What are the initial management and treatment guidelines for a patient presenting with acute stroke, considering their medical history and current condition?

Acute Stroke Management Guidelines

Immediate Prehospital Response

Activate 911/EMS immediately when stroke symptoms are recognized—this is the single most critical step in the stroke chain of survival. 1

Prehospital Assessment and Transport

• EMS personnel must assess and manage ABCs (airway, breathing, circulation) first 1
• Initiate cardiac monitoring and provide supplemental oxygen to maintain O₂ saturation >94% 1
• Establish IV access per local protocol but do NOT administer excessive IV fluids 1
• Determine blood glucose immediately and treat hypoglycemia if present (hypoglycemia can mimic stroke) 1
• Document the exact time of symptom onset or last known normal time—this is absolutely critical for treatment eligibility 1
• Do NOT initiate interventions for hypertension in the field unless directed by medical command 1
• Do NOT delay transport for any prehospital interventions 1
• Notify the receiving hospital immediately of pending stroke patient arrival to activate the stroke team before arrival 1
• Transport directly to the nearest stroke center capable of providing acute stroke care, bypassing hospitals without stroke resources 1

Critical Prehospital Pitfall

EMS should NOT administer dextrose-containing fluids in non-hypoglycemic patients, and patients must remain NPO (nothing by mouth) 1

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Emergency Department Evaluation

All patients with suspected acute stroke must be triaged with the same priority as acute myocardial infarction or serious trauma, regardless of neurological deficit severity. 1

Immediate ED Actions (Door-to-Imaging Goal: <25 minutes)

• Obtain non-contrast head CT or MRI immediately upon arrival to exclude hemorrhage and determine thrombolysis eligibility 1, 2
• Perform rapid neurological assessment using validated stroke severity scales (e.g., NIHSS) 1
• Obtain essential laboratory studies simultaneously: complete blood count, electrolytes, renal function, glucose, coagulation studies (PT/INR, aPTT), troponin, and ECG 1, 2
• Establish two large-bore IV lines 1

Stroke Mimics to Exclude

The following conditions can present identically to stroke and must be considered 1:

• Hypoglycemia (check glucose immediately—this is reversible)
• Seizures with postictal period
• Complicated migraine with aura
• Psychogenic presentations (look for inconsistent examination findings)
• Hypertensive encephalopathy
• CNS abscess (fever, drug abuse history, endocarditis)
• Drug toxicity (lithium, phenytoin, carbamazepine)

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Acute Reperfusion Therapy for Ischemic Stroke

Intravenous Thrombolysis (rtPA/Alteplase)

For patients presenting within 3 hours of clearly defined symptom onset, administer IV alteplase 0.9 mg/kg (maximum 90 mg) if no contraindications exist—this is the standard of care. 1, 2

Pre-Treatment Requirements

• Blood pressure MUST be reduced to <185/110 mmHg before alteplase administration 1, 2
• Blood pressure must be maintained ≤180/105 mmHg during and for 24 hours after treatment 1, 2
• Confirm no hemorrhage on CT/MRI 1

Extended Time Window (3-4.5 hours)

Treatment with IV alteplase is reasonable for carefully selected patients presenting between 3-4.5 hours from symptom onset 1

Special Populations Where IV Alteplase May Be Reasonable

The 2018 AHA/ASA guidelines expanded eligibility for several conditions 1:

• Small unruptured intracranial aneurysms (<10 mm): Administration is reasonable (Class IIa)
• 1-10 cerebral microbleeds on MRI: Administration is reasonable (Class IIa)
• Recent non-STEMI or inferior/right STEMI within 3 months: Treatment is reasonable (Class IIa)
• Concurrent acute MI and stroke: Treat with cerebral ischemia dose, followed by PCI if indicated (Class IIa)
• Pregnancy: May be considered when benefits outweigh risks of uterine bleeding (Class IIb)
• Sickle cell disease: Can be beneficial (Class IIa)
• Diabetic hemorrhagic retinopathy: Reasonable, but weigh vision loss risk against stroke benefit (Class IIa)

Critical Contraindications

• >10 cerebral microbleeds on MRI: Increased sICH risk, benefits uncertain (Class IIb) 1
• Giant unruptured aneurysm: Risk not well established (Class IIb) 1
• Active bleeding or recent major surgery 1

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Mechanical Thrombectomy (Endovascular Therapy)

Proceed immediately with mechanical thrombectomy using stent retriever devices if ALL of the following criteria are met 2:

• Prestroke modified Rankin Scale (mRS) 0-1 (functionally independent)
• Causative large vessel occlusion confirmed on CTA/MRA
• Age ≥18 years
• NIHSS ≥6
• ASPECTS ≥6 on imaging
• Groin puncture can be initiated within 6 hours of symptom onset

Extended Window for Thrombectomy

Highly selected patients may be considered for EVT within 24 hours based on advanced neurovascular imaging showing salvageable penumbra 1, 3

Time-Critical Nature

Every 30-minute delay in thrombectomy reduces the probability of favorable outcome by approximately 10.6%—do not delay transfer to comprehensive stroke centers 2

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Blood Pressure Management

For Patients NOT Receiving Thrombolysis

Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg 1, 4, 2

The rationale: Permissive hypertension maintains cerebral perfusion through collateral vessels in the acute phase 2. Aggressive BP lowering may worsen ischemia by decreasing perfusion pressure 1

For Patients Receiving Thrombolysis

Blood pressure MUST be <185/110 mmHg before rtPA and maintained ≤180/105 mmHg for 24 hours after treatment 1, 2

Agents to AVOID

Never use sublingual nifedipine or other agents causing precipitous BP reductions 4

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Antiplatelet Therapy

For Patients NOT Receiving Thrombolysis

Administer aspirin 325 mg orally within 24-48 hours after stroke onset 4, 2

Critical Timing Rule

Do NOT give aspirin or any antiplatelet agents within 24 hours of IV thrombolysis due to increased bleeding risk 4, 2

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Hospital Admission and Stroke Unit Care

All stroke patients must be admitted to a geographically defined stroke unit with specialized interdisciplinary staff—this intervention has mortality and morbidity benefits comparable to thrombolysis itself. 1, 4, 2

Essential Stroke Unit Components

• Specialized nursing staff with stroke expertise 1, 2
• Interdisciplinary team including physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 1, 4
• Standardized stroke order sets and integrated care pathways 1
• Continuous monitoring for neurological deterioration (approximately 25% of patients worsen in first 24-48 hours) 1

Stroke Center Certification

Hospitals should seek certification as Primary Stroke Centers (PSC) or Comprehensive Stroke Centers (CSC) by The Joint Commission or state health departments 1

PSC certification has been proven to:

• Shorten door-to-physician, door-to-CT, and door-to-rtPA times 1
• Increase rtPA utilization rates 1
• Improve clinical outcomes and reduce mortality 1

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Prevention and Management of Acute Complications

Swallowing Assessment

Perform swallowing screening before allowing any oral intake to prevent aspiration pneumonia 1, 4

Deep Vein Thrombosis Prophylaxis

Administer subcutaneous anticoagulants or use intermittent external compression stockings for all immobilized patients 4

Cerebral Edema Management

For patients with significant brain edema and increased intracranial pressure 4:

• Osmotherapy (mannitol or hypertonic saline)
• Hyperventilation
• Hemicraniectomy within 48 hours substantially reduces death and disability in selected patients (age 18-60 years) with extensive hemispheric infarcts 4

Bladder Management

Avoid indwelling bladder catheters when possible due to infection risk 4

Nutrition

Assess swallowing function before oral intake; use nasogastric tube if needed 4. If prolonged feeding support is anticipated, percutaneous endoscopic gastric tube placement is superior to nasogastric tubes 4

Fever and Infection

Monitor for and promptly treat pneumonia, which is an important cause of post-stroke death 4

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Secondary Prevention Workup (Initiated Acutely)

Cardiac Evaluation

• Transthoracic echocardiography to assess for cardioembolic sources 2
• Continuous cardiac monitoring for atrial fibrillation 1

Vascular Evaluation

All patients with carotid territory symptoms who are potential revascularization candidates must have urgent carotid duplex ultrasound 1, 4, 2

Laboratory Studies

Essential investigations include 1:

• Fasting lipid profile
• Hemoglobin A1c
• Erythrocyte sedimentation rate and/or C-reactive protein

Statin Therapy

Continue statin therapy during the acute period for patients already taking statins at stroke onset 4

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Treatments That Should NOT Be Used

Do NOT use the following interventions—they have been extensively studied without proven benefit 4, 2:

• Volume expansion
• Vasodilators
• Induced hypertension
• Neuroprotective agents (none have demonstrated efficacy)
• Routine anticoagulation with IV heparin (increases bleeding risk without benefit) 1

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Quality Improvement and Systems of Care

Telestroke Networks

For sites without in-house imaging interpretation expertise, FDA-approved teleradiology systems are recommended for timely review of brain CT/MRI 1

Performance Monitoring

Healthcare institutions must organize multidisciplinary quality improvement committees to review stroke care quality benchmarks, indicators, evidence-based practices, and outcomes 1, 4

Critical metrics to monitor include 4:

• Number of stroke alerts and true stroke rates
• Door-to-imaging times
• Door-to-needle times for thrombolysis
• Treatment rates
• Clinical outcomes

EMS Bypass Protocols

EMS should bypass hospitals without stroke treatment resources and transport to the closest stroke-capable facility 1