before giving any food, fluids, or oral medications 2, 5
• Videofluoroscopic modified barium swallow examination should be performed if bedside screening suggests aspiration risk 1
• Use chin tuck, small sips, multiple swallows, and upright positioning for patients with dysphagia 5

Nutrition:

• Sustaining nutrition is critical as malnutrition interferes with recovery 1, 2
• Insert nasogastric or nasoduodenal tube if prolonged inability to swallow safely 1
• Consider percutaneous endoscopic gastric tube if prolonged need anticipated 1

Venous Thromboembolism Prevention:

• Administer subcutaneous anticoagulants or use intermittent external compression stockings for immobilized patients 1
• Aspirin can be used for patients who cannot receive anticoagulants 1

Infection Management:

• Pneumonia is a major cause of death after stroke—treat with early appropriate antibiotics 1
• Avoid indwelling bladder catheters when possible due to infection risk; use intermittent catheterization instead 1

Cerebral Edema:

• Do NOT use corticosteroids for cerebral edema—they are not recommended 2
• Use osmotic therapy and hyperventilation for patients who deteriorate from increased intracranial pressure 2

Seizure Management:

• Do NOT administer prophylactic anticonvulsants to patients who have not had seizures 1

Temperature and Glucose Control:

• Actively monitor and treat fever—hyperthermia worsens stroke outcomes 2, 7
• Treat glucose levels >8 mmol/L as hyperglycemia predicts poor prognosis 7
• Insulin therapy in critically ill stroke patients is safe and reduces mortality 7

Early Mobilization and Rehabilitation

Begin rehabilitation assessment by specialized professionals within 48 hours of admission and start therapy as soon as the patient is medically stable. 2, 5

• Early mobilization reduces complications including pneumonia, deep vein thrombosis, pulmonary embolism, and pressure sores 1, 2
• Frequent turning, alternating pressure mattresses, and close skin surveillance prevent pressure sores 2
• Comprehensive rehabilitation should include physical, occupational, and speech therapy 5

Secondary Prevention

Commence aspirin 160-300 mg daily within 48 hours of acute ischemic stroke onset for patients not receiving thrombolysis. 2, 4, 5

Anticoagulation:

• Urgent anticoagulation is NOT routinely recommended—it increases risk of brain hemorrhage without reducing early recurrent stroke risk 1
• Routine anticoagulation should be avoided, especially in patients with moderately severe strokes 1, 2

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, 5
• Surgery should be performed as soon as possible after the event, ideally within 2 weeks 2
• Consider for select patients with 50-69% stenosis 2
• Emergent/urgent carotid endarterectomy for unstable neurological status or stroke-in-evolution has uncertain efficacy (Class IIb evidence) 1

Quality Improvement and Systems of Care

• Transport to Primary Stroke Centers reduces 30-day mortality (10.1% vs 12.5%) and increases fibrinolytic therapy use (4.8% vs 1.7%) compared to non-designated hospitals 1, 2
• Participation in Get With The Guidelines-Stroke programs improves care processes and adherence to performance measures 1, 2
• Standardized stroke orders and integrated pathways improve adherence to best practices 1, 5

Critical Pitfalls to Avoid

• Never delay treatment waiting for "complete" workup—time is brain tissue, with progressive irreversible loss occurring every minute 8, 7
• Never aggressively lower blood pressure in acute ischemic stroke unless meeting specific thresholds, as this worsens cerebral perfusion 4, 7
• Never use streptokinase as a substitute for rtPA—this is unsafe 1
• Never give prophylactic anticonvulsants without documented seizures 1
• Never use corticosteroids for cerebral edema in stroke 2