What is the management of stroke?

Management of Stroke

All stroke patients should be immediately transported to a stroke-capable hospital and admitted to a geographically defined stroke unit with specialized interdisciplinary staff, as this intervention provides mortality and morbidity benefits comparable to thrombolytic therapy itself. 1, 2

Prehospital and Emergency Response

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

• Emergency medical services should use the FAST mnemonic (Face drooping, Arm weakness, Speech difficulty, Time to call 911) for rapid stroke recognition 2
• Paramedics must obtain critical information including exact symptom onset time, current medications, and comorbidities while minimizing on-scene time 4
• Implement priority dispatch protocols with pre-notification to receiving hospitals to activate stroke teams before patient arrival 2, 5
• In rural settings, consider air transport and telestroke consultation to overcome geographic barriers 4

Emergency Department Assessment (Door-to-Decision <60 minutes)

Perform immediate neurological evaluation using the National Institutes of Health Stroke Scale (NIHSS) and obtain urgent brain CT or MRI within 24 hours to distinguish ischemic from hemorrhagic stroke. 2, 4

Initial Stabilization

• Assess and maintain airway, breathing, and circulation; intubate if airway is compromised 2
• Provide supplemental oxygen only if saturation <94%—avoid routine oxygen therapy 2
• Monitor cardiac rhythm during the first 24 hours, as arrhythmias are common 6
• Perform swallowing screening within 24 hours using a validated tool before allowing any oral intake to prevent aspiration pneumonia 1, 2

Acute Reperfusion Therapy for Ischemic Stroke

Administer intravenous alteplase within 4.5 hours of symptom onset for eligible patients—this is the most time-sensitive intervention with proven mortality benefit. 2, 4, 7

Blood Pressure Management During Thrombolysis

• Maintain blood pressure <180/105 mmHg during and for 24 hours after thrombolytic administration 4, 6
• This strict control is critical to prevent hemorrhagic transformation 1

Mechanical Thrombectomy

• Perform mechanical thrombectomy for large vessel occlusion within 6-24 hours based on specific imaging criteria 2
• Combined stent-retriever and aspiration approach achieves the fastest complete reperfusion 2

Blood Pressure Management (Non-Thrombolysis Patients)

For ischemic stroke patients NOT receiving thrombolysis, avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg, as premature reduction may worsen cerebral perfusion. 2, 4, 7

• Permissive hypertension in the acute phase maintains collateral flow to the ischemic penumbra 7, 8
• For hemorrhagic stroke with hypertension, lower systolic BP to 140 mmHg (strictly avoiding <110 mmHg) within 6 hours 4, 6

Stroke Unit Care (Mandatory for All Patients)

Stroke unit care reduces death by 24%, death or institutionalization by 24%, and death or dependency by 20% compared to general medical ward care. 1, 2

Key Features of Stroke Units

• Geographically defined beds occupied exclusively by stroke patients 1
• Interdisciplinary team including physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with stroke expertise 1, 2
• Standardized stroke orders and integrated care pathways to improve adherence to best practices 1, 2

Monitoring Protocol (First 24-48 Hours)

• Assess neurological status (level of consciousness, NIHSS score) at least hourly, as approximately 25% of patients deteriorate during this period 1, 6
• Notify stroke team immediately if consciousness changes, Canadian Neurological Scale score changes by ≥1 point, or NIHSS changes by ≥4 points 1
• Obtain repeat CT scan urgently when neurological deterioration occurs 1

Prevention and Management of Complications

Cerebral Edema and Increased Intracranial Pressure

• Do NOT use corticosteroids for cerebral edema—they are ineffective and potentially harmful 2
• Administer osmotic therapy (mannitol or hypertonic saline) and consider hyperventilation for patients with deterioration 1, 2
• Elevate head of bed 30 degrees for suspected elevated intracranial pressure 1
• Consider decompressive hemicraniectomy within 48 hours for malignant cerebral edema, ideally before significant decline in Glasgow Coma Scale or pupillary changes 1, 7

Venous Thromboembolism Prevention

• Administer subcutaneous anticoagulants (low-molecular-weight heparin or unfractionated heparin) or use intermittent external compression stockings for immobilized patients 1, 2
• For patients who cannot receive anticoagulants, use aspirin as alternative prophylaxis 1

Infection Prevention and Treatment

• Pneumonia is a major cause of post-stroke death, particularly in immobile patients unable to cough 1
• Promptly investigate fever and initiate appropriate antibiotics for confirmed infections 1
• Avoid indwelling bladder catheters when possible due to urinary tract infection risk; use intermittent catheterization instead 1

Metabolic Management

• Treat hyperglycemia >155 mg/dL, as glucose levels >8 mmol/L predict poor prognosis independent of stroke severity 7, 8
• Treat fever >37.5°C with antipyretic drugs, as hyperthermia worsens stroke outcomes 7, 8
• Maintain homeostasis (stable blood pressure, normoglycemia, normothermia) as this functions as first-line neuroprotection 8

Nutrition Support

• Sustaining nutrition is critical as malnutrition interferes with recovery 1, 2
• Insert nasogastric or nasoduodenal tube for patients who fail swallowing screening 1
• Consider percutaneous endoscopic gastrostomy tube if prolonged feeding support is anticipated 1

Pressure Ulcer Prevention

• Implement frequent turning, alternating pressure mattresses, and close skin surveillance 2
• Early mobilization reduces risk of pressure sores, pneumonia, deep vein thrombosis, and pulmonary embolism 1, 2

Early Rehabilitation

Initial assessment by rehabilitation professionals should occur within 48 hours of admission, with therapy beginning as soon as the patient is medically stable. 2

• Early mobilization is strongly recommended to prevent subacute complications 1, 2
• Rehabilitation can be delivered effectively in stroke rehabilitation units, general rehabilitation units, outpatient settings, day hospitals, or community programs 2

Secondary Prevention (Initiate During Acute Hospitalization)

Antiplatelet Therapy

• Commence aspirin 160-300 mg daily within 48 hours of acute ischemic stroke onset 2, 4
• This early aspirin reduces recurrent stroke risk without increasing hemorrhagic complications 2

Anticoagulation

• Do NOT use anticoagulation as standard acute treatment for ischemic stroke due to increased bleeding risk without proven benefit 2
• Exception: Administer anticoagulation for cerebral venous thrombosis 7

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
• Ideally perform surgery within 2 weeks of the event 2
• Consider for select patients with 50-69% stenosis 2
• The role of emergent/urgent carotid endarterectomy for acute stroke with small infarct core and large penumbra remains uncertain (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 thrombolytic 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
• Implement telestroke networks in rural areas to provide remote specialist access for thrombolysis decisions 4
• Support transition of community hospitals to Acute Stroke Ready Hospital certification to expand access 4

Common Pitfalls to Avoid

• Never delay thrombolysis for "minor" symptoms—even small strokes can cause significant disability 5
• Never lower blood pressure aggressively in acute ischemic stroke unless giving thrombolytics or BP is critically elevated—this worsens outcomes 7, 8
• Never assume a preserved gag reflex indicates safe swallowing—formal screening is mandatory 1
• Never use hormone replacement therapy during acute stroke hospitalization—it increases deep vein thrombosis risk in immobilized patients 1
• Never discharge stroke patients without comprehensive evaluation for stroke etiology and initiation of secondary prevention 1

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