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

Management of Acute Stroke

All stroke patients should be immediately transported to a designated stroke center and admitted to a geographically defined stroke unit with specialized interdisciplinary staff, as this intervention alone reduces mortality by 24%, death or institutionalization by 24%, and death or dependency by 20% compared to general medical ward care. 1

Immediate Recognition and Emergency Response

Time-critical recognition is essential—for stroke patients, time is brain tissue. 2

• Emergency medical services should use the FACE-ARM-SPEECH-TIME (FAST) mnemonic for rapid stroke recognition in the field 1, 3
• Paramedics must obtain exact symptom onset time (or last known well time), current medications (especially anticoagulants), and comorbidities while minimizing on-scene time 1
• High-priority transport to a Primary Stroke Center reduces 30-day mortality and increases thrombolytic therapy use compared to non-designated hospitals 1, 3

Emergency Department Assessment (Door-to-Needle Goal: <60 Minutes)

Perform immediate neurological evaluation using the National Institutes of Health Stroke Scale (NIHSS) to determine stroke severity and monitor for evolving changes. 1, 4

Critical Initial Steps:

• Stabilize airway, breathing, and circulation; provide supplemental oxygen only if saturation <94% 3, 5
• Obtain urgent non-contrast brain CT or MRI within 24 hours to distinguish ischemic from hemorrhagic stroke 1, 3
• Check fingerstick glucose immediately—hypoglycemia can mimic stroke and requires immediate correction 5
• Obtain essential laboratory studies: complete blood count, electrolytes, renal function, glucose, cardiac biomarkers, ECG, and coagulation studies 5, 4

Acute Blood Pressure Management

For patients NOT receiving thrombolysis: avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg. 3, 5

For patients receiving thrombolysis: maintain BP <180/105 mmHg during and for 24 hours after administration to prevent hemorrhagic transformation. 1

• Use short-acting agents with minimal cerebral vascular effects if treatment is required 5

Reperfusion Therapy (The Most Time-Sensitive Mortality-Reducing Intervention)

Intravenous Thrombolysis:

Administer intravenous alteplase (0.9 mg/kg, maximum 90 mg) within 4.5 hours of symptom onset for eligible patients—this is the single most important acute intervention with proven mortality benefit. 1, 5, 6

• The treatment window has been expanded from 3 to 4.5 hours, with stronger evidence for benefit when administered earlier 6
• Specialized MRI studies can extend the treatment window to 9 hours in select patients 4
• Close monitoring for bleeding complications is required during and after administration 3

Mechanical Thrombectomy:

• Consider for patients with large vessel occlusion within 6-24 hours according to specific imaging criteria 3
• Combined stent-retriever and aspiration approach achieves the most effective first-pass complete reperfusion 3
• Should be considered for patients ineligible for IV alteplase who can begin treatment within 6 hours 6

Stroke Unit Care (Comparable Benefit to Thrombolysis)

The benefits from stroke unit care are comparable to the effects achieved with intravenous rtPA administration. 3

Essential Components:

• Geographically defined beds occupied exclusively by stroke patients 1
• Interdisciplinary team including physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with stroke expertise 1
• Standardized stroke orders or integrated stroke pathways improve adherence to best practices 3
• Neurological status and vital signs assessed frequently during the first 24 hours (approximately 25% of patients deteriorate during this period) 3, 5

Prevention and Management of Complications

Cerebral Edema:

Do NOT use corticosteroids for cerebral edema—they are ineffective and potentially harmful. 1, 3

• Administer osmotic therapy (mannitol or hypertonic saline) for patients with deterioration 1, 3
• Consider hyperventilation for acute management 1

Aspiration Prevention:

Perform swallowing screening within 24 hours of admission using a validated tool before giving any food, fluids, or oral medications. 3, 5

• Pneumonia is a leading cause of post-stroke mortality 5

Venous Thromboembolism Prevention:

• Administer subcutaneous anticoagulants or use intermittent external compression stockings for immobilized patients 5
• Early mobilization lessens the likelihood of pneumonia, deep vein thrombosis, pulmonary embolism, and pressure sores 3

Pressure Ulcer Prevention:

• Frequent turning, use of alternating pressure mattresses, and close skin surveillance 3

Metabolic Management:

• Lower markedly elevated glucose to <300 mg/dL while avoiding overly aggressive treatment 5
• Maintain adequate hydration and nutrition, as dehydration may slow recovery and increase DVT risk 3

Early Rehabilitation (Begin Within 48 Hours)

Initial assessment by rehabilitation professionals should be performed within 48 hours of admission, with therapy beginning as soon as the patient is medically stable. 7, 3

Functional Assessment:

• Use standardized tools (FIM, Barthel, or Lawton) to measure functional status 7
• Assess aerobic capacity, cognition, balance, gait, motor function, muscle strength, range of motion, pain, self-care abilities (ADLs and IADLs), continence, and sexual activity 7

Rehabilitation Setting:

• If ongoing inpatient rehabilitation is needed, provide care in either a stroke rehabilitation unit or general rehabilitation unit 3
• Early supported discharge with intensive community-based therapy is as effective as continued inpatient rehabilitation for medically stable patients with adequate caregiver support 7
• Rehabilitation in the community (outpatient, day hospital, or home-based) is equally effective and should be offered to all stroke patients as needed 3

Secondary Prevention (Begin Within 48 Hours)

Commence aspirin 160-300 mg daily within 48 hours of acute ischemic stroke onset—this reduces recurrent stroke risk without increasing hemorrhagic complications. 1, 3

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. 1, 3

Additional Secondary Prevention:

• Carotid endarterectomy is recommended for patients with recent (within 6 months) non-disabling carotid artery territory ischemic stroke or TIA with ipsilateral carotid stenosis measured at 70-99% 3
• Surgery should be performed as soon as possible after the event, ideally within 2 weeks 3
• Consider for select patients with stenosis of 50-69% 3

Palliative Care Considerations

A palliative care approach should be applied when there has been a catastrophic stroke or stroke in the setting of significant pre-existing comorbidity. 7

Goals of Care Discussion:

• Initiate "goals of care" discussion with the patient and/or substitute decision-maker when prognosis is potentially poor 7
• Address preferred location of palliation, cessation of certain medical interventions, comfort care options, and resuscitation preferences 7
• Revisit advance care planning periodically when there is a change in the patient's health status 7
• Common palliative needs include pain, respiratory secretions, dyspnea, agitation, and psychological distress 7

Quality Improvement Measures

• Participation in Get With The Guidelines-Stroke programs improves care processes and sustained adherence to stroke performance measures 1, 3
• Use standardized stroke severity scales (NIHSS) for serial assessments to detect deterioration 5