What is the next best step in management for an adult patient with an acute ischemic infarct (stroke) in the brain, with no known allergies or contraindications?

Next Best Step in Management for Acute Ischemic Stroke

Immediately obtain a non-contrast CT head to exclude hemorrhage, establish IV access, check capillary blood glucose, and admit the patient to a specialized stroke unit with continuous cardiac and neurological monitoring. 1, 2

Immediate Emergency Department Actions (Within 60 Minutes of Arrival)

Critical Time-Sensitive Assessments

• Complete brain imaging within 25 minutes of ED arrival with interpretation within 45 minutes (door-to-interpretation time of 45 minutes). 1, 2
• Establish IV access immediately and obtain blood samples including complete blood count, comprehensive metabolic panel, coagulation studies, and lipid panel within 10 minutes of arrival. 2
• Check capillary blood glucose immediately as hypoglycemia can mimic stroke and requires urgent treatment with 50% dextrose if glucose is low. 2
• Perform neurological examination using the NIHSS scale to quantify stroke severity and guide treatment decisions. 1
• Obtain ECG due to the high incidence of cardiac disease in stroke patients and to identify atrial fibrillation. 1

Blood Pressure Management Strategy

• Do NOT treat blood pressure unless it exceeds 220/120 mmHg in patients not receiving thrombolysis, as cerebral autoregulation is impaired and perfusion pressure is needed. 2
• If BP >220/120 mmHg, lower by 15% during the first 24 hours using rapid-acting, controllable agents. 2
• For thrombolysis candidates, blood pressure must be reduced to <185/110 mmHg before treatment initiation and maintained at <180/105 mmHg for 24 hours post-thrombolysis. 2
• Avoid hypotension (SBP <90 mmHg) as it worsens cerebral perfusion. 2

Oxygen and Airway Management

• Administer supplemental oxygen ONLY if oxygen saturation is <94%—routine oxygen is not indicated and may be harmful. 1, 2
• Monitor airway support and breathing to determine continued need for oxygen support. 1

Hospital Admission and Monitoring

Stroke Unit Admission

• Admit all patients to a specialized stroke unit with an interprofessional team for continuous cardiac and neurological monitoring for at least the first 24 hours. 1, 3
• Patients with large hemispheric infarcts, right hemispheric strokes, or posterior fossa infarctions require particularly close observation for cerebral edema, which typically peaks at 3-5 days post-stroke. 2, 3

Vital Sign Monitoring Protocol

• Monitor temperature every 4 hours for the first 48 hours, then per ward routine. 1
• For temperature >37.5°C, increase monitoring frequency, initiate temperature-reducing measures, investigate for pneumonia or urinary tract infection, and initiate antipyretic and antimicrobial therapy as required. 1
• Monitor blood pressure closely in the first 48 hours after stroke onset. 1

Urgent Diagnostic Workup

Vascular Imaging

• Perform CT angiography or MR angiography of the head and neck (or carotid ultrasound) to identify carotid stenosis requiring urgent intervention. 2
• Continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation. 2
• Echocardiography if cardioembolic source is suspected. 2

Swallowing Assessment

• Keep patient NPO until swallowing screening is completed to prevent aspiration. 1, 2
• Perform swallowing screening ideally on the day of admission using validated screening tools. 1
• Abnormal swallowing screens should prompt referral to speech-language pathologist, occupational therapist, and/or dietitian. 1

Initial Medical Management

Antiplatelet Therapy Initiation

• For minor stroke or high-risk TIA: Initiate dual antiplatelet therapy with aspirin 81 mg plus clopidogrel 75 mg within 12-24 hours of symptom onset, continuing for 21-90 days before switching to monotherapy. 2, 4
• For moderate-to-severe stroke: Start aspirin 160-325 mg within 24-48 hours after stroke onset (or 24 hours after thrombolysis if given). 1, 2, 3

High-Intensity Statin Therapy

• Initiate atorvastatin 80 mg daily immediately for all ischemic stroke patients, regardless of baseline cholesterol levels. 2, 3
• Target LDL-C <70 mg/dL or achieve ≥50% reduction from baseline. 2, 3

Glycemic Control

• Treat hyperglycemia if glucose >180 mg/dL with insulin therapy targeting 140-180 mg/dL. 2
• Avoid aggressive glucose lowering below 140 mg/dL as it increases hypoglycemia risk without benefit. 2
• Do NOT use dextrose-containing IV fluids unless hypoglycemia is present—hyperglycemia worsens outcomes. 2

DVT Prophylaxis

• Initiate subcutaneous anticoagulation (unfractionated heparin 5000 units twice daily or low-molecular-weight heparin) for immobilized patients to prevent deep vein thrombosis. 1, 2
• Use pneumatic compression devices if anticoagulation is contraindicated. 1, 2

Early Mobilization and Rehabilitation

• Begin rehabilitation therapy as early as possible once the patient is medically stable to participate. 1
• Frequent, brief, out-of-bed activity involving active sitting, standing, and walking beginning within 24 hours of stroke onset is recommended if there are no contraindications. 1
• Obtain physical therapy, occupational therapy, and speech therapy consultations during hospitalization. 2

Seizure Management

• Treat new-onset seizures with appropriate short-acting medications (e.g., lorazepam IV) if they are not self-limiting. 1
• A single, self-limiting seizure within 24 hours should NOT be treated with long-term anticonvulsants. 1
• Prophylactic anticonvulsants are NOT recommended and may negatively affect neurological recovery. 1

Critical Pitfalls to Avoid

• Do NOT aggressively lower blood pressure unless >220/120 mmHg or patient is receiving thrombolysis—cerebral autoregulation is impaired and perfusion pressure is needed. 2
• Do NOT delay imaging—"time is brain" and every minute counts for thrombolytic eligibility. 2, 5
• Do NOT start dual antiplatelet therapy for moderate-to-severe strokes—only indicated for minor strokes/high-risk TIA. 2
• Do NOT use routine supplemental oxygen—only if saturation <94%. 1, 2