What are the initial management steps for a patient presenting with acute ischemic stroke according to Stem (Stroke) I guidelines?

Initial Management of Acute Ischemic Stroke

Patients with suspected acute ischemic stroke require immediate emergency triage with the same priority as myocardial infarction or major trauma, followed by rapid neuroimaging and consideration for IV alteplase within 3-4.5 hours of symptom onset. 1

Prehospital Management

EMS providers must immediately assess and stabilize airway, breathing, and circulation (ABCs), determine the exact time of symptom onset or last known normal time, and provide advance notification to the receiving hospital. 1, 2, 3

• EMS should bypass hospitals without stroke treatment capabilities and transport directly to the closest stroke center (Primary Stroke Center or Comprehensive Stroke Center). 1, 3
• Apply a validated stroke screening tool (such as FAST scale) in the field to confirm probable stroke. 3
• Check blood glucose immediately and treat if <60 mg/dL. 3
• Provide supplemental oxygen only if oxygen saturation <94%. 3
• Minimize on-scene time to ≤15 minutes. 3

Emergency Department Evaluation (Target: Door-to-Imaging ≤25 minutes)

Emergency brain imaging with non-contrast CT or MRI must be obtained immediately upon arrival to exclude hemorrhage before any specific stroke therapy is initiated. 1, 2

Critical Initial Steps:

• Perform rapid neurological examination using NIHSS score to assess stroke severity and prognosis. 2, 3
• Obtain vital signs with particular attention to blood pressure. 2, 3
• Draw blood for complete blood count, electrolytes, renal function, glucose, coagulation studies (PT/INR, aPTT), and troponin. 2
• Obtain 12-lead ECG. 2, 3
• Perform swallowing assessment before allowing any oral intake to prevent aspiration pneumonia. 2

Imaging Requirements:

• Brain imaging must be interpreted within 45 minutes of patient arrival by a physician with expertise in reading CT/MRI. 1
• If intra-arterial therapy or mechanical thrombectomy is contemplated, obtain noninvasive intracranial vascular imaging (CTA or MRA) during initial evaluation, but do not delay IV alteplase. 1

Acute Reperfusion Therapy (Target: Door-to-Needle ≤60 minutes)

Administer IV alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) if ALL eligibility criteria are met, as every 30-minute delay reduces probability of favorable outcome by approximately 10.6%. 1, 2

Absolute Requirements for IV Alteplase:

• Symptom onset clearly defined and within 3-4.5 hours. 1, 2
• No evidence of intracranial hemorrhage on CT/MRI. 1
• Blood pressure <185/110 mmHg before treatment initiation. 2, 3
• No contraindications per NINDS criteria (including recent surgery, active bleeding, platelet count <100,000, INR >1.7, or glucose <50 mg/dL). 1, 2

Critical Pitfall:

• Frank hypodensity involving more than one-third of the MCA territory on CT is a contraindication to IV alteplase due to increased hemorrhage risk. 1

Blood Pressure Management

Permissive hypertension is recommended to maintain cerebral perfusion through collaterals—avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg in patients NOT receiving reperfusion therapy. 2

• For patients receiving IV alteplase, blood pressure must be maintained <185/110 mmHg before treatment and <180/105 mmHg for 24 hours after treatment. 2, 3
• Do NOT use volume expansion, vasodilators, or induced hypertension—these have no proven benefit. 2

Antiplatelet Therapy

Administer aspirin 325 mg orally within 24-48 hours after stroke onset for patients NOT receiving thrombolysis. 1, 2

• Do NOT give aspirin or any antiplatelet agents within 24 hours of IV thrombolysis. 2

Post-Thrombolysis Monitoring

Perform neurological assessments every 15 minutes for 2 hours after alteplase administration, then every 30 minutes for 6 hours, then hourly until 24 hours. 3

• Monitor blood pressure closely and maintain <180/105 mmHg for 24 hours post-treatment. 3
• Obtain follow-up brain imaging at 24 hours before starting antiplatelet or anticoagulant therapy. 1

Stroke Unit Admission

ALL stroke patients must be admitted to a geographically defined stroke unit with specialized interdisciplinary staff, as this improves outcomes across all stroke severities. 1, 2

• The multidisciplinary team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists. 2

Airway Protection and Complications

Immediately intubate patients who develop neurological deterioration with respiratory insufficiency to protect the airway and maintain adequate oxygenation. 2

• Early mobilization is strongly recommended to prevent complications. 2

Secondary Prevention Workup (Within First 48 Hours)

• Perform urgent carotid duplex ultrasound for all patients with carotid territory symptoms who are potential revascularization candidates. 2
• Obtain transthoracic echocardiography to assess for cardioembolic sources. 2

Critical Pitfalls to Avoid

• Do NOT use neuroprotective agents—none have demonstrated efficacy in improving outcomes despite decades of research. 1, 2
• Do NOT delay IV alteplase for any reason if the patient meets eligibility criteria—time is brain tissue. 2, 4
• Do NOT routinely use urgent anticoagulation, as it increases hemorrhage risk without reducing early recurrent stroke. 1