What is the optimal management for a patient with a stroke?

Optimal Management of Acute Stroke

For acute ischemic stroke, immediately activate emergency medical services for rapid transport to a stroke-capable hospital, perform urgent brain imaging within 24 hours to exclude hemorrhage, and administer intravenous alteplase within 4.5 hours of symptom onset for eligible patients—this time-sensitive intervention provides the greatest mortality and morbidity benefit. 1, 2

Prehospital Recognition and Transport

Time is brain tissue—every minute of delay results in progressive, irreversible neuronal loss. 3

• Emergency medical services must be activated immediately (call 9-1-1) when stroke is suspected, as this is the preferred method for optimal prehospital care and ensures priority transport to stroke-capable facilities. 4
• Paramedics should use the FAST mnemonic (Face drooping, Arm weakness, Speech difficulty, Time to call 9-1-1) or other validated stroke screening tools for rapid recognition. 4, 1
• Critical prehospital information includes exact symptom onset time (or last known normal time), current medications (especially anticoagulants), and comorbidities—obtain this while minimizing on-scene time. 1, 2
• EMS should provide hospital prenotification before arrival, which significantly increases thrombolytic treatment rates and reduces door-to-needle times. 4
• For rural areas where ground transport exceeds 1 hour, air medical transport to the nearest stroke-capable hospital is reasonable. 4

Prehospital Management Protocol

Do not delay transport for interventions. 4

• Assess and manage airway, breathing, and circulation. 4
• Provide supplemental oxygen only if saturation <94%. 4
• Establish IV access per local protocol but do not administer excessive IV fluids. 4
• Determine blood glucose and treat if abnormal. 4
• Do not treat hypertension in the prehospital setting unless directed by medical command. 4
• Do not give anything by mouth—maintain NPO status. 4
• Do not administer dextrose-containing fluids in non-hypoglycemic patients. 4

Emergency Department Assessment

Triage stroke patients with the same priority as acute myocardial infarction or serious trauma, regardless of deficit severity. 5

• Perform immediate neurological evaluation using the National Institutes of Health Stroke Scale (NIHSS) to assess severity and guide treatment decisions. 1, 2, 5
• Obtain urgent brain CT or MRI within 24 hours to distinguish ischemic from hemorrhagic stroke and determine eligibility for reperfusion therapies. 1, 2, 5
• Activate the stroke team immediately in parallel with ED evaluation—do not wait for imaging results to mobilize resources. 5

Acute Reperfusion Therapy for Ischemic Stroke

Intravenous alteplase within 4.5 hours of symptom onset is the standard of care for eligible patients with moderate to severe neurological deficits—this represents the most time-sensitive intervention with proven mortality benefit. 1, 2, 6

Blood Pressure Management During Thrombolysis

• Maintain blood pressure <180/105 mmHg during and for 24 hours after alteplase administration to prevent hemorrhagic transformation. 1, 2
• For patients not receiving thrombolysis, avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg, as premature BP reduction may worsen cerebral perfusion. 2, 5

Mechanical Thrombectomy

• Consider mechanical thrombectomy for patients with large vessel occlusion within 6-24 hours based on specific imaging criteria—multiple randomized trials demonstrate substantial recanalization rates and improved outcomes compared to IV rtPA alone. 6
• Earlier reperfusion is associated with better clinical outcomes regardless of mode—do not delay IV rtPA while arranging thrombectomy. 6

Drip-and-Ship Model

• For patients at non-comprehensive stroke centers, begin intravenous rtPA before transfer rather than delaying until after transport—delaying thrombolysis decreases the chance for good outcome. 4
• Ensure strict adherence to blood pressure guidelines, assessment for clinical deterioration and bleeding, and aspiration precautions during interhospital transport. 4

Stroke Unit Care

All stroke patients should be admitted to a geographically defined stroke unit with specialized interdisciplinary staff—this intervention reduces death by 24%, death or institutionalization by 24%, and death or dependency by 20% compared to general medical ward care. 1, 2, 5

Stroke Unit Components

• The interdisciplinary team must include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with stroke expertise. 1, 2, 5
• Monitor neurological status and vital signs frequently during the first 24 hours. 5

Management of Acute Complications

Dysphagia Screening

• Perform swallowing screening within 24 hours of admission using a validated tool before giving food, fluids, or oral medications. 5
• Implement appropriate dietary modifications based on swallowing assessment results. 5
• Consider techniques such as chin tuck, small sips, multiple swallows, and upright positioning for patients with dysphagia. 5

Cerebral Edema

• Do not use corticosteroids for cerebral edema—they are ineffective and potentially harmful. 1
• Administer osmotic therapy (mannitol or hypertonic saline) and consider hyperventilation for patients with neurological deterioration from edema. 1

Secondary Prevention

Start aspirin 160-300 mg daily within 48 hours of acute ischemic stroke onset for patients not receiving thrombolysis—this reduces recurrent stroke risk without increasing hemorrhagic complications. 1, 2, 5

Long-term 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. 1
• For atrial fibrillation patients, warfarin is recommended with target INR 2.0-3.0 to prevent recurrent stroke—this reduces stroke risk by 60-86% in randomized trials. 7

Carotid Intervention

• Perform carotid endarterectomy for patients with recent non-disabling carotid territory ischemic stroke or TIA with ipsilateral 70-99% stenosis, ideally within 2 weeks. 2, 5

Rehabilitation

• Begin rehabilitation assessment by specialized professionals within 48 hours of admission. 5
• Start rehabilitation therapy as soon as the patient is medically stable. 5
• Provide comprehensive physical, occupational, and speech therapy. 5

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 to optimize care for patients, families, and caregivers. 4

• The interdisciplinary stroke team should have discussions with the patient and decision-makers regarding current state and likely progression, reaching agreement on whether care will focus on comfort or life prolongation and functional improvement. 4
• Document advance care planning discussions and reassess regularly with the active care team and substitute decision-maker. 4
• Provide access to palliative care specialists for patients with difficult-to-control symptoms, complex end-of-life decision-making, or complex psychosocial family issues. 4

Systems of Care and Quality Improvement

Transport to Primary Stroke Centers reduces 30-day mortality and increases thrombolytic therapy use compared to non-designated hospitals. 1, 2

• Implement local protocols for early notification by paramedics, high-priority transportation, and rapid access to imaging. 5
• Participate in quality improvement programs like Get With The Guidelines-Stroke to improve care processes and adherence to performance measures. 1, 5
• In rural settings, implement telestroke networks to provide remote specialist access for thrombolysis decisions and ongoing consultation. 2

Common Pitfalls to Avoid

• Do not delay transport for prehospital interventions—the most important factor determining eligibility for thrombolysis is time from symptom onset to hospital arrival. 4, 8
• Do not treat hypertension aggressively in acute ischemic stroke patients not receiving thrombolysis, as this may worsen cerebral perfusion. 2, 5
• Do not delay IV rtPA until after interhospital transfer—begin thrombolysis at the initial hospital if eligible. 4
• Despite expansion of the treatment window to 4.5 hours, only 25-30% of patients arrive within this timeframe, and this percentage has not improved over recent years—continued public education is essential. 8