What is the immediate management for a suspected stroke in an adult with risk factors like hypertension, diabetes, or cardiovascular disease?

Immediate Management of Suspected Stroke

For any adult with suspected stroke and risk factors like hypertension, diabetes, or cardiovascular disease, immediately activate emergency medical services (EMS) for rapid transport to a stroke-capable hospital, initiate the stroke protocol upon arrival with brain imaging within 30 minutes, and administer IV alteplase (0.9 mg/kg, max 90 mg) within 4.5 hours if eligible after excluding hemorrhage on CT scan. 1

Prehospital Phase: Recognition and Transport

Immediate Actions by EMS

• Use a validated stroke screening tool (CPSS or LAPSS) to rapidly identify stroke symptoms—these tools have 86-97% sensitivity after training 1
• Establish exact time of symptom onset or last known normal time—this is "time zero" and determines all treatment eligibility 1
• Provide prehospital notification to the receiving hospital to activate the stroke team before arrival—this significantly increases rates of thrombolytic therapy 1

Critical Prehospital Interventions

• Administer supplemental oxygen only if oxygen saturation <94%—routine oxygen is not beneficial 1
• Check capillary blood glucose immediately and treat if <60 mg/dL (3.3 mmol/L) with IV dextrose—hypoglycemia mimics stroke 1, 2
• Do NOT treat hypertension in the field unless systolic BP <90 mm Hg (hypotension)—prehospital BP intervention is not proven beneficial and may worsen cerebral perfusion 1
• Establish IV access en route but do not delay transport for this 1

Transport Destination

• Transport directly to a stroke center capable of providing IV thrombolysis and endovascular treatment—bypass protocols increase rtPA administration rates 1
• Bring a witness or family member to verify symptom onset time 1

Emergency Department Phase: First 60 Minutes

Immediate Assessment (Within 10 Minutes)

• Perform neurological assessment using NIHSS to quantify stroke severity—this guides treatment decisions 1, 3
• Obtain brain imaging (non-contrast CT or MRI) within 25-30 minutes of arrival and interpret within 45 minutes—this is the only definitive way to exclude hemorrhage and confirm ischemic stroke 1, 2
• Check blood glucose immediately before any other testing—this must precede alteplase administration 1

Essential Laboratory Tests (Do Not Delay Imaging)

• Draw blood for CBC, electrolytes, creatinine, PT/INR, aPTT, and troponin—but do not wait for results before initiating reperfusion therapy 1, 2
• Obtain 12-lead ECG to detect atrial fibrillation and acute MI 2
• Only blood glucose results must be available before giving alteplase 1

Blood Pressure Management: Critical Thresholds

For Patients Eligible for IV Thrombolysis

Blood pressure MUST be <185/110 mm Hg before initiating alteplase to limit bleeding risk 1

If BP is 185-230/105-120 mm Hg, treat with: 1

• Labetalol 10-20 mg IV over 1-2 minutes, may repeat once, OR
• Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5-15 minutes to max 15 mg/hr

If BP cannot be controlled below 185/110 mm Hg, the patient is NOT eligible for IV alteplase 1

During and After Thrombolysis

• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1
• Maintain BP <180/105 mm Hg during and after rtPA 1

For Patients NOT Receiving Thrombolysis

• Consider lowering BP only if systolic >220 mm Hg or diastolic >120 mm Hg—permissive hypertension maintains cerebral perfusion 1
• Lower BP by 15-25% within the first 24 hours if treatment is indicated 1
• Treat hypertension emergently only if acute MI, heart failure, aortic dissection, or preeclampsia/eclampsia present 1

IV Thrombolysis: Alteplase Administration

Inclusion Criteria 1

• Diagnosis of ischemic stroke with measurable neurological deficit
• Symptom onset <4.5 hours (or wake-up stroke with DWI-FLAIR mismatch on MRI)
• Age ≥18 years
• No hemorrhage on CT scan

Critical Exclusions 1

• Platelet count <100,000/mm³
• INR >1.7 or PT >15 seconds
• Current anticoagulant use
• Blood glucose <50 mg/dL
• Systolic BP >185 or diastolic >110 mm Hg (that cannot be controlled)
• Head trauma or prior stroke within 3 months
• History of intracranial hemorrhage

Additional Exclusions for 3-4.5 Hour Window 1

• Age >80 years
• NIHSS >25 (severe stroke)
• History of both diabetes AND prior stroke
• Any oral anticoagulant use regardless of INR

Dosing and Administration 1

Alteplase 0.9 mg/kg (maximum 90 mg) over 60 minutes:

• Give 10% as IV bolus over 1 minute
• Infuse remaining 90% over 59 minutes

Critical Timing Principles

• Initiate alteplase as soon as possible—every 15-minute delay reduces good outcomes 1
• Do NOT wait for all laboratory results except glucose 1
• Do NOT delay for advanced imaging (CT angiography, perfusion) in standard time window patients 1
• Give IV alteplase even if mechanical thrombectomy is planned—do not wait to assess response before proceeding to angiography 1

Mechanical Thrombectomy Consideration

• Patients with suspected large vessel occlusion (LVO) based on severe deficits should proceed directly to angiography without waiting for alteplase response 1
• CT or MR angiography can identify LVO candidates for endovascular treatment 2

General Supportive Care

Airway and Breathing

• Intubate if airway is compromised or ventilation insufficient due to decreased alertness or bulbar dysfunction 1
• Maintain oxygen saturation ≥94% with supplemental oxygen 1

Circulation

• Correct hypotension and hypovolemia with IV normal saline to maintain organ perfusion 1
• Avoid dextrose-containing fluids unless hypoglycemic—hyperglycemia worsens outcomes 1, 4

Temperature

• Treat fever immediately—hyperthermia worsens brain injury and outcomes 4

Common Pitfalls to Avoid

• Never assume stroke type without imaging—clinical features cannot reliably distinguish ischemic from hemorrhagic stroke 5
• Never delay imaging for laboratory results—only glucose must precede alteplase 1
• Never treat hypertension aggressively in non-thrombolysis candidates—permissive hypertension maintains cerebral perfusion 1
• Never give antiplatelet agents or anticoagulants before excluding hemorrhage on imaging 5
• Never delay transfer for IV alteplase in "drip-and-ship" scenarios—outcomes are better with immediate treatment 1

Special Considerations for High-Risk Patients

Diabetes

• Hyperglycemia >8 mmol/L (144 mg/dL) predicts poor outcomes—treat elevated glucose but avoid hypoglycemia 4
• Diabetics have 2.5-5.8 fold increased stroke risk—aggressive secondary prevention is essential 3, 6

Hypertension

• Hypertensive patients have 2-fold increased stroke risk 3, 6
• Acute BP management differs from chronic management—avoid aggressive lowering unless thrombolysis planned 1, 7

Cardiovascular Disease

• Check troponin and ECG for concurrent acute coronary syndrome—this may alter BP management 1, 2
• Atrial fibrillation is a major embolic source—ECG is mandatory 2