What is the management of stroke?

Management of Stroke

Immediate Recognition and Emergency Response

All suspected stroke patients require immediate activation of emergency medical services with rapid transport to a stroke-capable hospital, as time-critical interventions directly correlate with brain tissue salvage—remember "time is brain." 1

Prehospital Phase

• Emergency medical services should use the FAST mnemonic (Face drooping, Arm weakness, Speech difficulty, Time to call 911) for rapid stroke recognition 1
• Paramedics must obtain exact symptom onset time, current medications, and comorbidities while minimizing on-scene time 1
• Priority dispatch protocols with pre-arrival instructions should be implemented to expedite care 2
• In rural settings, consider air transport and telestroke consultation to overcome geographic barriers 2

Emergency Department Assessment

Initial Evaluation (Within Minutes of Arrival)

• Perform immediate neurological evaluation using the National Institutes of Health Stroke Scale (NIHSS) to assess severity and guide treatment decisions 1, 2
• Obtain urgent brain CT or MRI within 24 hours to distinguish ischemic from hemorrhagic stroke and determine reperfusion therapy eligibility 1, 3
• Monitor and maintain airway, breathing, and circulation—intubate if airway is compromised 3
• Provide supplemental oxygen only if saturation is <94% 3

Critical Pre-Treatment Data

• Document exact symptom onset time (essential for thrombolysis eligibility) 1
• Assess blood pressure, blood glucose, and temperature 4
• Perform swallowing screening within 24 hours using a validated tool before giving food, fluids, or oral medications 3

Acute Reperfusion Therapy for Ischemic Stroke

Intravenous Thrombolysis

Administer intravenous alteplase within 4.5 hours of symptom onset for eligible patients—this is the most time-sensitive intervention with proven mortality benefit. 1, 2

• Maintain blood pressure <180/105 mmHg during and for 24 hours after thrombolytic administration to prevent hemorrhagic transformation 1, 2
• Monitor closely for bleeding complications during the first 24 hours 3

Mechanical Thrombectomy

• Perform mechanical thrombectomy for patients with large vessel occlusion within 6-24 hours according to specific imaging criteria 3
• Combined endovascular approach using stent-retrievers and aspiration achieves the most effective first-pass complete reperfusion 3

Blood Pressure Management

For Ischemic Stroke Patients NOT Receiving Thrombolysis

• Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg, as premature BP reduction may worsen cerebral perfusion 3, 2
• Both high and low blood pressure levels correlate with poor prognosis—stabilization avoiding diastolic pressure falls improves outcomes 4

For Hemorrhagic Stroke

• Lower systolic BP to target of 140 mmHg within 6 hours 2

Metabolic and Physiologic Management

Blood Glucose Control

• Treat glucose levels >8 mmol/l (>144 mg/dL), as hyperglycemia predicts poor prognosis after correcting for age and stroke severity 4
• Insulin therapy in critically ill stroke patients is safe and determines lower mortality and complication rates 4

Temperature Management

• Control body temperature and treat hyperthermia early, as elevated temperature negatively affects stroke outcome 4
• Fever should be actively monitored and managed 3

Hydration and Nutrition

• Maintain adequate hydration, as dehydration may slow recovery and increase deep vein thrombosis risk 3
• Sustain nutrition to optimize recovery 3

Stroke Unit Care

All stroke patients should be admitted to a geographically defined stroke unit with specialized interdisciplinary staff—this intervention reduces death by 24%, death or institutionalization by 24%, and death or dependency by 20% compared to general medical ward care. 1, 3

• The stroke unit team must include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with stroke expertise 1, 2
• Stroke unit care provides mortality and morbidity benefits comparable to thrombolytic therapy 2
• Neurological status and vital signs should be assessed frequently during the first 24 hours 3

Prevention and Management of Complications

Cerebral Edema

• Do NOT use corticosteroids for cerebral edema—they are ineffective and potentially harmful 1, 3
• Administer osmotic therapy (mannitol or hypertonic saline) for patients with deterioration 1, 3
• Consider hyperventilation for patients with deterioration 1

Early Mobilization and Complication Prevention

• Favor early mobilization to lessen complications including pneumonia, deep vein thrombosis, pulmonary embolism, and pressure sores 3
• Implement frequent turning, alternating pressure mattresses, and close skin surveillance to prevent pressure sores 3

Rehabilitation

• Initial assessment by rehabilitation professionals should be performed within 48 hours of admission 3
• Begin rehabilitation therapy as soon as possible once the patient is medically stable 3
• If ongoing inpatient rehabilitation is needed, provide care in either a stroke rehabilitation unit or general rehabilitation unit 3
• Offer rehabilitation in the community (outpatient, day hospital, or home-based) to all stroke patients as needed—community rehabilitation is equally effective as hospital-based 3

Secondary Prevention

Antiplatelet Therapy

Commence aspirin 160-300 mg daily within 48 hours of acute ischemic stroke onset—this early aspirin reduces recurrent stroke risk without increasing hemorrhagic complications. 1, 2

Anticoagulation

• Do NOT use anticoagulation as standard acute treatment for ischemic stroke due to increased bleeding risk without proven benefit 1, 3
• Exception: cerebral venous thrombosis 1

Carotid Intervention

• Perform carotid endarterectomy for patients with recent (within 6 months) non-disabling carotid territory ischemic stroke or TIA with ipsilateral carotid stenosis of 70-99% 3, 2
• Consider carotid endarterectomy for select patients with stenosis of 50-69% 3
• Perform surgery as soon as possible after the event, ideally within 2 weeks 3

Systems of Care and Quality Improvement

Transport Destination

• Transport patients to Primary Stroke Centers when possible—this reduces 30-day mortality and increases thrombolytic therapy use compared to non-designated hospitals 1, 2
• In rural settings, implement telestroke networks to provide remote specialist access for thrombolysis decisions 2
• Support transition of hospitals to certified Acute Stroke Ready Hospital status to expand access 2

Quality Measures

• Participate in Get With The Guidelines-Stroke programs to improve care processes and adherence to performance measures 1, 3
• Participate in stroke registries and quality improvement collaboratives 2
• Use standardized stroke orders or integrated stroke pathways to improve adherence to best practices 3

Common Pitfalls to Avoid

• Never delay treatment to obtain "complete" history—obtain only essential information (symptom onset time, medications, comorbidities) while initiating evaluation 1
• Never lower blood pressure prematurely in ischemic stroke patients not receiving thrombolysis—this worsens cerebral perfusion 2
• Never use corticosteroids for cerebral edema—they cause harm 1
• Never delay imaging—brain CT or MRI must be obtained urgently, as any delay results in progressive, irreversible loss of brain tissue 5
• Never give food, fluids, or oral medications before swallowing screening—perform within 24 hours of admission 3