What is the initial treatment for a suspected stroke (cerebrovascular accident, CVA)?

Initial Treatment for Suspected Stroke (CVA)

Patients with suspected stroke must be treated as a medical emergency equivalent to acute myocardial infarction, with immediate focus on airway-breathing-circulation (ABC) stabilization, rapid neurological assessment, and urgent brain imaging to differentiate ischemic from hemorrhagic stroke—all while simultaneously determining eligibility for time-sensitive reperfusion therapies. 1

Immediate Stabilization and Assessment

Primary Survey (First Minutes)

• Assess and secure airway, breathing, and circulation immediately upon patient contact, as this takes absolute priority 2, 1
• Tracheal intubation is indicated for compromised airway or insufficient ventilation due to impaired alertness or bulbar dysfunction 2
• Provide supplemental oxygen to maintain oxygen saturation ≥94% 2, 1
• Correct hypotension and hypovolemia to maintain systemic perfusion necessary to support organ function 2, 1

Critical Time Determination

• The single most important piece of information is the exact time of symptom onset, defined as when the patient was last known to be at their baseline neurological state 1
• This determines eligibility for all time-sensitive interventions including thrombolysis (up to 4.5 hours) and mechanical thrombectomy (up to 24 hours in selected cases) 2

Rapid Neurological Evaluation

• Perform immediate neurological examination using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity 2
• Document vital signs including heart rate, rhythm, blood pressure, temperature, and oxygen saturation 2
• Initiate cardiac monitoring to detect atrial fibrillation and other potentially serious arrhythmias 2, 1

Urgent Diagnostic Studies

Brain Imaging (Cannot Be Delayed)

• Obtain non-contrast CT brain imaging immediately upon hospital arrival and before any specific stroke treatment 2, 1
• The CT scan should be completed within 25 minutes for patients potentially eligible for thrombolysis 2
• This imaging is essential to differentiate ischemic stroke from hemorrhagic stroke, as management differs fundamentally 2, 1

Vascular Imaging

• Perform CT angiography (CTA) from aortic arch to vertex immediately to identify large vessel occlusions that may benefit from mechanical thrombectomy 2
• For patients presenting 6-24 hours from symptom onset with suspected large vessel occlusion, obtain advanced imaging (CT perfusion or diffusion-weighted MRI) to determine thrombectomy eligibility 2

Point-of-Care Testing

• Check capillary blood glucose immediately—hypoglycemia (glucose <60 mg/dL or 3.3 mmol/L) must be treated urgently with IV dextrose as it mimics stroke 2, 1
• Obtain ECG without delay 2, 1

Laboratory Studies (Should Not Delay Treatment)

• Draw blood for complete blood count, electrolytes, coagulation studies (INR, aPTT), creatinine, and troponin 2, 1
• These tests should NOT delay imaging or initiation of reperfusion therapy 2
• Only blood glucose measurement must precede IV thrombolysis 2

Blood Pressure Management

For Thrombolysis Candidates (Ischemic Stroke)

• Lower blood pressure to <185/110 mmHg before initiating IV thrombolysis to reduce hemorrhagic complications 2, 1
• After thrombolysis, maintain blood pressure <180/105 mmHg for at least 24 hours 1, 3
• Monitor blood pressure every 15 minutes during the 60-minute thrombolysis infusion, then every 30 minutes for 6 hours, then hourly for 16 hours 2, 3

For Non-Thrombolysis Candidates (Ischemic Stroke)

• Only lower blood pressure when systolic exceeds 220 mmHg or diastolic exceeds 120 mmHg 2
• Avoid precipitous drops in blood pressure as this may worsen cerebral ischemia by decreasing perfusion pressure 2

For Hemorrhagic Stroke

• In spontaneous intracerebral hemorrhage presenting within 6 hours, reduce systolic blood pressure acutely to a target of 140 mmHg (strictly avoiding systolic <110 mmHg) 1

Specific Interventions by Stroke Type

Ischemic Stroke

• Administer IV alteplase (0.9 mg/kg, maximum 90 mg) as soon as possible if patient presents within 4.5 hours of symptom onset and meets eligibility criteria 2, 1
• Do NOT wait to evaluate response to thrombolysis before proceeding with mechanical thrombectomy if large vessel occlusion is identified 2
• Administer aspirin 160-300 mg/day within 48 hours of stroke onset, but generally wait 24 hours after thrombolysis 1

Hemorrhagic Stroke

• Immediately discontinue and reverse anticoagulation in anticoagulant-associated intracerebral hemorrhage 1
• Place external ventricular drain if hydrocefalia develops with decreased level of consciousness 1

Additional Acute Management

Temperature Control

• Monitor temperature every 4 hours or more frequently as needed 2
• Treat fever >38°C (>99.6°F) with acetaminophen as hyperthermia worsens stroke outcomes 2, 1

Seizure Management

• Treat new-onset seizures at stroke onset with short-acting medications (e.g., lorazepam IV) if not self-limited 2
• Do NOT use prophylactic anticonvulsants—there is no evidence of benefit and possible harm to neural recovery 2
• A single self-limiting seizure within 24 hours should not be treated with long-term anticonvulsants 2

Positioning and Aspiration Prevention

• Keep patients NPO (nothing by mouth) until formal swallowing screen is completed to prevent aspiration pneumonia 3
• Head positioning should be individualized but traditionally 25-30° elevation is used when increased intracranial pressure is suspected 2

Early Mobilization

• Initiate gradual early mobilization as tolerated 1

Critical Pitfalls to Avoid

• Do not delay imaging or treatment to obtain "complete" laboratory results—only glucose measurement is mandatory before thrombolysis 2
• Do not aggressively lower blood pressure in ischemic stroke patients not receiving thrombolysis—this may worsen cerebral ischemia 2
• Do not assume all neurological deficits are stroke—hypoglycemia is a critical mimic that requires immediate glucose measurement and correction 2, 1
• Do not transport suspected stroke patients to hospitals without stroke treatment capabilities when stroke centers are accessible 1