What are the guidelines for acute stroke management and treatment?

Acute Stroke Management Guidelines

Immediate Recognition and Emergency Response

Call 9-1-1 immediately when stroke is suspected—this is the single most critical action that determines outcomes, as EMS transport reduces time to imaging and increases likelihood of receiving life-saving thrombolytic therapy. 1

Stroke Recognition (FAST Mnemonic)

• Face drooping, Arm weakness, Speech difficulty are present in 88% of all strokes and TIAs 1
• Time to call 9-1-1 is critical—only 53% of stroke patients currently use EMS despite proven benefits 1
• Public education must emphasize that stroke symptoms warrant immediate 9-1-1 activation, not calling a primary care physician first 1

Prehospital EMS Management

• Assess and stabilize ABCs (airway, breathing, circulation) first 1
• Obtain exact symptom onset time—this single piece of information determines thrombolytic eligibility 2
• Provide advance hospital notification to activate stroke team and reduce door-to-imaging time 1
• Transport to designated stroke center when available—this reduces 30-day mortality compared to non-designated hospitals 2
• Minimize on-scene time while obtaining current medications and comorbidities 2

Emergency Department Assessment (Door-to-Decision Protocol)

Brain imaging must be completed within 25 minutes of arrival and treatment decision within 60 minutes for thrombolytic-eligible patients. 1

Immediate Diagnostic Steps

• Non-contrast CT brain scan is the first essential test—definitively excludes hemorrhage and identifies thrombolytic contraindications 1
• NIHSS score provides standardized severity assessment and guides treatment decisions 1
• Blood glucose must be checked immediately—hypoglycemia mimics stroke 1
• ECG and cardiac biomarkers (troponin preferred) to identify concurrent MI or atrial fibrillation 1

Essential Laboratory Tests (Do Not Delay Thrombolysis)

• Complete blood count, electrolytes, renal function, coagulation studies 1
• These should be drawn but results should not delay rtPA if patient otherwise qualifies 1

Tests That Should NOT Delay Treatment

• Chest X-ray (only 1.8% show relevant abnormalities in acute stroke) 1
• Advanced vascular imaging beyond initial CT 1
• Cardiac monitoring beyond admission ECG 1

Acute Reperfusion Therapy (The Most Time-Critical Intervention)

Intravenous alteplase (rtPA) administered within 4.5 hours of symptom onset is the single intervention with proven mortality benefit and must be prioritized above all other acute treatments. 2

Thrombolysis Eligibility and Administration

• Within 3 hours: Strongest evidence for benefit, broader eligibility 1
• 3 to 4.5 hours: Proven benefit but excludes patients with >1/3 MCA territory involvement on CT 1
• Dose: 0.9 mg/kg (maximum 90 mg), 10% as bolus, remainder over 60 minutes 1
• Must be administered by specialist physician with stroke expertise and established protocols 1

Critical Blood Pressure Management During Thrombolysis

• Maintain BP <180/105 mmHg during and for 24 hours after rtPA to prevent hemorrhagic transformation 2
• If BP >220/120 mmHg: Cautiously reduce by 10-20% maximum, monitor for neurological deterioration 1
• Avoid aggressive BP lowering—this can worsen ischemic injury 1

Absolute Contraindications to Thrombolysis

• Intracranial hemorrhage on CT 1

• 1/3 MCA territory involvement (for 3-4.5 hour window) 1

• Recent major surgery or trauma 1

Acute Antithrombotic Therapy

Aspirin 150-300 mg should be administered within 48 hours of symptom onset if CT excludes hemorrhage—this reduces early recurrent stroke risk. 1, 2

Antiplatelet Therapy

• Do NOT give aspirin before or during thrombolysis—wait 24 hours after rtPA 1
• For non-thrombolyzed patients: Start aspirin immediately after CT excludes hemorrhage 1

Anticoagulation

• Routine anticoagulation (IV heparin) is NOT recommended for unselected acute ischemic stroke patients 1
• Increased bleeding risk without proven benefit 2
• Exception: Cerebral venous thrombosis requires anticoagulation 2

Stroke Unit Care (Reduces Mortality by 24%)

All stroke patients should be admitted to a geographically defined stroke unit with dedicated interdisciplinary team—this intervention reduces death, institutionalization, and dependency more than any other non-thrombolytic treatment. 2

Essential Stroke Unit Components

• Geographically defined beds exclusively for stroke patients 2
• Interdisciplinary team: Physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, pharmacists with stroke expertise 2
• Continuous physiological monitoring: Neurological status (Glasgow Coma Scale), vital signs, oxygen saturation, glucose, temperature 1

Monitoring Frequency

• First 72 hours: Frequent neurological assessments to detect early deterioration 1
• Cardiac telemetry: To detect paroxysmal atrial fibrillation missed on admission ECG 1

Management of Complications

Cerebral Edema

• Do NOT use corticosteroids—they are ineffective and potentially harmful 2
• Osmotic therapy (mannitol or hypertonic saline) for patients with deterioration 2
• Neurosurgical consultation for hemicraniectomy in patients 18-60 years with massive MCA infarction within 48 hours of onset 1

Intracerebral Hemorrhage

• Maintain mean arterial pressure <130 mmHg in hypertensive patients 1
• Surgical evacuation may be considered for cerebellar hemorrhage >3 cm or superficial (<1 cm from surface) supratentorial hemorrhage 1
• Hemostatic drugs (rFVIIa) are experimental and not recommended outside trials 1

Transient Ischemic Attack (TIA) Management

High-risk TIA patients (ABCD² score ≥4) have 8% two-day stroke risk and require urgent assessment within 24 hours, ideally with admission to stroke unit. 1

Risk Stratification (ABCD² Score)

• Age ≥60 years: 1 point
• BP ≥140/90: 1 point
• Clinical features: Unilateral weakness (2 points), speech disturbance without weakness (1 point)
• Duration: ≥60 minutes (2 points), 10-59 minutes (1 point)
• Diabetes: 1 point 1

Urgent TIA Management

• ABCD² ≥4 (high risk): Admit to stroke unit or specialist TIA clinic within 24-48 hours 1
• ABCD² <4 (low risk): Outpatient assessment within 7-10 days acceptable 1
• CT brain and carotid ultrasound within 24 hours for high-risk, within 48-72 hours for low-risk 1

Critical pitfall: 31% of patients with recurrent stroke within 90 days never sought medical attention after their initial TIA—public education must emphasize that brief symptoms still require emergency evaluation. 3

Secondary Prevention (Initiated Before Discharge)

Early initiation of secondary prevention before hospital discharge increases 3-month adherence and reduces recurrent stroke risk. 1

Antiplatelet Therapy

• Aspirin 160-300 mg daily started within 48 hours (after thrombolysis period if applicable) 2
• Continue long-term for all ischemic stroke patients 1

Lipid Management

• Statin therapy for all ischemic stroke/TIA patients regardless of baseline cholesterol 1
• Initiate before discharge to improve adherence 1

Blood Pressure Control

• Antihypertensive therapy for long-term prevention regardless of baseline BP 1
• Avoid aggressive acute lowering in first 24-48 hours unless extremely elevated (>220/120) 1

Carotid Revascularization

• 70-99% symptomatic stenosis: Carotid endarterectomy within 2 weeks by specialist surgeon with low complication rates 1
• 50-69% symptomatic stenosis: Consider in select patients (age, gender, comorbidities) 1
• <50% stenosis: Endarterectomy not recommended 1
• Carotid stenting: Reserve for patients unfit for surgery (severe cardiac/pulmonary disease, age >80, anatomical contraindications) 1

Rehabilitation and Discharge Planning

Inpatient Rehabilitation

• Stroke rehabilitation unit preferred for ongoing inpatient needs 1
• Early mobilization within 24-48 hours if medically stable 1

Predischarge Assessment

• Home visit assessment to ensure safety and community access 1
• Carer training in personal care, communication strategies, physical handling, swallowing safety 1
• Identify physical, emotional, social, and financial needs with interdisciplinary team 1

Community Rehabilitation

• Equally effective whether delivered via outpatient, day hospital, or home-based services 1
• Should be offered to all stroke patients as needed 1

Quality Metrics and System Improvements

• Door-to-imaging time: <25 minutes 1
• Door-to-needle time: <60 minutes for thrombolysis 1
• Stroke unit admission rate: 100% of stroke patients 2
• Participation in registries (e.g., Get With The Guidelines-Stroke) improves care processes and adherence to performance measures 2