What is the management approach for stroke in the Emergency Room (ER)?

Emergency Department Management of Acute Stroke

Stroke must be treated as a medical emergency with immediate systematic evaluation and treatment within minutes of arrival, prioritizing rapid reperfusion therapy for eligible patients to minimize brain injury and maximize recovery. 1, 2

Immediate Assessment (Within 10 Minutes of Arrival)

Primary Survey and Stabilization

• Assess airway, breathing, and circulation (ABCs) immediately upon arrival 3, 2
• Administer oxygen only if hypoxemic (oxygen saturation <94%) 2
• Establish IV access with two large-bore lines and obtain baseline blood studies: complete blood count, coagulation studies (INR, aPTT), blood glucose, and electrolytes 3, 2
• Initiate continuous cardiac monitoring for the first 24 hours to detect atrial fibrillation and life-threatening arrhythmias 2

Rapid Neurological Assessment

• Perform focused neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity 3
• Document exact time of symptom onset or last known normal time 1, 2
• Obtain focused history including: anticoagulant use, recent procedures, seizure activity, and contraindications to thrombolysis 1, 3

Emergency Neuroimaging

• Order emergent non-contrast CT scan of the brain immediately—imaging should not be delayed by laboratory results 3, 2
• CT scan is mandatory to differentiate ischemic stroke from hemorrhagic stroke before any treatment decisions 3, 2
• For ischemic stroke with large vessel occlusion, obtain CT angiography to evaluate for mechanical thrombectomy candidacy 2
• For intracerebral hemorrhage (ICH), vascular imaging (CT angiography or MR angiography) is recommended to exclude underlying vascular lesions such as aneurysms or arteriovenous malformations 3

Management of Acute Ischemic Stroke

Thrombolytic Therapy Decision-Making

IV alteplase (tPA) at 0.9 mg/kg (maximum 90 mg) should be administered to eligible patients within 4.5 hours of symptom onset, with a door-to-needle time goal of less than 60 minutes. 1, 2, 4

Inclusion Criteria for IV tPA:

• Clinical diagnosis of ischemic stroke with measurable neurological deficit 1
• Symptom onset within 4.5 hours (or last known normal time) 1, 2
• Age ≥18 years 1
• CT scan showing no hemorrhage 1

Critical Exclusion Criteria for IV tPA:

• Evidence of intracranial hemorrhage on CT 1
• Systolic BP >185 mmHg or diastolic BP >110 mmHg (uncontrolled despite treatment) 1, 2
• Blood glucose <50 mg/dL or >400 mg/dL 1
• Platelet count <100,000 1
• INR >1.6 or PT >15 seconds 1
• Use of direct oral anticoagulants within 48 hours 1
• Recent major surgery or trauma within 14 days 1
• History of intracranial hemorrhage 1
• Active internal bleeding or gastrointestinal/genitourinary hemorrhage within 21 days 1
• Arterial puncture at non-compressible site within 7 days 1

Blood Pressure Management for Ischemic Stroke

• Before tPA administration: Blood pressure must be reduced to <185/110 mmHg 2
• After tPA administration: Maintain blood pressure <180/105 mmHg for at least 24 hours 2
• Use short-acting IV antihypertensives (labetalol or nicardipine) for precise control 3
• Do not treat hypertension aggressively in patients NOT receiving tPA unless systolic BP >220 mmHg or diastolic BP >120 mmHg 1

Mechanical Thrombectomy

• Mechanical thrombectomy is recommended for eligible patients with large vessel occlusions (internal carotid artery or MCA-M1 segment) 2
• Can be performed up to 24 hours from symptom onset in selected patients with favorable imaging 2
• Should not delay IV tPA administration when both are indicated 2

Glucose Management

• Treat hypoglycemia (blood glucose <60 mg/dL) immediately to achieve normoglycemia 2
• Manage hyperglycemia to achieve blood glucose levels between 140-180 mg/dL 2

Management of Intracerebral Hemorrhage (ICH)

Blood Pressure Control

For ICH patients with systolic BP between 150-220 mmHg, acute lowering to 140 mmHg is safe and can improve functional outcomes. 3

• Assess blood pressure every 15 minutes until stabilized 3
• Use nicardipine (preferred over labetalol for faster response and better control) for IV blood pressure management 3
• Avoid cerebral vasodilators like sodium nitroprusside in patients with elevated intracranial pressure 3

Reversal of Coagulopathy

• Patients on warfarin with elevated INR should receive immediate vitamin K-dependent factor replacement (prothrombin complex concentrate preferred), IV vitamin K, and warfarin should be withheld 3
• Patients with severe thrombocytopenia (<50,000) should receive platelet transfusion 3
• Patients on direct oral anticoagulants may require specific reversal agents 3

Management of Increased Intracranial Pressure

• Elevate head of bed 20-30 degrees to facilitate venous drainage 3
• Treat exacerbating factors: hypoxia, hypercarbia, hyperthermia 3
• Consider osmotherapy (mannitol 0.25-0.5 g/kg IV every 6 hours) for deteriorating patients 3
• Hyperventilation can be used as temporizing measure for herniation syndromes 3
• Corticosteroids are NOT recommended for cerebral edema management 3

Seizure Management

• Treat acute seizures at stroke onset with short-acting benzodiazepines (lorazepam IV) if not self-limited 3
• Single self-limited seizure does not require long-term anticonvulsant therapy 3
• Recurrent seizures should be treated with appropriate anticonvulsants 3

Surgical Consultation

• Obtain immediate neurosurgical consultation for cerebellar hemorrhage with neurological deterioration, brainstem compression, or hydrocephalus 3
• Consider early surgery for patients with Glasgow Coma Scale 9-12 3
• Surgical decompression may be lifesaving for large cerebellar infarctions causing brainstem compression 3

Critical Care and Monitoring

Admission and Monitoring

• Admit all stroke patients to specialized stroke unit or neurocritical care unit with neuroscience expertise 3, 2
• ICH patients require intensive care unit monitoring initially 3
• Perform validated neurological assessments (NIHSS) at baseline and hourly for first 24 hours 3
• Monitor for early deterioration—over 20% of ICH patients experience significant decline in first hours 3

Prevention of Complications

• Initiate intermittent pneumatic compression for venous thromboembolism prophylaxis on day of admission 3
• For ICH patients, consider pharmacological VTE prophylaxis (UFH or LMWH) after documenting hemorrhage stability on CT, typically 24-48 hours after onset 3
• Perform formal dysphagia screening before any oral intake to prevent aspiration pneumonia 3
• Avoid hypo-osmolar fluids (5% dextrose) as they worsen cerebral edema 3

Systems of Care and Transfer Protocols

Stroke Center Designation

• Hospitals should function as primary stroke centers with appropriate resources or have pre-established transfer protocols to comprehensive stroke centers 1, 2
• Telemedicine consultation can extend stroke expertise to hospitals without on-site neurologists 1
• Transfer decisions should not delay tPA administration if patient is eligible and within treatment window 1

Quality Metrics

• Door-to-imaging time: <25 minutes 1
• Door-to-needle time for tPA: <60 minutes 2, 4
• Door-to-groin puncture time for thrombectomy: <90 minutes 2

Critical Pitfalls to Avoid

• Do not delay imaging or treatment for complete laboratory results 3
• Do not withhold tPA based solely on mild or rapidly improving symptoms—these patients can still deteriorate 1
• Do not use graduated compression stockings alone for VTE prophylaxis—they are less effective than intermittent pneumatic compression 3
• Hematoma expansion occurs in 30-40% of ICH patients within first hours and predicts poor outcome—early aggressive BP control is critical 3
• Do not assume stroke cannot occur in hospitalized patients—in-hospital strokes are often delayed in recognition and treatment 1
• Seizure at stroke onset is an exclusion criterion for tPA administration 1