Initial Management Algorithm for Suspected Stroke
Patients with suspected stroke require immediate emergency triage with the same priority as acute myocardial infarction or serious trauma, followed by rapid stabilization, urgent brain imaging within 25 minutes, and determination of thrombolytic eligibility within 60 minutes of arrival. 1, 2
Prehospital Recognition and Transport
EMS Assessment and Screening
- Use a two-step screening process: First apply FAST (Face, Arm, Speech, Time) assessment, then perform a second validated severity screen for patients showing any FAST signs to identify potential endovascular therapy candidates (looking for aphasia, visual changes, neglect). 1
- Obtain capillary blood glucose measurement on-scene to exclude hypoglycemia as a stroke mimic. 1
- Limit on-scene time to 20 minutes or less for patients within the 4.5-hour treatment window—protocols with specific time limits achieve better scene times than general instructions to "minimize time." 1, 3
- Gather critical information: exact symptom onset time (or time last known well), current medications (especially anticoagulants), and advance directives. 1
- Transport directly to the closest stroke-capable facility with neuroimaging and thrombolysis capacity, bypassing non-stroke centers. 1
Emergency Department Immediate Actions (First 10 Minutes)
Stabilization and Stroke Team Activation
- Assess and stabilize ABCs (airway, breathing, circulation) immediately upon arrival, with particular attention to airway protection in posterior circulation strokes. 1, 2, 4
- Activate stroke team/pathway notification immediately—do not wait for imaging confirmation. 1, 4
- Monitor cardiac rhythm as arrhythmias frequently accompany stroke. 4
- Check vital signs every 30 minutes while in ED (every 15 minutes during thrombolytic infusion). 2, 4
- Treat fever >99.6°F (37.5°C) as hyperthermia worsens outcomes. 2, 4
- Position head of bed at 25-30° unless contraindicated. 4
Critical History Elements
- Establish time of symptom onset (defined as when patient was last at baseline or symptom-free)—this is the single most important piece of information determining treatment eligibility. 1, 2, 4
- Document specific symptoms to localize lesion:
- Note any preceding transient symptoms that resolved (suggesting prior TIA). 4
Diagnostic Workup (Target: Imaging Within 25 Minutes)
Urgent Brain Imaging
- Obtain non-contrast CT immediately to exclude hemorrhage and assess for early ischemic changes—this is the rate-limiting step for thrombolytic therapy. 1, 2, 4
- Perform CT angiography from aortic arch to vertex at the time of initial CT when possible to assess both extracranial and intracranial circulation for endovascular therapy planning. 2, 4
- Consider repeat imaging urgently if patient's condition deteriorates. 1
Laboratory Studies (Do Not Delay Imaging)
- Order immediately but do not wait for results before imaging: complete blood count, electrolytes, renal function (creatinine, eGFR), coagulation studies (INR, aPTT), blood glucose. 1, 2, 4
- Additional tests in selected patients: troponin/ECG, lipid panel, erythrocyte sedimentation rate/C-reactive protein. 1
Stroke Mimic Exclusion
High-Priority Differentials to Rule Out
- Hypoglycemia: Check point-of-care glucose immediately (already done by EMS)—low glucose with decreased consciousness suggests mimic. 1, 4
- Seizure with postictal state: History of witnessed seizure activity or known seizure disorder. 1, 4
- Complicated migraine: History of similar events with preceding aura and headache. 1, 4
- Psychogenic: Lack of objective cranial nerve findings, inconsistent examination, non-vascular distribution. 1, 4
- Hypertensive encephalopathy: Severe hypertension with headache, delirium, cerebral edema. 1, 4
Acute Treatment Decision Algorithm
Thrombolytic Eligibility Assessment (Within 60 Minutes of Arrival)
- For patients within 3-4.5 hours of symptom onset: Administer IV tPA 0.9 mg/kg (maximum 90 mg) if no contraindications. 2
- Blood pressure must be <185/110 mmHg before tPA administration—use short-acting IV agents (labetalol, nicardipine) to achieve this target. 2
- Review strict inclusion/exclusion criteria for tPA safety. 2
Blood Pressure Management
- For thrombolytic candidates: Lower BP to <185/110 mmHg before treatment. 2
- For non-thrombolytic patients: Only lower BP if systolic >220 mmHg or diastolic >120 mmHg. 2
- For hemorrhagic stroke with hypertension history: Keep mean arterial pressure <130 mmHg. 1
Early Management Priorities (First 24 Hours)
Complication Prevention
- Perform swallowing screening within 24 hours using a validated tool by trained personnel before any oral intake to prevent aspiration. 2, 4
- Monitor temperature every 4 hours for first 48 hours; initiate cooling measures if >37.5°C. 2
- Treat new-onset seizures with short-acting medications (lorazepam IV) if not self-limiting, but do not use prophylactic anticonvulsants. 2
- Encourage early mobilization and adequate hydration; consider low-molecular-weight heparin for high-risk patients to prevent venous thromboembolism (do not use anti-embolism stockings alone). 2
Neurosurgical Consultation
- Urgent neurosurgical referral for patients with "malignant" middle cerebral artery occlusion or cerebellar hemorrhage—hemicraniectomy within 48 hours substantially reduces death and disability in selected patients (18-60 years) with extensive hemispheric infarcts. 1
Critical Pitfalls to Avoid
- Failure to establish accurate symptom onset time excludes patients from time-sensitive interventions—if unknown, use "last known well" time. 4
- Delaying imaging for laboratory results—CT should be completed within 25 minutes for rtPA-eligible patients. 4
- Missing posterior circulation strokes—these present with atypical symptoms (vertigo, ataxia) and require special airway attention. 4
- Over-reliance on symptom severity—even mild deficits warrant full stroke protocol activation as severity can progress. 1