What is the management approach for a patient with stroke (Cerebrovascular Accident) in the emergency setting and long-term follow-up in the outpatient department (OPD)?

Emergency and Long-Term Management of Stroke

Emergency Department Management

Stroke must be treated as a medical emergency with immediate systematic evaluation and treatment within minutes of arrival, prioritizing rapid reperfusion therapy for eligible patients to minimize brain injury and maximize recovery. 1

Immediate Assessment (First 10 Minutes)

• Assess airway, breathing, and circulation (ABCs) immediately upon arrival 1
• Administer oxygen only if oxygen saturation is <94%; avoid supplemental oxygen in non-hypoxemic patients 1, 2
• Establish two large-bore IV lines and obtain baseline blood studies: complete blood count, coagulation studies (INR, aPTT), blood glucose, and electrolytes 1
• Perform validated neurological assessment using NIHSS at baseline and hourly for the first 24 hours 1
• Obtain urgent brain CT or MRI immediately to rule out intracranial hemorrhage and identify vessel occlusion 2

Acute Ischemic Stroke Treatment

For eligible patients with acute ischemic stroke, IV alteplase (tPA) at 0.9 mg/kg (maximum 90 mg) should be administered within 4.5 hours of symptom onset, with a door-to-needle time goal of less than 60 minutes. 1

Pre-tPA Requirements:

• Blood pressure must be reduced to <185/110 mmHg before tPA administration using labetalol, nicardipine, or clevidipine 1, 2
• Maintain blood pressure <180/105 mmHg for at least 24 hours after tPA administration 1, 2

Mechanical Thrombectomy:

• Perform endovascular thrombectomy for eligible patients with large vessel occlusions (internal carotid artery or MCA-M1 segment), particularly within 6 hours of symptom onset 1, 2
• Combined approaches using stent retrievers and aspiration techniques achieve the best reperfusion rates 2

Intracerebral Hemorrhage Management

• For ICH patients with systolic BP between 150-220 mmHg, acutely lower to 140 mmHg as this is safe and can improve functional outcomes 1
• Assess blood pressure every 15 minutes until stabilized 1
• Use nicardipine (preferred over labetalol for faster response and better control) for IV blood pressure management 1

Physiological Parameter Management

• Blood Glucose: Monitor regularly and treat hyperglycemia to maintain levels between 140-180 mg/dL; close monitoring is essential to prevent hypoglycemia 2
• Temperature: Check temperature every 4 hours for the first 48 hours; identify and treat sources of hyperthermia; administer antipyretic medications for temperatures >37.5°C 2
• Blood Pressure (Non-Thrombolysis Candidates): Use cautious approach; avoid treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg 2

Critical Early Interventions

• Admit all stroke patients to specialized stroke unit or neurocritical care unit with neuroscience expertise 1
• Initiate intermittent pneumatic compression for venous thromboembolism prophylaxis on day of admission 1
• Screen swallowing, nutritional, and hydration status as early as possible, ideally on the day of admission 2
• Begin initial assessment by rehabilitation professionals within 48 hours of admission 2

Transfer Protocols

• Hospitals should function as primary stroke centers with appropriate resources or have pre-established transfer protocols to comprehensive stroke centers 1
• Telemedicine consultation can extend stroke expertise to hospitals without on-site neurologists 1
• Transfer decisions should not delay tPA administration if patient is eligible and within treatment window 1

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Long-Term Outpatient Follow-Up

Secondary Prevention Strategy

Identify stroke etiology to guide secondary prevention strategies and initiate appropriate antithrombotic therapy before discharge. 2

Antiplatelet Therapy:

• Start or switch antiplatelet therapy based on stroke mechanism 3
• For non-cardioembolic ischemic stroke, initiate aspirin or other antiplatelet agents 3

Anticoagulation for Atrial Fibrillation:

• For persistent or paroxysmal atrial fibrillation with high-risk features (prior ischemic stroke/TIA, age >75 years, heart failure, hypertension, or diabetes), oral anticoagulation with warfarin targeting INR 2.0-3.0 is recommended 4
• For AF patients age 65-75 years without other risk factors (intermediate risk), use either warfarin or aspirin 325 mg/day 4
• For AF with mitral stenosis or prosthetic heart valves, anticoagulation with warfarin is recommended with target INR adjusted based on valve type 4

Post-Myocardial Infarction with Stroke:

• For high-risk patients (large anterior MI, significant heart failure, intracardiac thrombus, or history of thromboembolism), use combined moderate-intensity warfarin (INR 2.0-3.0) plus low-dose aspirin (≤100 mg/day) for 3 months 4

Venous Thromboembolism History:

• For first episode of DVT/PE secondary to transient risk factor, treat with warfarin for 3 months targeting INR 2.5 (range 2.0-3.0) 4
• For first episode of idiopathic DVT/PE, warfarin is recommended for at least 6-12 months 4
• For two or more episodes of documented DVT/PE, indefinite treatment with warfarin is suggested 4

Cardiovascular Risk Factor Management

• Hypertension: Optimize blood pressure control to prevent recurrent stroke 3
• Dyslipidemia: Obtain lipid panel and initiate statin therapy as appropriate 3
• Diabetes Mellitus: Optimize glycemic control 3
• Smoking Cessation: Counsel and provide resources for smoking cessation 3

Carotid Stenosis Evaluation

• Consider carotid imaging (carotid Doppler, MRA, or CTA) for patients with carotid territory symptoms who might be candidates for revascularization 2, 3

Rehabilitation and Functional Recovery

• Rehabilitation therapy should begin as early as possible once the patient is medically stable 2
• Frequent, brief, out-of-bed activity involving active sitting, standing, and walking should begin within 24 hours if no contraindications exist 2
• Continue outpatient rehabilitation services based on functional deficits and recovery trajectory 2

Monitoring Schedule

• Schedule follow-up within 1-2 weeks of hospital discharge to assess medication adherence, functional status, and complications
• For patients on warfarin, monitor INR regularly (initially weekly, then monthly once stable) to maintain therapeutic range 4
• Reassess risk-benefit periodically in patients receiving indefinite anticoagulant treatment 4

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Common Pitfalls to Avoid

• Delays in recognition and treatment significantly worsen outcomes: Every 30-minute delay in recanalization decreases the chance of good functional outcome by 8-14% 2
• Overly selective treatment criteria may exclude patients who could benefit from thrombolysis 2
• Inadequate blood pressure control before thrombolysis increases hemorrhagic risk 2
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) can worsen outcomes 2
• Overlooking the need for early rehabilitation can delay recovery 2
• Inadequate public education: 40% of Canadians do not know any FAST stroke signs, leading to delays in activating emergency services 5