What is the management and treatment of a stroke?

Stroke Management and Treatment

Stroke is a medical emergency requiring immediate recognition and treatment within minutes to hours, with the primary goals of minimizing brain injury through rapid reperfusion therapy when appropriate, preventing complications, and maximizing functional recovery through specialized stroke unit care. 1, 2

Immediate Recognition and Emergency Response

• Call 911 immediately when stroke symptoms are identified—EMS activation is critical as patients who use emergency services arrive faster and receive treatment sooner than those who self-transport 1, 2
• Recognize stroke using the FAST mnemonic: Face drooping, Arm weakness, Speech difficulty, Time to call 911 3
• EMS should use validated stroke screening tools during transport and provide early notification to receiving hospitals to expedite care 1, 2
• The concept "Time is Brain" drives all stroke care—every minute of delay results in irreversible loss of approximately 1.9 million neurons 1, 4

Emergency Department Evaluation ("Door-Data-Decision")

Immediate Stabilization

• Assess and maintain airway, breathing, and circulation—intubate if airway is compromised 3, 5
• Provide supplemental oxygen only if oxygen saturation is <94%—avoid routine oxygen administration 3, 5
• Establish IV access and obtain blood samples immediately 1, 2

Urgent Brain Imaging

• Perform non-contrast CT scan or MRI within 25 minutes of arrival to distinguish ischemic from hemorrhagic stroke 1, 2
• Brain imaging is the single most critical test—it determines eligibility for thrombolytic therapy 1, 3
• Repeat imaging urgently if the patient's neurological condition deteriorates 1, 2

Essential Laboratory Tests

• Obtain complete blood count, electrolytes, renal function, glucose, cardiac biomarkers, coagulation studies (PT/INR, aPTT), lipid panel, and ECG 1, 2, 5
• Measure glucose immediately—hypoglycemia can mimic stroke symptoms and requires urgent correction 2, 5
• Perform carotid duplex ultrasound urgently for patients with carotid territory symptoms who may be candidates for revascularization 1, 2

Stroke Severity Assessment

• Use a standardized stroke severity scale (National Institutes of Health Stroke Scale - NIHSS) to assess prognosis and guide treatment decisions 1, 2
• Perform frequent neurological assessments during the first 24-48 hours as approximately 25% of patients deteriorate during this period 5

Acute Treatment of Ischemic Stroke

Intravenous Thrombolysis ("Drug")

• Administer IV alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) within 3-4.5 hours of symptom onset for eligible patients—this is the most beneficial proven intervention for acute ischemic stroke 1, 2, 3
• Give 10% as bolus over 1 minute, then 90% as infusion over 60 minutes 1
• Thrombolysis should only be administered by physicians with stroke expertise, with established protocols for acute blood pressure management 1
• Do NOT give aspirin or other antiplatelet agents within 24 hours of thrombolytic therapy—early aspirin after alteplase increases symptomatic intracranial hemorrhage risk without improving outcomes 6

Mechanical Thrombectomy

• Consider mechanical thrombectomy for patients with large vessel occlusion within 6-24 hours based on specific imaging criteria 3
• Combined endovascular approach using stent-retrievers and aspiration achieves the fastest complete reperfusion 3

Antiplatelet Therapy for Non-Thrombolysis Patients

• Administer aspirin 160-300 mg within 48 hours of stroke onset if CT/MRI excludes hemorrhage—this prevents 10 deaths and recurrent strokes per 1,000 patients treated 1, 7, 8
• Aspirin can be given orally, rectally (suppository), or via nasogastric tube if swallowing is unsafe 7, 8
• Do NOT use routine anticoagulation (unfractionated heparin, low-molecular-weight heparin) in unselected patients—bleeding complications negate any benefits 1

Blood Pressure Management

• Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg in patients not receiving thrombolysis 1, 2, 3, 5
• Never use sublingual nifedipine—it causes precipitous BP drops that worsen outcomes 2
• For patients receiving thrombolysis, maintain BP <185/110 mmHg before treatment and <180/105 mmHg for 24 hours after 1
• Use short-acting IV agents (labetalol, nicardipine) if treatment is required 5

Management of Intracerebral Hemorrhage (ICH)

• Urgently reverse anticoagulation in patients with ICH due to warfarin or other anticoagulants 1, 2
• Lower blood pressure to keep mean arterial pressure <130 mmHg in hypertensive patients 1
• Do NOT use corticosteroids for cerebral edema—they are ineffective and potentially harmful 3
• Consider osmotic therapy (mannitol, hypertonic saline) and hyperventilation for patients with increased intracranial pressure 1, 2, 3
• Refer patients aged 18-60 years with extensive hemispheric infarcts for urgent neurosurgical evaluation within 48 hours for possible hemicraniectomy—this substantially reduces death and disability 1, 2
• Consider craniotomy for superficial ICH <1 cm from surface or stereotactic surgery for deep ICH 1
• Surgery is particularly beneficial for cerebellar hemorrhages causing brainstem compression and hydrocephalus 2

Stroke Unit Care ("Disposition")

• Admit ALL stroke patients to a geographically defined stroke unit with specialized interdisciplinary staff—this intervention is as effective as thrombolysis in reducing mortality and disability 1, 2, 3
• The stroke unit team must include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with stroke expertise 2, 3
• Stroke unit care reduces mortality and morbidity with benefits persisting for years 3
• Transport to Primary Stroke Centers (versus non-designated hospitals) leads to lower 30-day mortality and increased use of appropriate therapies 3

Prevention and Management of Complications

Swallowing and Aspiration Prevention

• Screen ALL patients for swallowing dysfunction within 24 hours using a validated tool before allowing any oral intake—aspiration pneumonia is a leading cause of post-stroke death 2, 3, 5
• If swallowing is unsafe, insert nasogastric or nasoduodenal tube for nutrition and medications 2
• Consider percutaneous endoscopic gastrostomy (PEG) tube if prolonged feeding support (>2-3 weeks) is anticipated 2

Infection Prevention and Treatment

• Investigate fever immediately—pneumonia is an important cause of death after stroke and requires prompt antibiotic therapy 2, 5
• Avoid indwelling bladder catheters when possible due to infection risk 2

Deep Vein Thrombosis Prevention

• Administer subcutaneous anticoagulants (low-molecular-weight heparin or unfractionated heparin) or use intermittent external compression stockings for all immobilized patients 2, 3, 5
• Dehydration increases DVT risk—maintain adequate hydration 3

Pressure Ulcer Prevention

• Turn patients frequently, use alternating pressure mattresses, and perform close skin surveillance 1, 3

Metabolic Management

• Correct hypoglycemia immediately—it mimics stroke symptoms and causes brain injury 2, 5
• Lower markedly elevated glucose to <300 mg/dL, but avoid overly aggressive treatment that can cause harmful fluid shifts 5
• Monitor and treat fever aggressively—hyperthermia worsens brain injury 1, 3

Cerebral Edema Management

• Monitor closely for deterioration from brain swelling, especially in the first 24-96 hours 1, 2
• Use osmotic agents (mannitol 0.25-0.5 g/kg IV) and hyperventilation for increased intracranial pressure 1, 2

Early Rehabilitation

• Begin rehabilitation assessment within 48 hours of admission by physiotherapists, occupational therapists, and speech-language pathologists 2, 3
• Start mobility training and activities of daily living practice as soon as medically stable 2, 3
• Early mobilization prevents complications including pneumonia, DVT, pulmonary embolism, and pressure sores 2, 3
• Evaluate and treat communication difficulties, cognitive impairment, and mood disorders early 1, 2
• Continue rehabilitation in stroke rehabilitation units, general rehabilitation units, or community settings as needed—all are equally effective if delivered with appropriate intensity 3

Secondary Prevention

Antiplatelet Therapy

• Continue aspirin 160-300 mg daily for long-term secondary prevention in ischemic stroke patients 3
• Base antiplatelet selection on stroke etiology (aspirin, clopidogrel, or combination therapy depending on mechanism) 2

Lipid Management

• Continue statin therapy during acute period for patients already taking statins at stroke onset 2
• Initiate statin therapy before discharge for all ischemic stroke patients regardless of baseline cholesterol 1

Blood Pressure Control

• Initiate or optimize antihypertensive therapy before discharge with target <140/90 mmHg (or <130/80 mmHg for some patients) 1

Carotid Revascularization

• Perform carotid endarterectomy within 2 weeks for patients with recent non-disabling stroke and ipsilateral 70-99% carotid stenosis 3
• Consider carotid endarterectomy for select patients with 50-69% stenosis 3

Lifestyle Modifications

• Provide smoking cessation counseling and pharmacotherapy 1
• Recommend Mediterranean diet, regular exercise, weight loss if overweight, and limited alcohol consumption 1

Quality Improvement and Monitoring

• Use written hospital protocols defining processes and responsibilities for stroke care 2
• Monitor key metrics including door-to-imaging time, door-to-needle time for thrombolysis, early aspirin administration, DVT prophylaxis, dysphagia screening, and stroke unit admission rates 1, 3
• Participate in stroke registries (e.g., Get With The Guidelines-Stroke) to drive quality improvement 3
• Review all stroke cases systematically to identify opportunities for improvement 2, 3