What is the immediate management for a patient presenting with a stroke?

Immediate Management of Acute Stroke

All patients presenting with suspected stroke require immediate clinical evaluation with rapid assessment of airway, breathing, and circulation, followed by urgent neuroimaging to differentiate ischemic from hemorrhagic stroke before any treatment decisions are made. 1

Prehospital and Emergency Department Arrival

Initial Stabilization (First 10 Minutes)

• Assess and secure airway, breathing, and circulation immediately upon patient arrival, particularly for seriously ill or comatose patients 1
• Conduct rapid neurological examination using a standardized stroke scale (NIHSS or Canadian Neurological Scale) to determine focal deficits and stroke severity 1
• Assess vital signs including heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity 1

Urgent Diagnostic Workup

• Obtain non-contrast CT head immediately to differentiate ischemic from hemorrhagic stroke—this is the single most critical decision point that determines all subsequent management 2
• Perform CT angiography immediately after non-contrast CT in patients arriving within 6 hours who are potentially eligible for endovascular thrombectomy 2
• Draw acute blood work including electrolytes, random glucose, complete blood count, coagulation status (INR, aPTT), creatinine, and troponin 1

Critical Pitfall: Blood work results should not delay imaging or treatment decisions unless there is a specific clinical reason (e.g., known warfarin use requiring INR) 1, 2. The principle of "neurons over nephrons" applies—do not wait for renal function tests before obtaining CTA in patients with disabling acute stroke symptoms 1.

Time-Critical Protocols

• Establish door-to-needle time goal of ≤60 minutes for IV alteplase administration in ≥50% of eligible patients 1
• Designate an acute stroke team including physicians, nurses, and laboratory/radiology personnel for coordinated rapid response 1
• EMS prenotification to the receiving hospital mobilizes resources and significantly reduces door-to-imaging times (26 vs 31 minutes) and door-to-needle times (78 vs 80 minutes) 1

Management Based on Stroke Type

For Ischemic Stroke (After CT Rules Out Hemorrhage)

Thrombolytic Therapy Decision (Within 3 Hours)

• Administer IV alteplase (0.9 mg/kg, maximum 90 mg) as soon as possible to eligible patients: 10% as IV bolus over 1 minute, remaining 90% as infusion over 60 minutes 2
• Blood pressure must be <185/110 mmHg before rtPA and maintained <180/105 mmHg for at least 24 hours after treatment 1, 2
• For patients not eligible for thrombolysis, only lower blood pressure when systolic >220 mmHg or diastolic >120 mmHg, as aggressive reduction may worsen ischemia by decreasing perfusion pressure 1

Endovascular Thrombectomy Consideration

• Rapidly identify patients with large vessel occlusions using validated triage tools for potential EVT 2
• EVT is indicated for eligible patients with large vessel occlusions, including those who received IV alteplase and those ineligible for IV alteplase 2

Antithrombotic Therapy

• Administer oral aspirin within 24-48 hours after stroke onset for patients not receiving thrombolysis 2
• Urgent anticoagulation is not recommended for acute ischemic stroke due to increased hemorrhage risk without proven benefit 1, 2

For Hemorrhagic Stroke (If CT Shows Blood)

Blood Pressure Management

• Assess blood pressure every 15 minutes until stabilized 3
• For systolic BP 150-220 mmHg without contraindications, acutely lower to 140 mmHg—this is safe and improves functional outcomes 2, 3
• Avoid antihypertensive agents that induce cerebral vasodilation (e.g., sodium nitroprusside) in patients with elevated intracranial pressure 3

Coagulopathy Reversal

• Immediately reverse anticoagulation in patients on vitamin K antagonists: withhold medication, administer therapy to replace vitamin K-dependent factors, correct INR, and give IV vitamin K 2, 3
• Administer appropriate factor replacement or platelets for severe coagulation factor deficiency or thrombocytopenia 3

Neurosurgical Consultation

• Obtain prompt neurosurgical consultation for evaluation of potential surgical interventions 3
• Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression/hydrocephalus require surgical removal as soon as possible 2, 3

Additional Immediate Management (Both Stroke Types)

Seizure Management

• Treat new-onset seizures occurring at stroke onset or within 24 hours with short-acting medications (e.g., lorazepam IV) if not self-limited 1, 3
• A single self-limiting seizure should not be treated with long-term anticonvulsants 1, 3

Ancillary Studies (Do Not Delay Treatment)

• Obtain ECG to assess cardiac rhythm, but defer until after acute treatment decisions unless patient is hemodynamically unstable 1
• Obtain chest X-ray only if evidence of acute heart or pulmonary disease, and defer until after acute treatment decisions unless hemodynamically unstable 1

Monitoring and Care Setting

• Admit to intensive care unit or dedicated stroke unit with neuroscience expertise 3
• Perform swallowing screen before oral intake using validated tool to reduce pneumonia risk 2
• Initiate intermittent pneumatic compression for VTE prevention beginning day of admission 2, 3

Key Principle: The entire evaluation and treatment process must be highly coordinated and time-sensitive—every minute of delay results in progressive, irreversible loss of brain tissue 4. Systems must prioritize rapid imaging and treatment decisions over completion of all diagnostic tests 1, 2.