What is the medical management of a stroke patient?

Medical Management of Acute Ischemic Stroke

All stroke patients should be immediately admitted to a specialized stroke unit with interdisciplinary care, as this intervention alone reduces mortality and disability comparable to thrombolytic therapy. 1, 2

Immediate Assessment and Stabilization

Airway, Breathing, and Circulation

• Provide airway support and ventilatory assistance for patients with decreased consciousness (Glasgow Coma Scale <8) or bulbar dysfunction to prevent aspiration 2, 3
• Maintain adequate oxygenation with supplemental oxygen if oxygen saturation falls below 94% 1
• Assess and stabilize hemodynamic status, correcting hypovolemia with normal saline and treating cardiac arrhythmias 1

Neurological Monitoring

• Perform serial neurological examinations and vital sign assessments every 15 minutes during the first 2 hours, then hourly for 6 hours, then every 4 hours for 16 hours 1
• Institute continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation and other arrhythmias 1, 2
• Monitor closely for signs of brain edema, increased intracranial pressure, and herniation syndromes, particularly in patients with large hemispheric or cerebellar infarctions 2, 3

Blood Pressure Management

For Patients NOT Receiving Thrombolysis

Avoid lowering blood pressure unless systolic BP >220 mmHg or diastolic BP >120 mmHg, as aggressive reduction can worsen ischemic injury. 1, 2, 4

• When treatment is necessary, lower blood pressure cautiously by approximately 15% during the first 24 hours 2
• Use easily titratable parenteral agents such as labetalol (10 mg IV over 1-2 minutes, may repeat every 10-20 minutes to maximum 300 mg) or nicardipine (5 mg/hr IV infusion, titrate by 2.5 mg/hr every 5 minutes to maximum 15 mg/hr) 1
• Avoid sublingual nifedipine due to risk of precipitous blood pressure decline 1, 3

For Patients Receiving Thrombolysis

• Maintain strict BP control with target <185/110 mmHg before alteplase administration 2
• Keep BP <180/105 mmHg for at least 24 hours after thrombolytic therapy to reduce hemorrhagic transformation risk 1

Critical Caveat

Do not aggressively lower blood pressure in watershed or hemodynamic strokes, as these result from hypoperfusion and require adequate perfusion pressure. 2, 4

Glucose Management

• Measure serum glucose immediately, as hypoglycemia can mimic stroke symptoms 3
• Treat hypoglycemia immediately to achieve normoglycemia 2
• Treat persistent hyperglycemia >140 mg/dL during the first 24 hours, as it is associated with poor outcomes and increased hemorrhagic transformation 2

Antiplatelet Therapy

Administer oral aspirin 160-325 mg within 24-48 hours after stroke onset for patients not receiving thrombolysis. 1, 2, 4

• For patients who received intravenous alteplase, delay aspirin administration until >24 hours after thrombolysis 1
• Consider dual antiplatelet therapy (aspirin plus clopidogrel) only for minor noncardioembolic strokes (NIHSS ≤3) and high-risk transient ischemic attacks, converting to single antiplatelet therapy after 21-90 days 2
• Patients with aspirin allergy should receive an alternative antiplatelet medication such as clopidogrel 1

Anticoagulation

Routine urgent anticoagulation is NOT recommended for acute ischemic stroke, as it increases hemorrhagic risk without proven benefit for preventing early recurrent stroke. 1, 2, 4, 3

• The exception is cerebral venous sinus thrombosis, where anticoagulation should be started immediately even if intracranial hemorrhage is present 1

Management of Cerebral Edema and Increased Intracranial Pressure

Corticosteroids are NOT recommended for cerebral edema management following ischemic stroke. 1

• Use osmotherapy (mannitol 0.25-0.5 g/kg IV or hypertonic saline) and hyperventilation for patients deteriorating due to increased intracranial pressure or herniation syndromes 1, 2
• Consider decompressive hemicraniectomy within 48 hours for patients aged 18-60 years with massive hemispheric infarction and malignant edema, as this substantially reduces death and disability 1, 3
• Surgical decompression and evacuation of large cerebellar infarctions causing brain stem compression and hydrocephalus is life-saving 1

Seizure Management

• Treat recurrent seizures with anticonvulsants as with any acute neurological condition 1
• Do NOT administer prophylactic anticonvulsants to patients who have not had seizures 1

Temperature Management

• Monitor body temperature continuously 1
• Treat fever (temperature >38°C) aggressively, as hyperthermia worsens outcomes 1
• Investigate and treat sources of fever including urinary tract infection, pneumonia, and deep vein thrombosis 1
• Do NOT use induced hypothermia, as insufficient evidence exists to recommend it 2

Nutrition and Swallowing

Perform swallowing assessment before allowing any oral intake to prevent aspiration pneumonia. 1, 4, 3

• A water swallow test at bedside is a useful screening tool 1
• Patients with abnormal gag reflex, impaired voluntary cough, dysphonia, incomplete oral-labial closure, high NIHSS score, or cranial nerve palsies are at highest risk 1
• Insert nasogastric or nasoduodenal tubes for patients who cannot swallow safely 3
• Consider percutaneous endoscopic gastric tube placement if prolonged feeding support (>2-3 weeks) is anticipated 3

Prevention of Venous Thromboembolism

Initiate early mobilization when the patient is neurologically stable. 1, 2

• Use intermittent pneumatic compression devices for patients with limited mobility who cannot receive anticoagulation 1, 2
• For immobilized patients, consider subcutaneous heparin 5000 units twice daily or low-molecular-weight heparin for deep vein thrombosis prophylaxis after 24 hours if no hemorrhagic transformation 3

Secondary Prevention Strategies

• Complete comprehensive diagnostic workup to define stroke etiology (including prolonged cardiac monitoring, echocardiography, and vascular imaging) 2
• Initiate high-intensity statin therapy (atorvastatin 80 mg or rosuvastatin 20-40 mg daily) regardless of baseline cholesterol levels 2, 4
• Evaluate for carotid stenosis with duplex ultrasound or CT angiography 3
• Perform urgent carotid revascularization (endarterectomy or stenting) within 2 weeks if ≥70% symptomatic stenosis is identified 2, 4

Critical Interventions to AVOID

• Do NOT use glycoprotein IIb/IIIa inhibitors (increased mortality without benefit) 4
• Do NOT use volume expansion, vasodilators, or induced hypertension strategies outside clinical trials (associated with serious complications without established benefit) 4
• Do NOT use hyperbaric oxygen therapy except for air embolization (may be harmful) 2
• Do NOT use neuroprotective agents (no demonstrated efficacy in improving outcomes) 3

Quality Metrics and System Organization

• Establish door-to-needle time goals: primary goal of ≤60 minutes in ≥50% of patients, with secondary goal of ≤45 minutes 1
• Implement multicomponent quality improvement initiatives including ED education and multidisciplinary teams with neurological expertise 1
• Ensure EMS provides prehospital notification to receiving hospitals for all suspected stroke patients 1