What is the immediate management and treatment for a patient who has suffered a stroke, considering potential contraindications and the need for urgent medical attention?

Immediate Stroke Management

Stroke must be treated as a life-threatening emergency requiring immediate evaluation and treatment within 60 minutes of hospital arrival, with the primary goal of determining eligibility for IV alteplase (tPA) within 4.5 hours of symptom onset. 1, 2

Prehospital Recognition and Response

Call 9-1-1 immediately—do not contact a primary care physician first. Patients who alarm their general practitioner instead of emergency medical services experience median onset-to-door times of 466 minutes versus 90 minutes, potentially eliminating treatment eligibility. 3

• EMS personnel must use the FAST screening tool (Face drooping, Arm weakness, Speech difficulty, Time) to identify stroke on scene. 1, 2
• Document exact time of symptom onset or last known normal time—this single piece of information determines treatment eligibility. 1, 2
• EMS should spend less than 15 minutes on scene and transport directly to a stroke-capable center with prenotification, which increases likelihood of receiving thrombolysis 3-fold. 2, 4
• Report current medications, especially anticoagulants, to receiving hospital. 1, 2

Emergency Department Immediate Evaluation (First 25 Minutes)

Target door-to-imaging time ≤25 minutes and door-to-needle time ≤60 minutes. 1, 2

Immediate Clinical Assessment

• Perform NIHSS (National Institutes of Health Stroke Scale) to quantify stroke severity—this score influences treatment decisions and prognosis. 1, 2
• Check capillary blood glucose immediately (hypoglycemia can mimic stroke). 1, 2
• Obtain vital signs: blood pressure, heart rate/rhythm, temperature, oxygen saturation. 1, 2

Immediate Laboratory Tests

• Draw blood for: CBC, electrolytes, glucose, creatinine/eGFR, INR/aPTT, troponin. 1, 2
• Obtain 12-lead ECG (atrial fibrillation is a critical finding; acute MI can cause stroke). 1

Immediate Brain Imaging

All suspected stroke patients require immediate non-contrast CT (NCCT) of the head to exclude hemorrhage before any treatment. 1, 2

• For patients arriving within 6 hours: obtain CT angiography (CTA) from aortic arch to vertex simultaneously to identify large vessel occlusions eligible for endovascular thrombectomy. 1, 2
• Do not delay imaging for any reason—advanced imaging like CT perfusion must not delay treatment decisions. 1

Blood Pressure Management

Blood pressure management differs dramatically based on thrombolysis eligibility:

For Thrombolysis Candidates

• Reduce blood pressure to <185/110 mmHg BEFORE administering alteplase to prevent hemorrhagic transformation. 1, 2
• Maintain blood pressure <180/105 mmHg for 24 hours AFTER alteplase administration. 1, 2
• Lower blood pressure cautiously to avoid precipitous drops that worsen ischemia. 1

For Non-Thrombolysis Candidates

• Only treat blood pressure if SBP >220 mmHg or DBP >120 mmHg—aggressive reduction may worsen brain ischemia by reducing perfusion pressure. 1, 2

Thrombolytic Therapy Decision (Within 4.5 Hours)

IV alteplase (0.9 mg/kg; maximum 90 mg) is the standard of care for eligible patients within 4.5 hours of symptom onset. 1, 2

Absolute Requirements for IV Alteplase

• Symptom onset <4.5 hours (or last known normal time <4.5 hours). 1, 2
• Blood pressure successfully lowered to <185/110 mmHg. 1, 2
• No hemorrhage on CT scan. 1, 2
• Adherence to NINDS selection criteria (no recent surgery, no active bleeding, platelet count adequate, INR acceptable). 1

Do not substitute streptokinase or other thrombolytic agents for alteplase—they are not safe alternatives. 1

Airway, Breathing, and Circulation Support

Protect airway, breathing, and circulation as life support measures, especially in seriously ill or comatose patients. 1

• Administer oxygen only if O₂ saturation <92%. 5
• Maintain euvolemia with normal saline—avoid hypotonic fluids. 5

Seizure Management

New-onset seizures at stroke onset or within 24 hours should be treated with short-acting medications (lorazepam IV) only if not self-limited. 1, 2

• Do not start prophylactic anticonvulsants—a single self-limiting seizure within 24 hours does not require long-term anticonvulsant therapy. 1, 2
• Monitor for recurrent seizures during routine vital sign checks. 1, 2
• Recurrent seizures should be treated as per standard seizure protocols. 1

Glucose and Temperature Management

Treat blood glucose >8 mmol/L (>144 mg/dL)—hyperglycemia predicts poor prognosis independent of stroke severity. 5

Treat hyperthermia immediately—elevated body temperature worsens stroke outcomes. 5

Aspirin Administration

Aspirin can be administered within 48 hours of stroke onset for reasonable safety and small benefit, but NOT within 24 hours of alteplase administration. 1

Post-Treatment Monitoring

Perform NIHSS assessments every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours to detect hemorrhagic transformation or neurological deterioration. 2

• Keep patient NPO (nothing by mouth) until formal swallowing screen completed to prevent aspiration pneumonia. 2
• Admit to comprehensive stroke unit—stroke unit care improves outcomes across all stroke severities. 1

Critical Pitfalls to Avoid

• Never delay imaging to obtain "complete" laboratory results—only glucose and basic labs are needed before imaging. 1, 2
• Never use urgent anticoagulation (heparin, warfarin) in acute stroke—it increases hemorrhage risk without reducing early recurrent stroke. 1
• Never administer neuroprotective agents—none have proven effective in clinical trials. 1
• Never lower blood pressure aggressively in non-thrombolysis candidates—this worsens brain ischemia. 1, 2