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

Management and Treatment of Stroke

Immediate Recognition and Emergency Response

Stroke must be treated as a life-threatening emergency requiring immediate activation of emergency medical services (EMS) through 911, as time-sensitive interventions within the first hours directly determine brain tissue survival and patient outcomes. 1, 2

Prehospital Phase

• EMS personnel should use validated stroke screening tools (such as the FAST mnemonic: Face drooping, Arm weakness, Speech difficulty, Time to call 911) to rapidly identify stroke patients 1, 3
• Critical information must be obtained including exact symptom onset time, current medications (especially anticoagulants), and medical history while minimizing on-scene time 1
• Supplemental oxygen should be administered to maintain oxygen saturation >94% 1, 4
• Intravenous access should be established in the field with blood samples obtained for laboratory testing 1
• Blood glucose must be checked immediately; if <60 mg/dL, intravenous glucose should be administered as hypoglycemia can mimic stroke symptoms 1, 4
• For hypotensive patients (systolic BP <120 mmHg), position the patient flat and administer isotonic saline 1
• Transport should be to a designated Primary Stroke Center or comprehensive stroke unit, as this reduces 30-day mortality compared to non-designated hospitals 2
• Prehospital notification to the receiving hospital is essential to expedite evaluation and treatment 1

Emergency Department Assessment (Door-to-Decision)

All suspected stroke patients require immediate neurological evaluation using the National Institutes of Health Stroke Scale (NIHSS) and urgent brain CT or MRI within 24 hours—ideally within minutes of arrival—to distinguish ischemic from hemorrhagic stroke. 2, 3

Initial Stabilization

• Airway, breathing, and circulation (ABCs) must be assessed and secured, particularly in seriously ill or comatose patients 1, 4
• Most acute ischemic stroke patients do not require emergency airway management unless they cannot protect their airway 1

Essential Diagnostic Workup

• Brain imaging (CT or MRI) is the single most critical test and must be obtained immediately 1, 2, 3
• Complete blood count, electrolytes, renal function, glucose, cardiac biomarkers, coagulation studies (PT/INR, aPTT), and ECG 4, 3
• For patients with carotid territory symptoms who are potential candidates for carotid revascularization, urgent carotid duplex ultrasound is indicated 3

Blood Pressure Management

Antihypertensive treatment should be avoided unless systolic BP >220 mmHg or diastolic >120 mmHg, as lowering blood pressure may worsen cerebral perfusion in acute ischemic stroke. 4, 3, 5

• If thrombolytic therapy is planned, blood pressure must be reduced to systolic <180 mmHg and diastolic <105 mmHg before and maintained for 24 hours after rtPA administration 2, 5
• Use short-acting agents (labetalol, nicardipine) with minimal cerebral vascular effects if treatment is required 4
• Avoid sublingual nifedipine and agents causing precipitous blood pressure drops 3

Acute Reperfusion Therapy for Ischemic Stroke

Intravenous alteplase (rtPA) at 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 to eligible patients. 1, 2, 4

rtPA Administration Protocol

• Safe use requires strict adherence to NINDS selection criteria 1
• Leukocytosis alone is not a contraindication to thrombolytic therapy 4
• Blood pressure must be maintained <180/105 mmHg during and for 24 hours after administration to prevent hemorrhagic transformation 2
• Close observation and careful ancillary care are mandatory 1
• Intravenous streptokinase or other thrombolytic agents cannot be safely substituted for rtPA 1

Intra-arterial Thrombolysis

• May be considered for selected patients beyond the 3-hour window, though patient selection criteria and effectiveness are not fully established 1
• Requires availability of a stroke interventionist and catheter laboratory facilities 1

Antiplatelet Therapy

Aspirin 160-300 mg should be administered within 48 hours of acute ischemic stroke onset, as this reduces recurrent stroke risk without increasing hemorrhagic complications. 2, 3

• Aspirin provides reasonable safety with modest benefit 1, 3
• Should not be given within 24 hours of rtPA administration 1

Anticoagulation

Urgent anticoagulation with intravenous unfractionated heparin is not recommended as standard acute treatment due to increased bleeding risk without proven benefit in reducing early recurrent stroke or improving outcomes. 1, 2, 3

• Exception: cerebral venous thrombosis may warrant anticoagulation 2
• For patients with atrial fibrillation requiring long-term anticoagulation, this should be deferred during the acute phase 3

Stroke Unit Care

All stroke patients should be admitted to a geographically defined stroke unit with an interdisciplinary specialized team, as this reduces death by 24%, death or institutionalization by 24%, and death or dependency by 20% compared to general medical ward care. 2, 3

Key Features of Stroke Units

• Interdisciplinary team including physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with stroke expertise 2, 3
• Geographically defined beds occupied exclusively by stroke patients 2
• Standardized protocols for monitoring and managing complications 3

Prevention and Management of Complications

Neurological Monitoring

• Frequent neurological assessments using standardized scales (NIHSS) during the first 24-48 hours, as approximately 25% of patients deteriorate during this period 4
• Repeat brain CT or MRI urgently if the patient's condition deteriorates 3

Cerebral Edema and Increased Intracranial Pressure

• Corticosteroids are not recommended for cerebral edema as they are ineffective and potentially harmful 2
• Osmotic therapy (mannitol or hypertonic saline) should be administered for patients with deterioration from cerebral edema 2, 3
• Hyperventilation may be considered as a temporizing measure 2
• Hemicraniectomy within 48 hours substantially reduces death and disability in selected patients (18-60 years old) with extensive hemispheric infarcts 3

Infection Prevention and Management

Fever after stroke should prompt immediate search for pneumonia, which is a leading cause of post-stroke mortality. 4

• Swallowing assessment using validated tools must be performed before allowing any oral intake to prevent aspiration pneumonia 4, 3
• Early treatment of hyperthermia is essential, as elevated body temperature negatively affects stroke outcome 6
• Appropriate antibiotics should be administered early when infection is identified 4

Deep Vein Thrombosis Prophylaxis

• Subcutaneous anticoagulants (low-molecular-weight heparin or unfractionated heparin) or intermittent external compression stockings for immobilized patients 4, 3
• Indwelling bladder catheters should be avoided when possible due to infection risk 3

Metabolic Management

Hypoglycemia must be corrected immediately as it can mimic stroke symptoms and cause brain injury. 4, 3

• Glucose levels >8 mmol/L (>144 mg/dL) are predictive of poor prognosis and should be treated 6
• Target glucose <300 mg/dL while avoiding overly aggressive treatment that can cause fluid shifts 4
• Insulin therapy in critically ill stroke patients is safe and associated with lower mortality 6

Nutrition and Hydration

• Swallowing assessment is crucial before oral intake 3
• Nasogastric or nasoduodenal tubes for feeding and medication administration when necessary 3
• Percutaneous endoscopic gastric tube placement is superior to nasogastric tube feeding if prolonged support is anticipated 3

Seizure Management

Prophylactic anticonvulsants are not recommended for patients who have had stroke but not seizures. 1

Early Rehabilitation

Early mobilization should begin as soon as medically stable to prevent complications, with assessment and management of mobility, activities of daily living, incontinence, and mood undertaken early after stroke. 3

• Rehabilitation is best performed using an interdisciplinary approach by experts with stroke experience 1
• Speech-language pathologists should evaluate and treat all patients for communication and swallowing difficulties 3
• For patients requiring intensive therapy (three modalities of intervention) or unable to transfer independently, inpatient rehabilitation is recommended 1

Secondary Prevention

Antithrombotic Therapy

• Appropriate therapy based on stroke etiology (aspirin for non-cardioembolic stroke, anticoagulation for atrial fibrillation) 3
• For patients already on statins at stroke onset, continuation during the acute period is reasonable 3

Risk Factor Management

• Blood pressure and cholesterol management 3
• All modifiable risk factors should be addressed 3

Management of Intracerebral Hemorrhage

For hemorrhagic stroke, anticoagulation-related ICH should be urgently reversed, and blood pressure should be lowered to maintain mean arterial pressure below 130 mmHg in patients with hypertension history. 3

• Surgical intervention (craniotomy for superficial ICH <1 cm from surface, stereotactic surgery for deep ICH) may be considered in specific situations 3
• Surgery is particularly beneficial for cerebellar hemorrhages causing brainstem compression and hydrocephalus 3

Quality Improvement

• In-hospital stroke performance metrics (stroke alerts, response times, imaging acquisition times, treatment rates and times, outcomes) should be examined and used to drive quality improvement efforts 3
• Participation in registries such as Get With The Guidelines-Stroke improves care processes and adherence to performance measures 2

Common Pitfalls to Avoid

• Delaying treatment while obtaining extensive workup—"time is brain" and irreversible tissue loss occurs with every minute of delay 7, 8, 6
• Aggressively lowering blood pressure in acute ischemic stroke without thrombolytic therapy, which can worsen cerebral perfusion 4, 5
• Using prophylactic anticonvulsants without documented seizures 1
• Administering oral intake before formal swallowing assessment 4, 3
• Routine urgent anticoagulation, which increases hemorrhage risk without proven benefit 1, 3