What is the immediate management and treatment for a patient presenting with symptoms of a stroke?

Immediate Stroke Management

All patients with suspected stroke require immediate activation of emergency protocols with a target door-to-imaging time of ≤25 minutes and door-to-needle time of ≤60 minutes for IV alteplase administration, as delays directly correlate with irreversible brain tissue loss. 1

Prehospital Recognition and Emergency Response

Stroke recognition and immediate EMS activation are critical first steps:

• Any witness to stroke symptoms must immediately call 9-1-1, as EMS transport with prenotification increases the likelihood of receiving IV thrombolysis by 3-fold compared to private transport 1
• EMS personnel should use the FAST screening tool (Face drooping, Arm weakness, Speech difficulty, Time to call 9-1-1) to identify stroke in the field 2, 1
• Document the exact time of symptom onset or last known normal time, as this determines treatment eligibility for time-sensitive therapies 1, 3
• Report current medications, particularly anticoagulants, which affect treatment decisions 1
• Administer supplementary oxygen only to hypoxemic patients (oxygen saturation <94%) or those with unknown oxygen saturation 2
• Do not intervene for blood pressure in the prehospital setting unless the patient is hypotensive (systolic blood pressure <90 mmHg) 2
• Provide prenotification to the receiving hospital to activate the stroke team before arrival 2

Emergency Department Immediate Evaluation

Time-critical assessment must occur within minutes of arrival:

• Perform rapid neurological examination using the NIH Stroke Scale (NIHSS) to quantify stroke severity 1, 3
• Obtain non-contrast CT scan immediately to rule out hemorrhage before any treatment, with target door-to-imaging time of ≤25 minutes 1, 3
• Check capillary blood glucose immediately, as hypoglycemia can mimic stroke and hyperglycemia worsens outcomes 1, 4
• Draw blood work including CBC, electrolytes, glucose, INR/aPTT, creatinine/eGFR, and troponin 1
• Obtain ECG to detect atrial fibrillation or acute myocardial infarction 3
• Assess vital signs including heart rate/rhythm, blood pressure, temperature, and oxygen saturation 1

Blood Pressure Management

Blood pressure control follows different protocols depending on thrombolysis eligibility:

• For patients eligible for IV alteplase, blood pressure must be reduced to <185/110 mmHg before administration to avoid hemorrhagic complications 1, 3
• Post-thrombolysis, maintain blood pressure <180/105 mmHg for at least 24 hours 1, 3
• For non-thrombolysis candidates, only lower blood pressure when systolic BP >220 mmHg or diastolic BP >120 mmHg, as aggressive reduction may worsen ischemia by reducing cerebral perfusion 1
• Avoid diastolic blood pressure drops, which have been associated with worse outcomes 4

Thrombolytic Therapy Decision

IV alteplase is the standard of care for eligible patients within 4.5 hours of symptom onset:

• Administer IV alteplase (tPA) at 0.9 mg/kg (maximum 90 mg) for patients presenting within 3 hours of symptom onset if no contraindications exist 3
• Extended window up to 4.5 hours is acceptable for select patients 1, 3
• Absolute requirements include: symptom onset <4.5 hours, blood pressure <185/110 mmHg, no evidence of hemorrhage on CT, and no recent surgery or bleeding 1
• Target door-to-needle time is ≤60 minutes, as every 15-minute delay reduces the likelihood of good outcome 1, 5

Contraindications to thrombolysis include:

• Previous hemorrhagic stroke, seizure at stroke onset, internal bleeding, intracranial hemorrhage 5
• Recent surgery, platelet count <100 × 10³/μL, untreated blood pressure >185/110 mmHg 5
• Symptoms lasting >4.5 hours, vascular malformation 5

Acute Supportive Care

General medical management begins immediately and continues throughout hospitalization:

• Keep patient NPO (nothing by mouth) until formal swallowing screen is completed to prevent aspiration pneumonia 1
• Treat blood glucose levels >8 mmol/l (>144 mg/dL), as hyperglycemia predicts poor prognosis independent of stroke severity 4
• Treat hyperthermia aggressively, as elevated body temperature worsens stroke outcomes 4
• Maintain oxygen saturation ≥94% with supplemental oxygen if needed 2
• Stabilize airway, breathing, and circulation, especially in seriously ill or comatose patients 3

Antiplatelet Therapy

Aspirin administration follows specific timing protocols:

• Administer aspirin 160-300 mg within 48 hours of stroke onset for patients not receiving thrombolysis 3
• For patients who received thrombolysis, delay aspirin for 24 hours to reduce hemorrhagic risk 3

Seizure Management

New-onset seizures require immediate but judicious treatment:

• Treat new-onset seizures at stroke onset or within 24 hours with short-acting medications such as lorazepam IV if not self-limited 1
• Do not treat a single self-limiting seizure occurring within 24 hours of stroke with long-term anticonvulsants, but monitor for recurrent seizure activity 1

Post-Treatment Monitoring

Intensive neurological monitoring detects complications early:

• Perform neurological assessments using the NIHSS scale every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1
• Monitor specifically for hemorrhagic transformation, cerebral edema, and neurological deterioration 1
• Watch for cerebral edema, which typically peaks 3-5 days after stroke but can occur earlier with large infarctions 3
• Monitor for complications including pneumonia, urinary tract infections, and deep vein thrombosis 3

Stroke Unit Care

All stroke patients should be admitted to a comprehensive stroke unit:

• Comprehensive stroke unit care is recommended for all patients with ischemic stroke, as it reduces mortality and improves functional outcomes 3
• Begin early mobilization when the patient is medically stable 3
• Initiate rehabilitation addressing motor, sensory, language, and cognitive deficits as soon as possible 3
• Implement measures to prevent aspiration, malnutrition, deep vein thrombosis, pulmonary embolism, and pressure sores 3

Common Pitfalls to Avoid

• Delaying EMS activation: Patients and families often attribute stroke symptoms to less serious conditions, causing critical delays 2
• Private transport instead of EMS: This eliminates prenotification benefits and reduces thrombolysis rates by two-thirds 1
• Aggressive blood pressure lowering in non-thrombolysis candidates: This can worsen ischemia by reducing cerebral perfusion pressure 1
• Allowing oral intake before swallowing assessment: This significantly increases aspiration pneumonia risk 1
• Missing the treatment window: Every 15-minute delay in door-to-needle time reduces the probability of good outcome, emphasizing that "time is brain" 6, 5