What is the protocol for managing a brain stroke?

Brain Stroke Protocol

Immediate Actions Upon Patient Arrival

All suspected stroke patients must be evaluated and treatment decisions made within 60 minutes of emergency department arrival, with brain imaging completed and analyzed within 25-30 minutes. 1, 2

First 10 Minutes: Stabilization and Team Activation

• Activate the acute stroke team immediately upon patient arrival, including physicians, nurses, and laboratory/radiology personnel 1
• Secure airway, breathing, and circulation; administer supplemental oxygen if oxygen saturation <94% 2
• Establish IV access and draw blood for complete blood count, coagulation studies (PT/INR, aPTT), platelet count, electrolytes, renal function, glucose, and cardiac troponin 1, 2
• Laboratory results must be available within 20 minutes of blood sampling for thrombolysis candidates 2
• Obtain 12-lead ECG due to high incidence of cardiac disease in stroke patients 1

Minutes 10-15: Neurological Assessment

• Perform focused neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to determine stroke severity and guide treatment decisions 1, 2
• Establish precise time of symptom onset by interviewing patient, family, or EMS personnel—this is critical for determining thrombolysis eligibility 1
• Document last known normal time if exact onset is unknown 1

Minutes 15-30: Urgent Neuroimaging

• Obtain non-contrast CT scan immediately as the priority imaging modality to definitively exclude hemorrhage and assess for early ischemic changes 1, 2
• Complete CT scan and interpretation within 25-30 minutes of arrival 1, 2
• Do not delay thrombolysis for non-essential tests such as routine chest X-ray unless specific cardiac or pulmonary concerns exist 1, 2

Reperfusion Therapy Decision (Minutes 30-60)

For Ischemic Stroke Candidates

Administer intravenous alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) if eligibility criteria are met, with a door-to-needle time goal of ≤60 minutes in ≥50% of patients and ≤45 minutes as the optimal target. 2

Pre-thrombolysis Blood Pressure Management

• Blood pressure must be reduced to <185/110 mmHg before initiating thrombolysis 2
• Use labetalol 10-20 mg IV over 1-2 minutes (may repeat once) or nicardipine IV 5 mg/hr, titrated up by 2.5 mg/hr every 5-15 minutes (maximum 15 mg/hr) 2
• Maintain blood pressure <180/105 mmHg during and for 24 hours after thrombolytic treatment 2

Mechanical Thrombectomy Consideration

• For patients with large vessel occlusion in the anterior circulation, mechanical thrombectomy should be performed in addition to IV thrombolysis if the patient can be treated within 24 hours of symptom onset 1, 3
• Time from stroke onset to groin puncture directly correlates with recanalization success—every minute matters 4

For Hemorrhagic Stroke

• Control systolic blood pressure to 130-150 mmHg; for patients with hypertension history and intracerebral hemorrhage, keep mean arterial pressure below 130 mmHg 2, 3
• Immediately reverse anticoagulation with dedicated reversal agents if patient is anticoagulated 3
• Administer tranexamic acid for active bleeding as soon as possible 3

Continuous Monitoring and Supportive Care

Physiological Monitoring (First 24-48 Hours)

• Institute continuous automated monitoring of oxygen saturation, arterial blood pressure, heart rhythm, and body temperature 2
• Cardiac monitoring for at least 24 hours to detect atrial fibrillation and life-threatening arrhythmias 2
• Monitor temperature every 4 hours for the first 48 hours, then per ward routine 2
• Perform frequent neurological assessments using NIHSS to rapidly detect complications or stroke progression 2

Metabolic Management

• Treat glucose levels >8 mmol/l (>144 mg/dL) as hyperglycemia predicts poor prognosis after correcting for age and stroke severity 5
• Treat hyperthermia aggressively—elevated body temperature worsens stroke outcomes 2, 5
• Avoid hypoxemia (maintain O₂ saturation ≥92%) as it worsens prognosis 5

Complication Prevention

Venous Thromboembolism Prophylaxis

• Apply intermittent pneumatic compression (IPC) devices immediately for all immobilized patients 2
• Continue IPC until patient becomes independently mobile, at discharge, or by 30 days (whichever comes first) 2
• Add low-molecular-weight heparin (enoxaparin) for high-risk patients; use unfractionated heparin for those with renal failure 2
• Do not use anti-embolism stockings alone without IPC or pharmacological prophylaxis—this is inadequate 2

Swallowing and Feeding

• Perform swallow evaluation before allowing oral intake 1
• Implement deep vein thrombosis prophylaxis protocols 1

Early Rehabilitation and Stroke Unit Care

Specialized Stroke Unit Admission

Admit all stroke patients to a specialized stroke unit, which reduces mortality by 14% at 1 year and improves functional outcomes compared to general medical wards. 3

Early Mobilization

• Conduct initial rehabilitation assessment by specialized therapists within 48 hours of admission 2
• Begin frequent, brief out-of-bed activity (sitting, standing, walking) within 24 hours if no contraindications exist 2

Written Care Protocols and EMS Coordination

Protocol Requirements

• Maintain written care protocols for acute stroke available in the emergency department and reviewed annually by a multidisciplinary team using evidence-based guidelines 1
• Protocols should exclude certain orders (e.g., prohibition of anticoagulants immediately after IV tPA) and mandate specific activities (e.g., swallow evaluation before feeding) 1

EMS System Integration

• EMS personnel should transport acute stroke patients directly to the nearest Primary Stroke Center or facility capable of providing stroke center-level care 1
• EMS must demonstrate proficiency in stroke recognition using validated scales (Cincinnati Prehospital Stroke Scale or Los Angeles Prehospital Stroke Screen), patient stabilization, establishing time of onset, and effective communication with receiving facilities 1
• Stroke centers should conduct cooperative educational activities with EMS at least twice per year 1

Critical Pitfalls to Avoid

• Never delay thrombolysis for non-essential tests such as routine chest X-ray or additional imaging unless specific concerns exist 1, 2
• Do not treat single self-limiting seizures with long-term anticonvulsants 2
• Do not allow hyperthermia to persist untreated—it significantly worsens outcomes 2, 5
• Avoid both excessive blood pressure elevation and precipitous drops in diastolic pressure, as both extremes worsen prognosis 5
• Do not refuse admission to neurosurgical units for patients requiring emergency surgery due to lack of critical care beds—surgery remains the priority 1

Special Considerations for Surgical Intervention

Malignant Cerebral Edema

• For swollen supratentorial hemispheric ischemic stroke, consider decompressive craniectomy with dural expansion in patients who continue to deteriorate neurologically 3
• For swollen cerebellar stroke, perform suboccipital craniectomy with dural expansion in patients who deteriorate neurologically 3

Transfer Protocols

• Establish predetermined interhospital transfer protocols and agreements for patients requiring higher-level care 1
• Target maximum 4 hours from injury to surgery for expanding hematomas requiring evacuation 1