What are the recent guidelines for managing a patient presenting with a stroke, including treatment and secondary prevention strategies?

Recent Stroke Management Guidelines

All stroke patients should be immediately transported via emergency medical services to a dedicated stroke unit with 24/7 access to CT imaging, thrombolysis capability, and a multidisciplinary stroke team, as this organized approach provides mortality and morbidity benefits comparable to thrombolytic therapy itself. 1

Immediate Prehospital Management

• Activate emergency medical services (EMS) immediately upon recognition of stroke symptoms using the FAST assessment (Face asymmetry, Arm weakness, Speech disturbance, Time of onset), as EMS transport significantly reduces time to stroke team activation by approximately 8 minutes compared to private transportation 2, 3, 4

• Document the exact time of symptom onset or last known normal during initial assessment, as this determines eligibility for time-sensitive interventions like thrombolysis (effective within 4.5 hours) 1, 3

• Check blood glucose immediately to exclude hypoglycemia, which commonly mimics stroke with focal neurological deficits 5, 2, 3

• Transport directly to a comprehensive stroke center capable of providing thrombolysis and endovascular therapy, bypassing closer facilities if necessary 2, 3

Emergency Department Protocol (First 60 Minutes)

Imaging and Diagnosis

• Obtain non-contrast CT or MRI within 30 minutes of arrival to differentiate ischemic stroke, hemorrhagic stroke, and stroke mimics—this is the only definitive method to guide treatment 5, 2

• Perform CT angiography or MR angiography from aortic arch to vertex within 24 hours to identify large vessel occlusions amenable to mechanical thrombectomy 5

• Do not administer thrombolytics or antiplatelet agents until hemorrhagic stroke is definitively excluded by imaging, regardless of clinical presentation 5

Essential Laboratory Testing

• Complete blood count, electrolytes, glucose, renal function, coagulation studies (PT/INR, aPTT), troponin, and 12-lead ECG to identify atrial fibrillation or acute coronary syndrome 5, 2, 3

Acute Treatment Phase

Thrombolytic Therapy

• Administer intravenous tissue plasminogen activator (tPA) with door-to-needle time <60 minutes for eligible ischemic stroke patients presenting within 4.5 hours of symptom onset, as earlier treatment (0-90 minutes) provides number-needed-to-treat of 4.5 compared to 14.1 for later treatment (181-270 minutes) 1

• The Helsinki University Central Hospital model demonstrates that 31% of ischemic stroke patients can receive thrombolysis when systems are optimized, compared to only 3.3% in typical European hospitals 1

Stroke Unit Care

• Admit all stroke patients to a geographically defined stroke unit staffed by a dedicated multidisciplinary team including neurologists, specialized nurses, physiotherapists, occupational therapists, speech therapists, and social workers 1

• Implement continuous monitoring for the first 24-48 hours to detect early deterioration, which occurs in 25-33% of patients and is associated with increased mortality 1

• Begin early mobilization and rehabilitation within 24 hours ("out of bed within 24-hour principle") as part of comprehensive stroke unit care 1

Prevention of Acute Complications

Neurological Complications

• Monitor closely for cerebral edema (peaks 3-4 days post-stroke but can occur within 24 hours with reperfusion), particularly in large hemispheric or posterior fossa infarctions requiring potential neurosurgical intervention 1

• Implement swallowing screening before oral intake to prevent aspiration pneumonia, which is a compulsory quality indicator 1

Cardiovascular Monitoring

• Continue cardiac monitoring for at least 24 hours to detect paroxysmal atrial fibrillation and potentially lethal arrhythmias, with consideration for extended Holter or event-loop recording 1

• Treat clinically significant arrhythmias that may compromise cerebral perfusion, though routine prophylactic antiarrhythmic therapy is not beneficial 1

Venous Thromboembolism Prevention

• Administer enoxaparin 40 mg subcutaneously once daily or unfractionated heparin 5000 IU twice daily for deep vein thrombosis prophylaxis in immobilized patients, as the PREVAIL Trial demonstrated superior efficacy of enoxaparin with low bleeding risk 1

• Combine pharmacologic prophylaxis with early mobilization and external compression devices 1

Other Complications

• Prevent and treat myocardial infarction, urinary tract infections, dehydration, malnutrition, skin breakdown, and metabolic disorders through standardized protocols initiated in the emergency department 1

Secondary Prevention Strategies

Immediate Interventions

• Initiate antiplatelet therapy at discharge for ischemic stroke patients (compulsory quality indicator) 1

• Start anticoagulation at discharge for patients with atrial fibrillation (compulsory quality indicator) 1

• Perform carotid revascularization for ≥50% symptomatic carotid stenosis according to NASCET criteria 1

Risk Factor Management

• Address all major modifiable risk factors including hypertension, diabetes, hyperlipidemia, smoking, obesity, and physical inactivity through organized approaches that improve adherence compared to usual care 1

• Implement standardized protocols to identify barriers to compliance beginning at hospital admission, including targeted physician education regarding secondary prevention guidelines 1

Quality Indicators and System Requirements

Compulsory Stroke Unit Requirements

The European Stroke Organisation mandates these six compulsory quality indicators 1:

1. Door-to-needle time <60 minutes for thrombolysis patients
2. All acute stroke patients admitted to stroke unit or ICU
3. Brain imaging (CT/MRI) in every suspected stroke
4. Antiplatelet therapy at discharge for ischemic stroke
5. Anticoagulation at discharge for atrial fibrillation patients
6. Swallowing disorder screening for all patients

Infrastructure Requirements

• 24/7 availability of CT/MRI, CT angiography, neurosurgery, vascular surgery, interventional neuroradiology, and cardiology consultation 1

• Intra-arterial interventions (mechanical thrombectomy) available 24/7 at comprehensive stroke centers 1

• Telemedicine capabilities to serve as referral hub for peripheral hospitals, expanding access to stroke expertise 1

Rehabilitation and Discharge Planning

• Conduct standardized screening evaluation during initial hospitalization to identify patients with residual impairments requiring rehabilitation 1

• Initiate rehabilitation planning involving caregivers within 24 hours, as 50-70% of patients regain functional independence but 15-30% remain permanently disabled 1

• Provide structured patient and family education about stroke causes, risk factors, warning signs, secondary prevention strategies, and proper EMS activation before discharge 1

• Ensure smooth transition to outpatient care with timely transfer of discharge information to the subsequent treating physician and clear follow-up plans 1

Critical Pitfalls to Avoid

• Never delay imaging to obtain additional history or laboratory results when thrombolysis is being considered, as every 15-minute delay reduces treatment efficacy 1, 5

• Do not assume stroke severity or type based on clinical presentation alone, as there is substantial overlap between hemorrhagic and ischemic presentations requiring definitive imaging 5

• Avoid dismissing transient symptoms, as TIA patients presenting within 48 hours require urgent evaluation and imaging at higher-level facilities 1

• Do not overlook posterior circulation strokes, which may present with less obvious signs like isolated dizziness, ataxia, or visual disturbances rather than classic hemiparesis 2, 3