What is the treatment for a stroke?

Stroke Treatment: A Medical Emergency

Stroke must be treated as a life-threatening emergency requiring immediate IV alteplase (0.9 mg/kg, maximum 90 mg) within 4.5 hours of symptom onset for eligible ischemic stroke patients, combined with mechanical thrombectomy for large vessel occlusions, as this directly reduces mortality and disability. 1, 2

Immediate Recognition and Response

Time is brain tissue—every 30-minute delay in recanalization decreases the probability of good functional outcome by 8-14%. 2, 3

• Activate Emergency Medical Services (EMS) immediately when stroke symptoms are recognized 2
• Patients should be evaluated within 10 minutes of emergency department arrival 1
• Target door-to-needle time of less than 60 minutes for thrombolytic therapy 1

Initial Emergency Assessment

Airway, Breathing, Circulation (ABC)

• Provide airway support and ventilatory assistance for patients with decreased consciousness or bulbar dysfunction 1, 4
• Administer supplemental oxygen to maintain saturation ≥94% 1, 4
• Establish IV access and obtain baseline blood studies (complete blood count, coagulation studies, blood glucose) 1

Urgent Neurological Evaluation

• Use a validated stroke severity scale (NIHSS) to assess neurological deficit 4
• Order emergent non-contrast CT scan of the brain immediately to rule out hemorrhage—this is the most widely used modality because it is time-efficient and effectively excludes hemorrhage 2
• Cardiac monitoring during the first 24 hours to detect atrial fibrillation and life-threatening arrhythmias 1

Acute Reperfusion Therapies

Intravenous Thrombolysis (rtPA)

IV alteplase is strongly recommended for carefully selected patients within 4.5 hours of symptom onset. 5, 1, 2

• Dose: 0.9 mg/kg (maximum 90 mg) given over 60 minutes with initial 10% as bolus 5, 1
• Blood pressure requirements: Must be <185/110 mmHg before administration and maintained <180/105 mmHg for at least 24 hours after treatment 1, 2
• Use labetalol, nicardipine, or clevidipine to lower blood pressure in eligible candidates 2
• Safe use requires strict adherence to NINDS selection criteria, close observation, and careful ancillary care 5

Critical caveat: Intravenous streptokinase or other thrombolytic agents cannot be substituted safely for rtPA 5

Mechanical Thrombectomy

• Recommended for eligible patients with large vessel occlusions (internal carotid artery or MCA-M1) within 6-24 hours 5, 1, 2
• Intra-arterial thrombolysis is an option for basilar artery occlusion, even up to 6-12 hours after symptom onset 4
• Requires immediate access to cerebral angiography and interventional neuroradiology 4

Blood Pressure Management

For Patients Receiving Thrombolysis

• Blood pressure must be carefully controlled as described above to prevent hemorrhagic transformation 5
• Avoid sublingual nifedipine due to rapid absorption and precipitous blood pressure decline 5

For Patients NOT Receiving Thrombolysis

Avoid antihypertensive treatment unless systolic BP is >220 mmHg or diastolic >120 mmHg. 5, 2, 4

• Elevated blood pressure should be lowered cautiously 5
• Use parenteral agents like labetalol that are easily titrated and have minimal vasodilatory effects on cerebral vessels 5
• Emergency treatment is indicated for hypertensive encephalopathy, aortic dissection, acute renal failure, acute pulmonary edema, or acute myocardial infarction 5, 4

Metabolic Management

Glucose Control

• Promptly measure serum glucose and rapidly correct hypoglycemia (<60 mg/dL) as it can cause focal neurological signs mimicking stroke 5, 1
• Treat hyperglycemia to maintain blood glucose between 140-180 mg/dL 1
• Monitor blood glucose regularly and treat hyperglycemia to maintain levels <300 mg/dL 4

Temperature Management

• Identify and treat sources of hyperthermia (temperature >38°C) 1, 4
• Use antipyretics for elevated temperatures 4

Volume Status

• Correct hypovolemia with intravenous normal saline 1, 4
• Optimize cardiac output and correct arrhythmias 5

Stroke Unit Care

Admission to a specialized stroke unit or neurocritical care unit is essential for optimal outcomes. 1

• Comprehensive stroke unit care can be given to a broad spectrum of patients and improves outcomes 5
• Multiprofessional team approach with physicians, nurses, physiotherapists, occupational therapists, speech therapists, neuropsychologists, and social workers 5
• All groups of stroke patients benefit, including hemorrhagic and ischemic stroke, with elderly patients and those with severe stroke benefiting most 5

Early Mobilization and Rehabilitation

• Initial assessment by rehabilitation professionals should be performed within 48 hours of admission 4
• Frequent and brief out-of-bed activity involving active sitting, standing, and walking should begin within 24 hours if no contraindications exist 4
• Rehabilitation therapy should begin as soon as possible once the patient is medically stable 4

Antiplatelet Therapy

Aspirin can be administered within the first 48 hours because of reasonable safety and a small benefit. 5

• For secondary prevention after TIA and minor stroke, aspirin is effective in reducing stroke risk 2
• Urgent administration of anticoagulants has not been associated with lessening the risk of early recurrent stroke and can increase the risk of brain hemorrhage, especially among patients with moderately severe strokes—routine use cannot be recommended 5

Complication Management

Cerebral Edema and Increased Intracranial Pressure

• Corticosteroids are NOT recommended 2, 4
• Osmotic therapy and hyperventilation are recommended for patients who deteriorate 4
• Surgical decompression may be necessary for large cerebellar infarcts causing brainstem compression and hydrocephalus 4

Seizures

• Administration of anticonvulsants to patients who have had stroke but not seizures is not recommended 5
• Treat new-onset seizures with appropriate short-acting medications (e.g., lorazepam IV) if not self-limiting 4

Systems of Care

• Hospitals should function as primary stroke centers or have pre-established transfer protocols to appropriate stroke centers 1
• Telemedicine can extend stroke expertise to underserved areas 1
• Standardized stroke orders or integrated stroke pathways improve adherence to best practices 1
• Regional or local organized programs to expedite stroke care are recommended 5

Common Pitfalls to Avoid

• Delays in recognition and treatment: Every delay results in progressive, irreversible loss of brain tissue 3
• Overly selective treatment criteria: May exclude patients who could benefit from therapy 4
• Inadequate blood pressure control before thrombolysis: Increases risk of hemorrhage 4
• Failure to monitor complications: Swallowing difficulties, infections, and venous thromboembolism can worsen outcomes 4
• Using sublingual nifedipine: Causes precipitous blood pressure decline 5

Secondary Prevention Considerations

• Identify stroke etiology to guide secondary prevention strategies 2
• For patients with nonvalvular atrial fibrillation who are candidates for anticoagulation, warfarin with target INR 2.0-3.0 is the drug of choice 2
• Evaluation to determine the most likely cause should lead to institution of medical or surgical therapies to lessen the risk of recurrent stroke 5