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

Management of Stroke Patients

All stroke patients must be treated as medical emergencies with the same priority as acute myocardial infarction or serious trauma, requiring immediate activation of stroke protocols and rapid transport to a stroke-capable facility. 1

Immediate Recognition and Prehospital Response

• Emergency medical services should use the FAST mnemonic (Face drooping, Arm weakness, Speech difficulty, Time to call 911) for rapid stroke recognition, as this increases awareness and prompts earlier medical attention. 2, 3
• Paramedics must obtain exact symptom onset time (defined as when patient was last at baseline or symptom-free), current medications, and comorbidities while minimizing on-scene time. 1, 2
• Local protocols must include early notification by paramedic staff, high-priority transportation, and rapid access to imaging upon arrival. 3

Emergency Department Assessment and Stabilization

• Immediately stabilize airway, breathing, and circulation (ABCs), with tracheal intubation indicated for patients with compromised airway. 1, 3
• Provide supplemental oxygen only to maintain oxygen saturation >94%, not routinely for all patients. 3
• Perform neurological evaluation using the National Institutes of Health Stroke Scale (NIHSS) immediately upon arrival. 2
• Obtain urgent brain CT or MRI within 24 hours to distinguish ischemic from hemorrhagic stroke and determine eligibility for reperfusion therapies. 1, 2, 3

Acute Reperfusion Therapy for Ischemic Stroke

For eligible patients with ischemic stroke, administer intravenous alteplase (or tenecteplase as an alternative) within 4.5 hours of symptom onset, as this is the most time-sensitive intervention with proven mortality benefit. 1, 2, 4

Blood Pressure Management During Thrombolysis

• For patients receiving thrombolytic therapy, maintain blood pressure <180/105 mmHg during and for 24 hours after administration to prevent hemorrhagic transformation. 1, 2
• For patients NOT receiving thrombolysis, avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg. 1, 3

Mechanical Thrombectomy

• Consider mechanical thrombectomy for patients with large vessel occlusion within 6-24 hours based on specific imaging criteria, with the treatment window now extended based on advanced imaging selection. 1, 2, 4
• Combined endovascular therapy using stent-retrievers and aspiration achieves the most effective first-pass complete reperfusion. 3

Stroke Unit Care

Admit all stroke patients to a geographically defined stroke unit with specialized interdisciplinary staff, as this reduces death by 24%, death or institutionalization by 24%, and death or dependency by 20% compared to general medical ward care. 1, 2, 3

• The stroke unit team must include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with stroke expertise. 2
• Monitor neurological status and vital signs frequently during the first 24 hours after admission. 1, 3
• The benefits from stroke unit care are comparable to the effects achieved with intravenous thrombolysis. 3

Management of Complications

Swallowing Dysfunction

• Perform swallowing screening within 24 hours of admission using a validated tool before giving any food, fluids, or oral medications. 1, 3
• Implement dietary modifications based on assessment results, using techniques such as chin tuck, small sips, multiple swallows, and upright positioning for patients with dysphagia. 1

Cerebral Edema

• Do NOT use corticosteroids for cerebral edema, as they are ineffective and potentially harmful. 2, 3
• Administer osmotic therapy (mannitol or hypertonic saline) and consider hyperventilation for patients who deteriorate. 2, 3

Prevention of Other Complications

• Treat fever, hyperglycemia (glucose levels >8 mmol/l are predictive of poor prognosis), and maintain homeostasis. 3, 5
• Early mobilization lessens the likelihood of pneumonia, deep vein thrombosis, pulmonary embolism, and pressure sores. 3
• Use frequent turning, alternating pressure mattresses, and close skin surveillance to prevent pressure sores. 3
• Sustain adequate nutrition and hydration, as dehydration may slow recovery and is a potential cause of deep vein thrombosis. 3

Rehabilitation

Begin rehabilitation assessment by specialized professionals (physical therapy, occupational therapy, speech-language pathology) within 48 hours of admission. 1, 3

• Start rehabilitation therapy as soon as the patient is medically stable, using a comprehensive approach including physical, occupational, and speech therapy. 6, 1, 3
• All stroke patients should receive a psychosocial assessment by a social worker, including evaluation of prestroke functioning, family/caregiver situation, resources, spiritual and cultural activities, and patient/family understanding of condition and prognosis. 6
• Assessment of cognition and arousal should address learning and memory, visual neglect, attention, apraxia, and problem solving. 6
• Rehabilitation can be effectively provided in outpatient settings, day hospital, or community if a multidisciplinary team exists, allowing for early supported discharge. 6, 3

Secondary Prevention

Commence aspirin 160-300 mg daily within 48 hours of acute ischemic stroke onset for patients not receiving thrombolysis, as this reduces recurrent stroke risk without increasing hemorrhagic complications. 1, 2, 3

Carotid Intervention

• Perform carotid endarterectomy for patients with recent (within 6 months) carotid artery territory ischemic stroke with ipsilateral stenosis of 70-99%, ideally within 2 weeks of the event. 1, 3
• Consider carotid endarterectomy for select patients with stenosis of 50-69%. 3

Anticoagulation

• Do NOT use anticoagulation as standard acute treatment for ischemic stroke due to increased bleeding risk without proven benefit, except in cases of cerebral venous thrombosis. 2, 3

Risk Factor Management

• Identify and aggressively manage modifiable risk factors including hypertension, diabetes, hyperlipidemia, and smoking cessation. 1, 7

Healthcare System Organization

• Develop efficient stroke pathways with standardized stroke orders to improve adherence to best practices. 1, 3
• Transport to Primary Stroke Centers reduces 30-day mortality and increases thrombolytic therapy use compared to non-designated hospitals. 2, 3
• Participate in quality improvement programs like Get With The Guidelines-Stroke to improve care processes and sustained adherence to stroke performance measures. 1, 2, 3

Critical Pitfall to Avoid

The most common pitfall is delay in treatment initiation—remember that "time is brain tissue," with progressive, irreversible loss of brain tissue occurring with every minute of delay. 8, 5 Every aspect of stroke care, from prehospital recognition through acute treatment to rehabilitation, must prioritize speed and efficiency to maximize brain tissue salvage and functional outcomes.