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

Management of Acute Stroke

All stroke patients require immediate emergency evaluation and treatment within minutes of symptom onset, with intravenous alteplase (0.9 mg/kg, maximum 90 mg) administered within 3-4.5 hours for eligible ischemic stroke patients, followed by admission to a specialized stroke unit. 1

Prehospital Emergency Response

• Emergency Medical Services (EMS) must be activated immediately via 9-1-1 when stroke symptoms are identified using the FAST mnemonic (Face drooping, Arm weakness, Speech difficulty, Time to call 911) 2
• Paramedics should obtain exact symptom onset time, current medications, and comorbidities while minimizing on-scene time to under 15 minutes 2
• Supplemental oxygen should be administered to maintain oxygen saturation >94% 2, 1
• Prehospital glucose testing is critical, with intravenous glucose administered if blood glucose is <60 mg/dL 2
• For hypotensive patients (systolic BP <120 mmHg), position the stretcher flat and administer isotonic saline 2
• Establish intravenous access in the field and obtain blood samples for laboratory testing to expedite emergency department evaluation 2
• Provide advance notification to receiving hospital to activate stroke team and prepare for immediate imaging 2

Emergency Department Assessment and Triage

• Immediate triage to high-acuity area upon arrival with goal of door-to-imaging time <25 minutes 2
• Perform National Institutes of Health Stroke Scale (NIHSS) evaluation immediately to assess stroke severity 1, 3
• Obtain urgent non-contrast CT or MRI brain imaging within 20 minutes of arrival to distinguish ischemic from hemorrhagic stroke 2, 1
• Essential laboratory investigations include complete blood count, electrolytes, renal function, glucose, cardiac biomarkers, coagulation studies (PT/INR, aPTT), and ECG 1, 4
• Correct hypoglycemia immediately as it can mimic stroke symptoms and cause brain injury 5, 6

Blood Pressure Management

Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg in patients not receiving thrombolytic therapy. 2, 1, 5

• For patients eligible for thrombolysis, blood pressure must be lowered to <185/110 mmHg before treatment and maintained <180/105 mmHg for 24 hours after alteplase administration 1
• Use short-acting intravenous agents (labetalol, nicardipine) with minimal cerebral vascular effects when treatment is required 5
• Avoid sublingual nifedipine and agents causing precipitous blood pressure drops, as these can worsen cerebral perfusion 4
• Hypotension (systolic BP <120 mmHg) should be treated with isotonic saline to maintain cerebral perfusion pressure 2

Acute Reperfusion Therapy for Ischemic Stroke

Intravenous alteplase (0.9 mg/kg, maximum 90 mg) is the most time-sensitive intervention with proven mortality benefit and must be administered within 3-4.5 hours of symptom onset for eligible patients. 2, 1

• Administer 10% of total dose as bolus over 1 minute, followed by remaining 90% as infusion over 60 minutes 2
• Safe use requires strict adherence to NINDS inclusion/exclusion criteria and close monitoring for hemorrhagic complications 2
• Do not substitute streptokinase or other thrombolytic agents for alteplase, as they are not safe alternatives 2
• Intra-arterial thrombolysis may be considered for patients presenting beyond 3-4.5 hours with large vessel occlusions, though patient selection criteria are not fully established 2
• Endovascular thrombectomy should be considered for patients with large vessel occlusions presenting within 24 hours of last known well 3

Antiplatelet and Anticoagulation Therapy

• Aspirin 160-300 mg should be administered within 48 hours of acute ischemic stroke onset (after thrombolysis is completed or excluded) to reduce recurrent stroke risk 2, 1, 4
• Urgent anticoagulation with heparin is not recommended as standard acute treatment due to increased bleeding risk without proven benefit 2, 4
• Do not administer aspirin or anticoagulants within 24 hours after alteplase administration 2
• For atrial fibrillation patients requiring long-term anticoagulation, warfarin (target INR 2.0-3.0) or direct oral anticoagulants should be initiated after the acute period 7, 8

Stroke Unit Care

All stroke patients must be admitted to a geographically defined stroke unit with specialized interdisciplinary staff, as this reduces death by 24%, death or institutionalization by 24%, and death or dependency by 20% compared to general medical ward care. 1, 4

• The stroke unit team must include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with stroke expertise 1, 4
• Comprehensive stroke unit care incorporating early rehabilitation should begin immediately upon admission 2, 4
• Transport to Primary Stroke Centers reduces 30-day mortality and increases thrombolytic therapy use compared to non-designated hospitals 1

Prevention and Management of Acute Complications

Airway and Respiratory Management

• Protect airway in seriously ill or comatose patients with decreased level of consciousness 2
• Administer supplemental oxygen to maintain saturation >94% 2, 1
• Perform swallowing assessment using validated tools before allowing any oral intake to prevent aspiration pneumonia 5, 4

Cerebral Edema and Increased Intracranial Pressure

• Do not use corticosteroids for cerebral edema, as they are ineffective and potentially harmful 1
• Administer osmotic therapy (mannitol 0.25-0.5 g/kg IV or hypertonic saline 3%) for patients with deterioration from cerebral edema 1, 4
• Consider hyperventilation (target PaCO2 30-35 mmHg) as temporary measure for acute herniation 1
• Hemicraniectomy within 48 hours substantially reduces death and disability in selected patients aged 18-60 years with extensive hemispheric infarcts 4

Seizure Management

• Do not administer prophylactic anticonvulsants to patients who have not had seizures, as this is not recommended 2
• Treat seizures if they occur with standard anticonvulsant therapy 2

Infection Prevention and Treatment

• Fever after stroke should prompt immediate search for pneumonia, which is a leading cause of post-stroke mortality 5
• Administer appropriate antibiotics early when infection is identified 5
• Avoid indwelling bladder catheters when possible due to infection risk 4

Venous Thromboembolism Prevention

• Administer subcutaneous anticoagulants (unfractionated heparin 5000 units SC q8-12h or low-molecular-weight heparin) or use intermittent external compression stockings for DVT prevention in immobilized patients 5, 4
• Begin prophylaxis within 24-48 hours after stroke onset 5

Metabolic Management

• Lower markedly elevated glucose to <180-300 mg/dL while avoiding overly aggressive treatment that can cause fluid shifts 5, 6
• Glucose levels >8 mmol/L (144 mg/dL) predict poor prognosis and should be treated with insulin therapy 6
• Maintain normothermia, as hyperthermia (temperature >37.5°C) worsens stroke outcome and should be treated immediately with antipyretics 5, 6

Nutrition and Hydration

• Perform swallowing assessment before allowing oral intake 4
• Insert nasogastric or nasoduodenal tube for feedings and medication administration when oral intake is unsafe 4
• Consider percutaneous endoscopic gastric tube placement if prolonged feeding support (>2-3 weeks) is anticipated 4

Neurological Monitoring

• Perform frequent neurological assessments using standardized NIHSS during the first 24-48 hours, as approximately 25% of stroke patients deteriorate during this period 5
• Obtain repeat urgent brain CT or MRI when patient's condition deteriorates 4
• Monitor for hemorrhagic transformation, especially in patients who received thrombolytic therapy 2

Early Rehabilitation

• Begin early mobilization within 24-48 hours to prevent complications, though avoid very early intensive mobilization 4
• Assess and manage mobility, activities of daily living, incontinence, and mood early after stroke 4
• Speech-language pathologists should evaluate and treat all stroke patients for communication and swallowing difficulties 4
• The rehabilitation goal is maximum functional recovery with return to premorbid activities when possible 2

Secondary Prevention Evaluation

• Perform carotid duplex ultrasound urgently in all patients with carotid territory symptoms who are potential candidates for carotid revascularization 4
• Obtain transthoracic echocardiography and cardiac telemetry monitoring to identify cardioembolic sources 3
• Measure fasting lipid profile, as statin therapy should be continued during acute period for patients already taking statins 4
• Evaluate for modifiable risk factors including hypertension, diabetes, hyperlipidemia, and atrial fibrillation 4

Management of Hemorrhagic Stroke

• Reverse anticoagulation urgently in patients with intracerebral hemorrhage due to warfarin or other anticoagulants 4
• Lower blood pressure to mean arterial pressure <130 mmHg in patients with history of hypertension 4
• Consider surgical intervention (craniotomy for superficial hemorrhage <1 cm from surface, stereotactic surgery for deep hemorrhage) in selected patients 4
• Surgery is particularly beneficial for cerebellar hemorrhages causing brainstem compression and hydrocephalus 4

Special Considerations

Subarachnoid Hemorrhage

• Consider subarachnoid hemorrhage in patients presenting with sudden severe headache 3
• Perform lumbar puncture if CT is negative but clinical suspicion remains high 3

Cerebellar Stroke

• Evaluate patients with cerebellar symptoms using HINTS examination (head-impulse, nystagmus, test of skew), which is more sensitive than early MRI for cerebellar stroke 3

Quality Improvement

• Participate in Get With The Guidelines-Stroke programs to improve care processes and adherence to performance measures 1
• Monitor metrics including stroke alert response times, imaging acquisition times, door-to-needle times for thrombolysis, and clinical outcomes 4
• Review in-hospital stroke performance data to drive focused quality improvement efforts 4