What is the management plan for a patient with a potential stroke in a hospital setting, particularly one with a history of atrial fibrillation, presenting within 4.5 hours of symptom onset?

Management of Potential Stroke in a Hospital Setting

Immediate Emergency Department Assessment (Within 10 Minutes)

For a patient with potential stroke presenting within 4.5 hours of symptom onset, particularly with atrial fibrillation history, immediately activate the stroke team, obtain emergent CT brain imaging, and prepare for IV alteplase administration while simultaneously evaluating for endovascular thrombectomy eligibility. 1

Initial Stabilization and Triage

• Assess airway, breathing, and circulation immediately upon ED arrival 1
• Establish IV access and obtain blood samples for complete blood count, coagulation studies, and blood glucose 1
• Check fingerstick glucose immediately to rule out hypoglycemia as a stroke mimic 1
• Perform neurological screening using the NIHSS to quantify stroke severity 1, 2
• Verify exact time of symptom onset or last known well time through interviewing witnesses, family, and EMS providers 1

Critical Time Targets (NINDS Benchmarks)

• Door-to-physician assessment: 10 minutes 1
• Door-to-CT completion: 25 minutes 1
• Door-to-CT interpretation: 45 minutes 1
• Door-to-thrombolytic therapy initiation: 60 minutes 1

Imaging Protocol

Immediate Non-Contrast CT Brain

• Obtain emergent non-contrast CT scan before any specific stroke treatment to exclude hemorrhage and identify early ischemic changes 1, 2
• CT should be performed within 25 minutes of ED arrival 1

Neurovascular Imaging for Thrombectomy Evaluation

• Obtain CT angiography from aortic arch to vertex immediately after non-contrast CT to identify large vessel occlusion 1, 2
• For patients presenting within 6 hours: proceed directly to CTA after non-contrast CT 1
• For patients presenting 6-24 hours: consider advanced imaging (CT perfusion or MRI with diffusion-weighted imaging) to identify salvageable tissue 1

Blood Pressure Management

For Thrombolysis Candidates

Blood pressure must be reduced to <185/110 mmHg before administering alteplase 1

• If BP >185/110 mmHg, administer:
  • Labetalol 10-20 mg IV over 1-2 minutes (may repeat once), OR 1
  • Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5-15 minutes to maximum 15 mg/hr 1
• Do not administer alteplase if BP cannot be maintained ≤185/110 mmHg 1

During and After Thrombolysis

• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1
• If systolic BP 180-230 mmHg or diastolic BP 105-120 mmHg during treatment, use labetalol continuous infusion 2-8 mg/min or nicardipine titration 1

Thrombolytic Therapy Decision

Within 3 Hours of Symptom Onset

Administer IV alteplase 0.9 mg/kg (maximum 90 mg) for all eligible patients—this has the strongest evidence for benefit 1, 2

Between 3-4.5 Hours of Symptom Onset

Administer IV alteplase for eligible patients, though benefit is somewhat reduced compared to <3 hour window 1

Beyond 4.5 Hours

Do not administer IV alteplase—evidence shows no benefit and potential harm 1

Critical caveat: The extended 3-4.5 hour window should not be interpreted as permission to slow down treatment; every minute of delay results in loss of 1.9 million brain cells 1

Endovascular Thrombectomy Evaluation

Within 6 Hours

• All patients with large vessel occlusion on CTA should be considered for mechanical thrombectomy 1, 2
• Thrombectomy can be performed with or without prior IV alteplase 1

6-24 Hour Window

• Highly selected patients may benefit from thrombectomy using advanced imaging criteria (CT perfusion or MRI showing salvageable penumbra) 1
• Requires consultation with neurointerventional team and stroke neurologist 1

Cardiac Monitoring and Atrial Fibrillation Management

Immediate Cardiac Assessment

• Obtain 12-lead ECG (does not take priority over CT scan) to identify atrial fibrillation or acute myocardial infarction 1
• Initiate continuous cardiac monitoring for first 24 hours to detect paroxysmal atrial fibrillation and life-threatening arrhythmias 1

Anticoagulation Timing for Atrial Fibrillation

Critical management point: For patients with known atrial fibrillation and acute ischemic stroke:

• Do NOT use heparin or heparinoids within 48 hours—they increase symptomatic intracranial hemorrhage without net benefit 1
• Start oral anticoagulation within 2 weeks for secondary prevention, but exact timing within this window remains uncertain 1
• Consider starting NOACs (novel oral anticoagulants) earlier than warfarin based on infarct size, though optimal timing lacks definitive trial evidence 1
• Larger infarcts may require delayed anticoagulation (7-14 days) due to higher hemorrhagic transformation risk 1

Supportive Care Measures

Oxygen and Respiratory Management

• Administer supplemental oxygen only if oxygen saturation <94%—routine oxygen is not beneficial 1, 2
• Assess airway protection, particularly in posterior circulation strokes with altered consciousness 1

Temperature Management

• Treat fever >99.6°F (37.5°C) as hyperthermia is associated with poor outcomes 1
• Monitor temperature at least every 30 minutes in ED 1

Aspiration Prevention

• Perform swallowing screen using validated tool before any oral intake or medications 2
• Keep patient NPO until swallowing assessment completed 2

DVT Prophylaxis

• Early mobilization is preferred 1
• For immobilized patients with severe stroke, consider enoxaparin 40 mg subcutaneously once daily (more effective than unfractionated heparin 5000 units twice daily) 1

Admission and Ongoing Care

Stroke Unit Admission

All acute stroke patients should be admitted to a dedicated stroke unit—this improves outcomes independent of specific therapies 1

• Stroke units provide specialized nursing care, early rehabilitation, and protocol-driven management 1
• Approximately 25% of patients experience neurological deterioration in first 24-48 hours, requiring close monitoring 1, 3

Common Pitfalls to Avoid

• Do not delay imaging for laboratory results—CT scan takes priority 1
• Do not treat blood pressure aggressively unless patient is thrombolysis candidate or BP extremely elevated (>220/120 mmHg)—cerebral autoregulation may be impaired 1, 4
• Do not use "bridging" heparin in acute stroke with atrial fibrillation—increases hemorrhage risk without benefit 1
• Do not interpret extended time windows as permission to slow down—faster treatment always yields better outcomes 1