From the Guidelines
The emergency management of acute stroke requires rapid assessment and intervention to minimize brain damage, with the most critical step being immediate call to emergency services if stroke symptoms are suspected, as "time is brain" 1. Upon arrival at the hospital, patients should undergo rapid neurological assessment using the NIH Stroke Scale and urgent brain imaging (CT or MRI) to distinguish between ischemic and hemorrhagic stroke.
- Key considerations in acute stroke management include:
- Prehospital care: rapid recognition of stroke symptoms and immediate activation of emergency medical services
- Emergency department care: rapid neurological assessment, urgent brain imaging, and initiation of appropriate treatment
- Acute inpatient care: continuous monitoring of vital signs, management of complications, and initiation of secondary prevention strategies For ischemic stroke, if the patient arrives within 4.5 hours of symptom onset and has no contraindications, intravenous tissue plasminogen activator (tPA, alteplase) should be administered at 0.9 mg/kg (maximum 90 mg), with 10% given as bolus and the remainder over 60 minutes 1.
- For eligible patients within 24 hours, endovascular thrombectomy may be considered, as recent guidelines have extended the time window for this treatment 1. Hemorrhagic stroke management includes blood pressure control (targeting systolic BP <140-160 mmHg), reversal of anticoagulation if applicable (using prothrombin complex concentrate, vitamin K, or specific reversal agents like idarucizumab for dabigatran), and neurosurgical consultation.
- All stroke patients require continuous monitoring of vital signs, oxygen saturation (maintaining >94%), blood glucose (targeting 140-180 mg/dL), and temperature control. Aspirin (325 mg) should be given within 24-48 hours for ischemic stroke patients not receiving tPA.
- Early management also includes dysphagia screening before oral intake, DVT prophylaxis, and initiation of secondary prevention strategies, with the goal of reducing morbidity, mortality, and improving quality of life for patients with acute stroke 1.
From the Research
Emergency Management of Acute Stroke
- The primary therapy for acute ischemic stroke is thrombolysis with intravenous alteplase, which is approved in most countries 2.
- Early administration of alteplase improves functional outcome, but the benefit and risk depend on the time elapsed between stroke onset and initiation of treatment 2.
- Randomized controlled trials have demonstrated benefit from intravenous thrombolysis when initiated up to 4.5 hours after symptom onset 2.
Treatment Options
- Intravenous tissue plasminogen activator and mechanical thrombectomy are powerful tools for the treatment of acute ischemic stroke 3.
- Treatment algorithms for acute ischemic stroke are evolving rapidly, and strokes in select patients can now be treated up to 24 hours after last known well time 3.
- Thrombectomy can be done in patients given antiplatelets and probably in those given anticoagulants 4.
Prehospital and Emergency Care
- The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible 5.
- Prehospital considerations and initial evaluation of the patient with history, examination, and imaging are crucial in acute ischemic stroke management 6.
- Emergency medical services protocols for identification of patients with stroke can help minimize delays in treatment 5.
Risks and Complications
- Treatment with alteplase carries a risk of bleeding, with symptomatic intracranial hemorrhage (SICH) of around 3% 2.
- Pretreatment with aspirin monotherapy increases the bleeding risk of alteplase, and the risk of intracerebral haemorrhage is increased with the combination of aspirin and clopidogrel 4.
- Antiplatelet drugs should not be given in the first 24 h after alteplase treatment 4.