What are the primary recommendations for managing a patient with acute stroke?

Acute Stroke Management

For patients with acute stroke, immediate recognition and rapid transport to a specialized stroke center is critical, followed by urgent brain imaging to differentiate ischemic from hemorrhagic stroke, with intravenous tissue plasminogen activator (rtPA) at 0.9 mg/kg (maximum 90 mg) administered within 3-4.5 hours for eligible ischemic stroke patients, and all patients admitted to a dedicated stroke unit for comprehensive multidisciplinary care. 1, 2

Prehospital Phase

• Emergency Medical Services (EMS) must be activated immediately (call 911) when stroke symptoms are recognized, as this is the first critical step in the stroke chain of survival 2
• EMS personnel should use validated stroke screening tools (such as the Cincinnati Prehospital Stroke Scale) to rapidly assess suspected stroke patients in the field 2
• Paramedics should provide early notification to the receiving hospital, ensure high-priority transportation, and facilitate rapid triage and expedited access to imaging upon arrival 2

Emergency Department Evaluation

Immediate Imaging and Assessment

• All patients with suspected stroke must undergo urgent non-contrast CT scan of the brain immediately upon arrival to differentiate ischemic from hemorrhagic stroke - this is the single most critical diagnostic step before any treatment can be initiated 2, 3
• The goal is door-to-imaging completion within 25 minutes and door-to-needle time (for rtPA administration) of 60 minutes or less in at least 80% of treated patients 1, 2
• CT angiography should be performed immediately after the non-contrast CT in patients presenting within 6 hours who are potential candidates for endovascular thrombectomy 3
• A standardized stroke severity assessment using the National Institutes of Health Stroke Scale (NIHSS) should be performed to quantify neurological deficits and guide treatment decisions 2

Essential Laboratory Investigations

• Obtain immediately: complete blood count, electrocardiogram, electrolytes, renal function, glucose, coagulation studies (PT/INR, aPTT), and troponin 2, 4
• Hypoglycemia (glucose <60 mg/dL) must be identified and corrected immediately as it can mimic stroke symptoms 2, 3
• These tests should not delay imaging or treatment but should be obtained concurrently 3

Acute Ischemic Stroke Management

Intravenous Thrombolysis

For carefully selected patients with acute ischemic stroke, intravenous rtPA at 0.9 mg/kg (maximum 90 mg total dose) is strongly recommended when administered within 3 hours of clearly defined symptom onset (Class I, Grade A recommendation). 1

• The treatment window can be extended to 4.5 hours in select patients, though benefit decreases with time and earlier treatment is always superior 1, 2
• Administer 10% of the total dose as an intravenous bolus over 1 minute, followed by the remaining 90% as a continuous infusion over 60 minutes 3

Critical blood pressure requirements for rtPA administration:

• Blood pressure MUST be lowered to and maintained below 185/110 mmHg BEFORE rtPA administration 1, 3
• Blood pressure MUST remain below 180/105 mmHg for at least 24 hours AFTER rtPA treatment 1, 3
• Avoid sublingual nifedipine and other agents causing precipitous blood pressure drops 2

Key exclusion criteria include:

• Patients taking direct thrombin inhibitors (dabigatran) or direct factor Xa inhibitors (rivaroxaban, apixaban) without reliable methods to measure their effects 1
• Recent major surgery, active bleeding, or other hemorrhagic risks 1

Endovascular Thrombectomy

• All acute ischemic stroke patients should be evaluated for potential endovascular thrombectomy, particularly those with large vessel occlusions identified on CT angiography 2, 4
• Endovascular therapy is indicated for patients with large vessel occlusions, including those who have received IV rtPA and those ineligible for IV thrombolysis 3
• This intervention can be performed up to 24 hours from symptom onset in highly selected patients with favorable imaging profiles 5

Antiplatelet Therapy for Non-Thrombolysis Candidates

• For patients NOT receiving thrombolysis, aspirin 160-325 mg should be administered within 24-48 hours of stroke onset 1, 2, 4
• Aspirin provides modest benefit with reasonable safety and reduces early stroke recurrence 1, 6
• Urgent anticoagulation with intravenous heparin is NOT recommended for acute ischemic stroke due to increased bleeding risk without proven benefit 1, 3, 6

Blood Pressure Management in Ischemic Stroke

For patients NOT receiving thrombolysis:

• Do not treat elevated blood pressure unless systolic BP exceeds 220 mmHg or diastolic BP exceeds 120 mmHg - permissive hypertension is the standard approach for the first 48-72 hours 2, 4
• If treatment is required, lower blood pressure cautiously by approximately 15% (not more than 25%) over the first 24 hours 4

For patients receiving thrombolysis: Follow the strict blood pressure parameters outlined above 1, 3

Acute Hemorrhagic Stroke Management

Intracerebral Hemorrhage (ICH)

Blood Pressure Management:

• For ICH patients with systolic blood pressure between 150-220 mmHg and no contraindications, acute lowering of systolic BP to 140 mmHg is safe and may improve functional outcomes 3
• Blood pressure should be assessed every 15 minutes until stable 3

Reversal of Anticoagulation:

• ICH due to anticoagulation must be urgently reversed 2
• For patients on warfarin with elevated INR: immediately discontinue warfarin, administer intravenous vitamin K, and provide appropriate factor replacement therapy (prothrombin complex concentrate or fresh frozen plasma) 3
• For patients with severe coagulation factor deficiency or severe thrombocytopenia, provide appropriate factor replacement or platelet transfusion 3

Surgical Intervention:

• Surgical decompression and evacuation of large cerebellar hemorrhages causing brainstem compression and hydrocephalus is strongly recommended as a life-saving measure 1, 2, 3
• Craniotomy may be considered for superficial ICH less than 1 cm from the cortical surface, or stereotactic surgery for deep ICH in select cases 2
• For large hemispheric infarctions with malignant edema, hemicraniectomy within 48 hours substantially reduces death and disability in patients aged 18-60 years 2

Stroke Unit Care

All stroke patients should be admitted to a geographically defined, dedicated stroke unit with specialized interdisciplinary staff - this is one of the most evidence-based interventions in stroke care. 2, 4

• The stroke unit team must include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists with expertise in stroke management 2
• Stroke unit care reduces mortality and improves functional outcomes compared to general medical ward care 2
• Patients should be admitted to the stroke unit as soon as possible, ideally within 3 hours of hospital arrival 4

Prevention and Management of Complications

Airway and Oxygenation

• Provide supplemental oxygen only if oxygen saturation falls below 94% 4, 3
• Support airway and provide ventilatory assistance for patients with decreased consciousness or bulbar dysfunction 4, 3

Dysphagia Screening and Nutrition

• Perform formal bedside dysphagia screening before allowing ANY oral intake to reduce aspiration pneumonia risk 2, 4, 3
• If prolonged feeding support is anticipated, percutaneous endoscopic gastrostomy tube placement is superior to nasogastric tube feeding 2
• Correct hypovolemia with normal saline intravenous fluids 3

Temperature Management

• Monitor temperature routinely and treat fever if temperature exceeds 37.5°C (some guidelines use 38°C threshold), as hyperthermia is associated with increased morbidity and mortality 4, 3

Glucose Management

• Treat hypoglycemia (glucose <60 mg/dL) immediately to achieve normoglycemia 3
• Treat hyperglycemia to maintain blood glucose between 140-180 mg/dL 3

Venous Thromboembolism Prevention

• For immobilized stroke patients, administer subcutaneous low-dose unfractionated heparin or low-molecular-weight heparin for deep vein thrombosis prophylaxis 1, 4, 6
• Intermittent pneumatic compression should be initiated on the day of hospital admission 3
• Avoid indwelling bladder catheters when possible due to infection risk 2

Cerebral Edema and Increased Intracranial Pressure

• For patients deteriorating due to increased intracranial pressure, osmotherapy (mannitol or hypertonic saline) and hyperventilation are recommended 1, 2, 3
• Corticosteroids are NOT recommended for cerebral edema management following ischemic stroke 1
• Surgical drainage of cerebrospinal fluid can treat increased intracranial pressure secondary to hydrocephalus 1

Seizure Management

• Treat recurrent seizures as with any acute neurological emergency using standard anticonvulsant protocols 1, 4
• Prophylactic anticonvulsants for patients who have not had seizures are NOT recommended 1

Early Rehabilitation

• Early mobilization is strongly recommended to prevent complications such as pneumonia, deep vein thrombosis, pressure ulcers, and contractures 2, 3
• Assessment and management of mobility, activities of daily living, incontinence, and mood should begin early after stroke 2
• Speech-language pathologists should evaluate and treat all stroke patients for communication and swallowing difficulties 2

Secondary Prevention Initiation

• Appropriate antithrombotic therapy should be prescribed based on stroke etiology (aspirin, clopidogrel, or anticoagulation for cardioembolic sources) 2
• For patients already taking statins at stroke onset, continuation during the acute period is reasonable 2
• After stabilization (typically day 3-4), initiate or restart antihypertensive therapy if blood pressure remains ≥140/90 mmHg for long-term secondary prevention 4
• Address all modifiable risk factors including cholesterol management 2

Common Pitfalls to Avoid

• Do not delay imaging or treatment to obtain "complete" laboratory results - obtain tests concurrently with imaging 3
• Do not use neuroprotective agents - none have demonstrated efficacy in improving outcomes after ischemic stroke 2
• Do not routinely anticoagulate acute ischemic stroke patients - this increases bleeding risk without proven benefit 1, 3
• Do not withhold rtPA in patients with "minor" or "rapidly improving" symptoms if they remain potentially disabling - approximately one-third of such untreated patients have poor outcomes 1
• Do not administer aspirin within 24 hours of rtPA administration - wait the full 24 hours to reduce hemorrhagic risk 1