What is the management and treatment for a patient who has suffered a stroke?

Management and Treatment of Stroke

Immediate Recognition and Emergency Response

Stroke must be treated as a life-threatening emergency requiring immediate activation of emergency medical services (EMS) through 9-1-1, with the goal of initiating treatment within minutes to hours of symptom onset. 1, 2

• EMS personnel should use validated stroke screening tools (such as the FAST mnemonic: Face drooping, Arm weakness, Speech difficulty, Time to call 911) to rapidly identify stroke patients in the field 1, 3
• Paramedics must document the exact time of symptom onset (or last known well time), current medications, and medical history while minimizing on-scene time 1
• Prehospital care should focus on airway, breathing, and circulation (ABCs), with supplemental oxygen administered to maintain oxygen saturation >94% 1, 4
• Establish intravenous access in the field and obtain blood samples for laboratory testing to expedite emergency department evaluation 1
• Blood glucose should be checked immediately in the field; if <60 mg/dL, administer intravenous glucose as hypoglycemia can mimic stroke symptoms 1, 4
• For hypotensive patients (systolic BP <120 mmHg), position the stretcher flat and administer isotonic saline to improve cerebral perfusion 1
• Avoid routine prehospital blood pressure lowering unless systolic BP ≥220 mmHg, and consult medical control for extreme hypertension 1
• Provide advance notification to the receiving hospital to activate the stroke team and prepare for immediate evaluation 1

Emergency Department Assessment and Diagnosis

All patients with suspected stroke must undergo immediate neurological evaluation using the National Institutes of Health Stroke Scale (NIHSS) and urgent brain CT or MRI within 24 hours—ideally within minutes of arrival—to distinguish ischemic from hemorrhagic stroke. 2, 3, 5

Critical Initial Evaluation Steps:

• Perform NIHSS assessment to determine stroke severity and monitor for clinical changes 5
• Obtain non-contrast head CT immediately (goal: within 25 minutes of arrival) to exclude hemorrhage before considering thrombolytic therapy 1
• Essential laboratory tests include: complete blood count, electrolytes, renal function, glucose, cardiac biomarkers, coagulation studies (PT/INR, aPTT), and lipid panel 4, 3
• Obtain 12-lead ECG to identify atrial fibrillation or acute myocardial infarction 4
• Maintain blood pressure <180/105 mmHg if thrombolytic therapy is being considered 2

Urgent CT Indications (if not routinely available): 1

• Depressed level of consciousness of uncertain cause
• Suspected subarachnoid hemorrhage or cerebellar hematoma
• Diagnostic uncertainty requiring exclusion of subdural hematoma or space-occupying lesion
• Planning anticoagulation or thrombolytic therapy
• Worsening neurological deficits
• History or clinical findings suggesting trauma
• Ongoing seizures
• Stroke occurring while on anticoagulation

Acute Reperfusion Therapy for Ischemic Stroke

Intravenous alteplase (recombinant tissue plasminogen activator, rtPA) at 0.9 mg/kg (maximum 90 mg) is strongly recommended for eligible patients within 3-4.5 hours of symptom onset, as this is the most time-sensitive intervention with proven mortality benefit. 1, 2, 6

Thrombolytic Therapy Protocol:

• Administer 10% of total dose as bolus over 1 minute, followed by remaining 90% as infusion over 60 minutes 1
• Strict adherence to NINDS selection criteria is mandatory for safe rtPA use 1
• Blood pressure must be maintained <180/105 mmHg during and for 24 hours after thrombolytic administration to prevent hemorrhagic transformation 2
• Avoid sublingual nifedipine and other agents causing precipitous blood pressure drops 3
• Do not administer aspirin, heparin, or other antithrombotic agents for 24 hours after rtPA 1
• Leukocytosis alone is not a contraindication to thrombolytic therapy 4

Alternative Reperfusion Options:

• Intra-arterial thrombolysis may be considered for patients presenting beyond 3 hours, though patient selection criteria and effectiveness are not fully established 1
• Endovascular thrombectomy should be considered for large vessel occlusions presenting within 24 hours of last known well 5

Blood Pressure Management

Avoid antihypertensive treatment in acute ischemic stroke unless systolic BP >220 mmHg or diastolic BP >120 mmHg, as lowering blood pressure can worsen cerebral perfusion and outcomes. 4, 3

• For patients NOT receiving thrombolytic therapy: treat only if systolic BP >220 mmHg or diastolic BP >120 mmHg 1, 4
• For patients RECEIVING thrombolytic therapy: maintain BP <180/105 mmHg during and for 24 hours after treatment 2
• Use short-acting intravenous agents (labetalol, nicardipine) with minimal cerebral vascular effects if treatment is required 4
• Avoid oral sublingual agents that cause unpredictable, precipitous drops in blood pressure 3

Early Antithrombotic Therapy

Aspirin 160-300 mg should be administered within 48 hours of acute ischemic stroke onset (but not within 24 hours of thrombolytic therapy) as this reduces recurrent stroke risk without increasing hemorrhagic complications. 1, 2, 3

• Aspirin provides reasonable safety with modest benefit for early secondary prevention 1
• Urgent anticoagulation with heparin is NOT recommended as standard acute treatment due to increased bleeding risk without proven benefit in reducing early recurrent stroke 1, 3
• Exception: anticoagulation may be considered for cerebral venous thrombosis 2

Stroke Unit Care

All stroke patients should be admitted to a geographically defined stroke unit with an interdisciplinary specialized team, as this reduces death by 24%, death or institutionalization by 24%, and death or dependency by 20% compared to general medical ward care. 2, 3

Key Features of Stroke Units:

• Geographically defined beds occupied exclusively by stroke patients 2
• Interdisciplinary team including physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with stroke expertise 2, 3
• Standardized protocols for monitoring and managing complications 3
• Early mobilization and rehabilitation initiated within 24-48 hours 3

Prevention and Management of Complications

Neurological Complications:

Do NOT administer corticosteroids for cerebral edema, as they are ineffective and potentially harmful. 2

• For patients with deterioration from cerebral edema, administer osmotic therapy (mannitol 0.25-0.5 g/kg IV or hypertonic saline 3%) 2
• Consider hyperventilation (target PaCO2 30-35 mmHg) as a temporizing measure for increased intracranial pressure 2
• Hemicraniectomy within 48 hours substantially reduces death and disability in selected patients (age 18-60 years) with extensive hemispheric infarcts 3
• Do NOT administer prophylactic anticonvulsants to patients without seizures 1

Respiratory Complications:

• Perform swallowing assessment using validated tools before allowing ANY oral intake to prevent aspiration pneumonia 4, 3
• Pneumonia is a leading cause of post-stroke mortality and requires immediate antibiotic therapy when identified 4
• Maintain oxygen saturation >94% with supplemental oxygen as needed 1, 4

Metabolic Management:

• Correct hypoglycemia immediately as it can mimic stroke symptoms and cause brain injury 4
• Lower markedly elevated glucose to <300 mg/dL (ideally <180 mg/dL), but avoid overly aggressive treatment causing fluid shifts 4, 7
• Glucose levels >8 mmol/L (144 mg/dL) predict poor prognosis and should be treated 7
• Use isotonic saline for hydration; avoid excessive dextrose-containing fluids that can exacerbate cerebral injury 1

Temperature Management:

• Treat fever aggressively as hyperthermia worsens stroke outcomes 7
• Fever should prompt immediate search for infection, particularly pneumonia and urinary tract infection 4

Venous Thromboembolism Prevention:

• Administer subcutaneous anticoagulants (low-molecular-weight heparin or unfractionated heparin 5000 units twice daily) or use intermittent external compression stockings for immobilized patients 4, 3
• Avoid indwelling bladder catheters when possible due to infection risk 3

Nutrition Support:

• Assess swallowing function before oral intake 3
• Insert nasogastric or nasoduodenal tube for feeding and medication administration if swallowing is unsafe 3
• Consider percutaneous endoscopic gastrostomy (PEG) tube if prolonged feeding support (>2-3 weeks) is anticipated 3

Monitoring and Assessment

Perform frequent neurological assessments using standardized stroke severity scales (NIHSS) during the first 24-48 hours, as approximately 25% of stroke patients deteriorate during this period. 4

• Repeat urgent brain CT or MRI if patient's condition deteriorates 3
• Continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation 5
• Monitor blood pressure, oxygen saturation, temperature, and glucose closely 7

Early Rehabilitation

Early mobilization and comprehensive rehabilitation should begin within 24-48 hours of stroke onset to prevent complications and optimize functional recovery. 3

• Assess and manage mobility, activities of daily living, incontinence, and mood early after stroke 3
• Speech-language pathologists should evaluate all patients for communication and swallowing difficulties 3
• Physical and occupational therapy should begin as soon as medically stable 1
• For patients requiring intensive rehabilitation (needing three or more therapy modalities or unable to transfer independently), inpatient rehabilitation is preferable 1

Secondary Prevention Evaluation

While in the acute phase, initiate evaluation to determine stroke etiology and begin secondary prevention strategies. 1, 3

• Perform carotid duplex ultrasound urgently for patients with carotid territory symptoms who are potential candidates for revascularization 3
• Obtain transthoracic echocardiography (or transesophageal if indicated) to identify cardioembolic sources 5
• Continue statin therapy for patients already taking statins at stroke onset 3
• Address modifiable risk factors including hypertension, diabetes, hyperlipidemia, and smoking cessation 3

Management of Hemorrhagic Stroke

For patients with intracerebral hemorrhage (ICH):

• Urgently reverse anticoagulation if ICH is due to anticoagulant therapy 3
• Lower blood pressure to keep mean arterial pressure <130 mmHg in patients with history of hypertension 3
• Consider surgical intervention for superficial ICH <1 cm from surface or cerebellar hemorrhage causing brainstem compression and hydrocephalus 3
• Osmotic therapy and management of increased intracranial pressure as needed 3

Systems of Care and Quality Improvement

Transport to Primary Stroke Centers reduces 30-day mortality and increases thrombolytic therapy use compared to non-designated hospitals. 2

• Establish written hospital protocols defining processes and responsibilities for stroke care 3
• Participate in quality improvement programs (such as Get With The Guidelines-Stroke) to improve care processes and adherence to performance measures 2
• Monitor metrics including stroke alert response times, imaging acquisition times, treatment rates, door-to-needle times, and outcomes 3
• Regional or local organized programs to expedite stroke care increase the number of patients who can be treated 1

Common Pitfalls to Avoid

• Do NOT delay treatment waiting for "perfect" conditions—time is brain tissue, and every minute counts 8, 6
• Do NOT use intravenous streptokinase or other thrombolytic agents as substitutes for rtPA 1
• Do NOT administer neuroprotective agents, as none have demonstrated efficacy in improving outcomes 1, 3
• Do NOT lower blood pressure aggressively in acute ischemic stroke unless meeting specific thresholds 4, 3
• Do NOT give aspirin or anticoagulants within 24 hours of thrombolytic therapy 1
• Do NOT allow oral intake before formal swallowing assessment 4, 3