What is the best management approach for a patient with a brain stem stroke and left hemiparesis?

Management of Brainstem Stroke with Left Hemiparesis

For a patient with brainstem stroke and left hemiparesis, immediate admission to an intensive care or stroke unit with continuous neuromonitoring is essential, followed by strict NPO status until dysphagia screening, early mobilization within 24 hours if medically stable, and aggressive prevention of secondary complications including aspiration pneumonia, deep vein thrombosis, and neurological deterioration. 1

Immediate Triage and Monitoring

• Transfer immediately to an intensive care unit or dedicated stroke unit with neuromonitoring capabilities, as brainstem strokes carry high risk for rapid deterioration and require multidisciplinary care from neurologists, neurointensivists, and neurosurgeons 1, 2
• Establish continuous cardiac monitoring for at least 24-48 hours to detect arrhythmias, particularly atrial fibrillation, which may compromise cerebral perfusion 1
• Monitor vital signs every 4 hours for the first 48 hours: call physician if systolic BP >185 or <110 mm Hg, diastolic BP >105 or <60 mm Hg, pulse <50 or >110/min, respirations >24/min, or temperature >99.6°F 1
• Maintain oxygen saturation ≥92% with supplemental oxygen at 2-3 L/min via nasal cannula if needed 1

Airway and Aspiration Prevention

• Keep patient strictly NPO (nothing by mouth) including all oral medications until formal dysphagia screening is completed by trained personnel, as dysphagia occurs in 40-78% of acute stroke patients and brainstem location is a high-risk feature for prolonged dysphagia 3, 1
• Perform dysphagia screening within 4 hours of hospital arrival using a validated screening tool; if screening cannot be completed within 4 hours, maintain NPO status and provide IV fluids for hydration 3, 1
• Elevate head of bed at least 30° to reduce aspiration risk, particularly given the hemiparesis and potential for impaired swallowing 1
• Position patient on the paretic (left) side when possible to facilitate communication and further prevent aspiration 1

If Dysphagia Screening is Failed:

• Maintain strict NPO status and refer immediately for comprehensive swallowing evaluation by speech-language pathologist within 24 hours 3
• For anticipated dysphagia <7 days: maintain IV hydration only 3
• For anticipated dysphagia 7-14 days: insert nasogastric tube for enteral nutrition 3
• For anticipated dysphagia >14 days: consider percutaneous endoscopic gastrostomy (PEG) tube placement 3

Positioning and Early Mobilization

• Begin initial rehabilitation assessment by rehabilitation professionals within 48 hours of admission 1
• Initiate frequent, brief out-of-bed activity involving active sitting, standing, and walking within 24 hours of stroke onset if there are no contraindications such as hemodynamic instability or severe neurological impairment 1
• Keep neck straight and avoid slumped sitting to maintain airway patency and prevent hypoxia 1
• Bed rest is appropriate initially, but transition to mobilization as soon as medically stable 1

Fluid and Metabolic Management

• Establish 2-3 IV sites for fluid administration, medications, and potential thrombolytic therapy if within treatment window 1
• Administer normal saline at 75-100 mL/h to maintain normovolemia; avoid glucose-containing solutions (D5W) as hyperglycemia worsens stroke outcomes 1, 4
• Treat blood glucose levels >8 mmol/L (>144 mg/dL) aggressively with insulin therapy, as elevated glucose is predictive of poor prognosis even after correcting for age and stroke severity 4
• Correct hypovolemia with isotonic fluids 1
• Monitor intake and output closely 1

Temperature Management

• Monitor temperature every 4 hours for the first 48 hours 1
• For temperature >37.5°C, increase monitoring frequency, initiate temperature-reducing measures, investigate for infection (pneumonia, UTI), and administer antipyretics as hyperthermia negatively affects stroke outcome 1, 4
• Treat infections promptly with appropriate antibiotics, as pneumonia and urinary tract infections are common complications 1

Blood Pressure Management

• Avoid aggressive blood pressure lowering unless systolic BP >220 mm Hg or diastolic BP >120 mm Hg, as both very high and very low blood pressure are associated with poor prognosis 1, 4
• Avoid antihypertensive agents that induce cerebral vasodilation, particularly in patients at risk for increased intracranial pressure 1
• Blood pressure stabilization and avoiding falls in diastolic pressure are associated with better prognosis 4

Prevention of Venous Thromboembolism

• Initiate pharmacological VTE prophylaxis with low-molecular-weight heparin or unfractionated heparin (for renal failure) within 24 hours for immobilized patients 1
• Combine with intermittent pneumatic compression devices 1
• Do not use anti-embolism stockings alone, as they are ineffective 1
• Encourage early mobilization and adequate hydration to help prevent VTE 1

Monitoring for Neurological Deterioration

• Assess for signs of brainstem compression or herniation: declining Glasgow Coma Scale score, pupillary changes, worsening hemiparesis, or new cranial nerve deficits 1
• Brainstem strokes can deteriorate rapidly due to edema (peaks 3-5 days), hemorrhagic transformation, or progressive ischemia 1, 5
• Obtain repeat brain CT or MRI at 24-48 hours after stroke or sooner if clinical deterioration occurs 1
• Neurosurgical consultation should be obtained early if there is risk of cerebellar infarction with mass effect, as decompressive surgery may be lifesaving 1

Seizure Management

• Do not use prophylactic anticonvulsants, as they are not recommended and may negatively affect neurological recovery 1
• If seizures occur, treat with short-acting medications (e.g., lorazepam IV) if not self-limiting 1
• A single self-limiting seizure within 24 hours should not be treated with long-term anticonvulsants 1

Antithrombotic Therapy

• Hold aspirin, clopidogrel, heparin, and warfarin for 24 hours if thrombolytic therapy was administered, then start antithrombotic therapy as ordered 1
• If thrombolytic therapy was not given, initiate aspirin 100-300 mg within the first 24 hours of hospital admission 1
• If craniectomy is likely, avoid antiplatelet agents until surgical decision is finalized 1

Common Pitfalls to Avoid

• Do not assume preserved gag reflex means safe swallowing—many patients with intact gag reflexes still aspirate, and gag reflex testing is unreliable 3
• Do not delay dysphagia screening beyond 4 hours, as early screening reduces aspiration pneumonia risk 3
• Do not use glucose-containing IV fluids, as hyperglycemia worsens secondary brain injury 1, 4
• Do not aggressively lower blood pressure unless severely elevated, as this may worsen cerebral perfusion in the acute phase 1, 4
• Do not overlook cardiac monitoring, as arrhythmias can compromise cerebral perfusion and worsen outcomes 1