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

Management and Treatment of Acute Stroke

All stroke patients should be immediately transported to a designated stroke center via EMS with advance notification, undergo urgent brain imaging within 24 hours (ideally immediately), receive IV alteplase within 3-4.5 hours if eligible for ischemic stroke, and be admitted to a specialized stroke unit with interdisciplinary care. 1, 2

Prehospital Emergency Response

Immediate Recognition and EMS Activation:

• Stroke must be recognized as a medical emergency requiring immediate 9-1-1 activation 3, 2
• EMS personnel should use validated stroke screening tools (such as FAST mnemonic: Face drooping, Arm weakness, Speech difficulty, Time to call 911) for rapid assessment 3, 2
• Critical information must be obtained including exact symptom onset time, current medications, and comorbidities while minimizing on-scene time 1
• Advance notification to receiving hospital by EMS shortens time to physician evaluation, brain imaging, and increases thrombolytic use 3

Prehospital Stabilization:

• Assess and manage airway, breathing, and circulation (ABCs) first 3, 1
• Administer supplemental oxygen to maintain saturation >94% 3, 1
• For hypotensive patients (systolic BP <120 mmHg), place stretcher flat and administer isotonic saline 3
• For extreme hypertension (systolic BP ≥220 mmHg), consult medical control before treatment 3
• Perform immediate glucose testing; if <60 mg/dL, administer IV glucose as hypoglycemia can mimic stroke 3, 4
• Establish IV access in the field and obtain blood samples for laboratory testing 3
• Use normal saline for rehydration rather than dextrose-containing fluids in non-hypoglycemic patients 3

Emergency Department Assessment and Management

Immediate Triage and Evaluation:

• Triage immediately to high-acuity area upon arrival 3, 2
• Perform standardized neurological evaluation using the National Institutes of Health Stroke Scale (NIHSS) 1, 4
• Obtain urgent brain CT or MRI within 24 hours of symptom onset, but ideally as soon as possible, to distinguish ischemic from hemorrhagic stroke 1, 2

Essential Diagnostic Workup:

• Complete blood count, electrolytes, renal function, glucose, cardiac biomarkers, ECG, and coagulation studies 4, 2
• Fasting lipids, erythrocyte sedimentation rate and/or C-reactive protein 2
• Urgent carotid duplex ultrasound for all patients with carotid territory symptoms who are potential candidates for carotid revascularization 2

Urgent CT Indications (if not already performed):

• Depressed level of consciousness of uncertain cause 3
• Suspected subarachnoid hemorrhage or cerebellar hematoma 3
• Diagnosis in doubt to exclude subdural hematoma, space-occupying lesion, or stroke mimics 3
• Anticoagulants or thrombolytic therapy planned 3
• Worsening neurological deficits 3
• History or clinical findings suggestive of trauma 3
• Ongoing seizures or stroke on anticoagulation 3

Acute Reperfusion Therapy for Ischemic Stroke

Thrombolytic Therapy:

• Administer IV alteplase (0.9 mg/kg, maximum 90 mg) within 3-4.5 hours of symptom onset for eligible patients—this is the most time-sensitive intervention with proven mortality benefit 1, 4
• Blood pressure must be maintained <180/105 mmHg during and for 24 hours after thrombolytic administration to prevent hemorrhagic transformation 1
• Leukocytosis alone is not a contraindication to thrombolysis 4

Blood Pressure Management:

• Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg 4, 2
• If treatment required, use short-acting agents with minimal cerebral vascular effects 4
• Avoid sublingual nifedipine and agents causing precipitous BP reductions 2

Antiplatelet Therapy:

• Administer aspirin 160-300 mg daily within 48 hours of acute ischemic stroke onset to reduce recurrent stroke risk without increasing hemorrhagic complications 1, 2

Anticoagulation:

• Do not use anticoagulation (e.g., IV unfractionated heparin) as standard acute treatment for ischemic stroke due to increased bleeding risk without proven benefit 2
• Exception: cerebral venous thrombosis 1

Management of Intracerebral Hemorrhage (ICH)

Acute ICH Management:

• Urgently reverse anticoagulation-related ICH 2
• Lower blood pressure in hypertensive ICH patients to keep mean arterial pressure below 130 mmHg 2
• Consider surgical intervention for specific situations: craniotomy for superficial ICH <1 cm from surface, stereotactic surgery for deep ICH 2
• Surgery is particularly beneficial for cerebellar hemorrhages causing brainstem compression and hydrocephalus 2

Stroke Unit Care

Admission to Specialized Stroke Unit:

• All stroke patients should be admitted to a geographically defined stroke unit with specialized interdisciplinary staff—this reduces death by 24%, death or institutionalization by 24%, and death or dependency by 20% compared to general medical ward care 1, 2
• The multidisciplinary team must include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with stroke expertise 1, 2

Prevention and Management of Complications

Cerebral Edema Management:

• Do not use corticosteroids for cerebral edema—they are ineffective and potentially harmful 1
• Administer osmotic therapy (mannitol or hypertonic saline) for patients with deterioration 1
• Consider hyperventilation for increased intracranial pressure 1
• Hemicraniectomy within 48 hours substantially reduces death and disability in selected patients (18-60 years old) with extensive hemispheric infarcts 2

Infection Prevention and Management:

• Perform swallowing assessment using validated tools before allowing any oral intake to prevent aspiration pneumonia 4, 2
• Fever after stroke should prompt immediate search for pneumonia, which is a leading cause of post-stroke mortality 4
• Administer appropriate antibiotics early when infection is identified 4

Venous Thromboembolism Prevention:

• Administer subcutaneous anticoagulants or use intermittent external compression stockings for DVT prevention in immobilized patients 4, 2

Metabolic Management:

• Correct hypoglycemia immediately as it can mimic stroke symptoms and cause brain injury 4, 2
• Lower markedly elevated glucose to <300 mg/dL while avoiding overly aggressive treatment that can cause fluid shifts 4
• Glucose levels >8 mmol/L predict poor prognosis and should be treated 5

Other Complications:

• Avoid indwelling bladder catheters when possible due to infection risk 2
• Actively prevent deep venous thrombosis, pyrexia, pressure ulcers, falls, and pain 2

Monitoring Strategy

Serial Neurological Assessment:

• Perform frequent neurological assessments during the first 24-48 hours as approximately 25% of stroke patients deteriorate during this period 4
• Use standardized stroke severity scales (NIHSS) for serial assessments 4
• Repeat brain CT or MRI urgently when patient's condition deteriorates 2

Rehabilitation

Early Rehabilitation Initiation:

• Begin early mobilization to prevent complications once medically stable 2
• Consult rehabilitation services (physical therapy, occupational therapy, speech-language pathology) as soon as patient is medically stable 3
• Assess mobility, activities of daily living, incontinence, and mood early after stroke 2
• Speech-language pathologists should evaluate and treat all stroke patients for residual communication difficulties 2

Rehabilitation Setting:

• Multidisciplinary assessment using standard procedures should be undertaken for all patients 3
• Inpatient rehabilitation is recommended for patients requiring three modalities of intervention or unable to transfer independently 3
• Early supported discharge with intensive community-based therapy is as effective as continued inpatient rehabilitation for selected patients 3

Functional Assessment:

• Use standardized tools such as the Functional Independence Measure (FIM) to assess aerobic capacity, cognition, balance, continence, gait, motor function, muscle performance, pain, range of motion, and self-care 3

Secondary Prevention

Risk Factor Management:

• Address all modifiable risk factors including blood pressure and cholesterol 2
• Continue statin therapy during acute period for patients already taking statins at stroke onset 2
• Prescribe appropriate antithrombotic therapy based on stroke etiology 2

Quality Improvement and Systems of Care

Transport and Hospital Systems:

• Transport to Primary Stroke Centers reduces 30-day mortality and increases thrombolytic therapy use compared to non-designated hospitals 1
• Written hospital protocols defining processes and responsibilities should be established 2
• Participation in Get With The Guidelines-Stroke programs improves care processes and adherence to performance measures 1

Performance Monitoring:

• Examine in-hospital stroke performance and quality data to drive focused quality improvement efforts 2
• Review metrics including stroke alerts, true stroke rates with subtypes, response times, imaging acquisition times, treatment rates, treatment times, and outcomes 2
• Report all stroke cases to a registry to monitor true incidence and provide data for future research 2

Common Pitfall: Delaying treatment while awaiting complete diagnostic workup—evaluation and treatment should proceed simultaneously in acute stroke, as time is critical for brain tissue survival 6, 7, 8