What is the immediate management and treatment for a patient with an acute ischemic or hemorrhagic stroke?

Immediate Management of Acute Stroke

Critical First Steps: Stabilization and Rapid Assessment

Treat stroke as a medical emergency with the same priority as acute myocardial infarction or major trauma, initiating immediate evaluation of airway, breathing, and circulation (ABCs) upon patient arrival. 1, 2, 3

Initial Stabilization (First 5-10 Minutes)

• Assess and secure airway, breathing, and circulation immediately - most acute ischemic stroke patients do not require emergency airway management, but this must be verified first 1

• Administer supplemental oxygen if oxygen saturation <94% to prevent hypoxemia-related secondary brain injury 1, 3

• Check fingerstick glucose immediately - hypoglycemia (<60 mg/dL) is a common stroke mimic that can be reversed with IV glucose 1, 3

• Establish IV access and obtain blood samples for complete blood count, electrolytes, random glucose, coagulation status (INR, aPTT), and creatinine 1, 2

• Document the exact time the patient was last known to be normal - this is "time zero" for all treatment decisions, not when symptoms were discovered 3

Neurological Assessment

• Perform rapid neurological examination using a standardized stroke scale (National Institutes of Health Stroke Scale - NIHSS) to determine focal deficits and assess stroke severity 1, 2

• Assess heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity 1

• Obtain medication history, particularly anticoagulant use, and inquire about advanced care directives 1, 2

Immediate Imaging: Distinguish Ischemic from Hemorrhagic Stroke

Obtain immediate neuroimaging with CT or MRI to confirm diagnosis, location, and extent of hemorrhage or ischemia - this is mandatory and should not be delayed 1, 2

For Hemorrhagic Stroke (If CT Shows Blood)

• Obtain vascular imaging (CT angiography, MR angiography, or catheter angiography) to exclude underlying lesions such as aneurysms or arteriovenous malformations 2

• Transfer immediately to intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 2

• Obtain prompt neurosurgical consultation for evaluation of potential surgical interventions 2

Blood Pressure Management: Different Targets for Ischemic vs. Hemorrhagic

For Ischemic Stroke (No Hemorrhage on CT)

If the patient is NOT a candidate for thrombolytic therapy:

• Only lower blood pressure if systolic >220 mmHg or diastolic >120 mmHg - aggressive blood pressure reduction may decrease perfusion pressure and worsen ischemia 1

If the patient IS a candidate for thrombolytic therapy:

• Blood pressure must be reduced to systolic <185 mmHg and diastolic <110 mmHg before administering thrombolytics to avoid hemorrhagic complications 1

For Hemorrhagic Stroke (Blood on CT)

• For systolic blood pressure between 150-220 mmHg without contraindications, acutely lower systolic BP to 140 mmHg - this is safe and can improve functional outcomes 2

• Assess blood pressure every 15 minutes until stabilized 2

• Avoid antihypertensive agents that induce cerebral vasodilation (such as sodium nitroprusside) in patients with markedly elevated intracranial pressure 2

• Nicardipine is superior to labetalol for achieving and maintaining goal blood pressure, with faster response time and fewer treatment failures 2

Management of Coagulopathy (Hemorrhagic Stroke)

• For patients on vitamin K antagonists with elevated INR: withhold medication, administer therapy to replace vitamin K-dependent factors, correct the INR, and give intravenous vitamin K 2

• For severe coagulation factor deficiency or severe thrombocytopenia: administer appropriate factor replacement therapy or platelets 2

Seizure Management

• Treat new onset seizures occurring immediately before or within 24 hours of stroke onset with short-acting medications (e.g., lorazepam IV) if not self-limited 1, 2

• Do NOT treat a single, self-limiting seizure occurring at onset or within 24 hours with long-term anticonvulsant medications 1, 2

• Monitor patients with immediate post-stroke seizure for recurrent seizure activity 1

Positioning and Fluid Management

• Position the patient's head flat (not elevated) if hypotensive (systolic BP <120 mmHg) and administer isotonic saline to improve cerebral perfusion 1, 3

• For hemorrhagic stroke: elevate the head of the bed by 20-30 degrees to help venous drainage and manage increased intracranial pressure 2

• Avoid hypo-osmolar fluids such as 5% dextrose in water as they may worsen cerebral edema 2

• Use normal saline for rehydration in nonhypoglycemic patients, as excessive dextrose-containing fluids can exacerbate cerebral injury 1

Monitoring and Ongoing Care

• Conduct validated neurological scale assessment at baseline and repeat at least hourly for the first 24 hours, depending on patient stability 2

• Maintain nurse-patient ratio of 1:2 for the first 24 hours, then 1:4 if patient condition is stable 2

• Treat factors that exacerbate raised intracranial pressure (hypoxia, hypercarbia, hyperthermia) 2

Prevention of Complications

• Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 2

• Perform formal screening procedure for dysphagia before initiating oral intake to reduce the risk of pneumonia 2

• For hemorrhagic stroke: consider starting pharmacological VTE prophylaxis with UFH or LMWH after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset 2

Surgical Considerations (Hemorrhagic Stroke)

• Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus should undergo surgical removal of the hemorrhage as soon as possible 2

• Consider early surgery for patients with Glasgow Coma Scale score 9-12 2

• External ventricular drainage with intraventricular fibrinolysis for intraventricular hemorrhage promotes hematoma clearance, decreases mortality, and improves functional outcomes 2

Critical Pitfalls to Avoid

• Do NOT delay imaging or treatment decisions for diagnostic tests - blood work should be obtained but must not delay CT scan or thrombolytic therapy 1, 2

• Early deterioration is common in the first few hours after hemorrhagic stroke - over 20% of patients experience a decrease in GCS of 2 or more points between prehospital assessment and initial ED evaluation 2

• Hematoma expansion occurs in 30-40% of hemorrhagic stroke patients and is a predictor of poor outcome; risk factors include presence of contrast extravasation ("spot sign"), early presentation, anticoagulant use, and initial hematoma volume 2

• Do NOT use corticosteroids for management of cerebral edema and increased intracranial pressure - they are not recommended 2

• Do NOT use graduated compression stockings - they are less effective than intermittent pneumatic compression for VTE prevention 2

• For ischemic stroke: do NOT perform emergent carotid endarterectomy in patients with unstable neurological status - risks are high and current evidence does not support this approach 1