What is the immediate management of a patient with an acute stroke?

Immediate Management of Acute Stroke

Treat acute stroke as a medical emergency with the same urgency as myocardial infarction, immediately securing airway, breathing, and circulation, obtaining emergent CT imaging to differentiate ischemic from hemorrhagic stroke, and rapidly determining eligibility for reperfusion therapy within minutes of arrival. 1

Initial Stabilization and Assessment

ABCs and Vital Support

• Assess and secure airway, breathing, and circulation immediately upon patient arrival, though most acute ischemic stroke patients do not require emergency airway management 1
• Administer supplemental oxygen only if oxygen saturation is <94% to prevent hypoxemia-related secondary brain injury 1
• Establish IV access immediately and obtain blood samples for complete blood count, electrolytes, glucose, coagulation studies (PT/INR), and creatinine 1
• Check fingerstick glucose immediately as hypoglycemia is a common stroke mimic that can be reversed with IV glucose 1

Rapid Neurological Evaluation

• Perform rapid neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to determine focal deficits and assess stroke severity 1
• Determine the exact time of symptom onset, as this is crucial for reperfusion therapy eligibility 2
• Do NOT delay imaging for diagnostic blood work—laboratory tests should be obtained but must not delay CT scan or treatment decisions 1

Emergency Neuroimaging

• Obtain immediate non-contrast CT scan or MRI to confirm diagnosis, differentiate ischemic from hemorrhagic stroke, and assess location and extent of injury 1, 2
• This imaging must be performed emergently and is the single most critical diagnostic step 2

Blood Pressure Management

For Ischemic Stroke (Non-Thrombolytic Candidates)

• Only lower blood pressure if systolic >220 mmHg or diastolic >120 mmHg, as aggressive reduction may decrease perfusion pressure and worsen ischemia 1

For Ischemic Stroke (Thrombolytic Candidates)

• Blood pressure must be reduced to systolic <185 mmHg and diastolic <110 mmHg before administering thrombolytics to avoid hemorrhagic complications 1

For Hemorrhagic Stroke

• Acutely lower systolic BP to 140 mmHg if initial systolic blood pressure is between 150-220 mmHg without contraindications 1

Reperfusion Therapy for Ischemic Stroke

Intravenous Thrombolysis

• Administer IV rtPA (0.9 mg/kg, maximum 90 mg) in carefully selected patients within 3 hours of symptom onset 2, 3
• The therapeutic window can be extended to 4.5 hours in selected patients meeting specific criteria 2, 3
• Tenecteplase is emerging as an alternative to alteplase and is now considered a cornerstone treatment 3

Endovascular Thrombectomy

• Endovascular thrombectomy has become the standard of care for large vessel occlusions in both anterior and posterior circulation strokes 3
• Recent advances have expanded eligibility boundaries, improving outcomes for previously ineligible patients 3

Key Contraindications to Thrombolysis

• Intracranial hemorrhage, recent major surgery, recent head trauma, uncontrolled hypertension, and coagulopathies 2

Hospital Admission and Specialized Care

• Admit patients to a specialized stroke unit or neurocritical care unit immediately, as approximately 25% of patients experience neurological worsening within the first 24-48 hours 4
• Treatment in stroke units reduces mortality and morbidity with benefits comparable to IV rtPA administration 4
• Admission to Primary Stroke Centers (PSC) versus non-designated hospitals reduces 30-day mortality (10.1% vs 12.5%) and increases fibrinolytic therapy use (4.8% vs 1.7%) 4

Monitoring and Positioning

• Conduct validated neurological scale assessment at baseline and repeat at least hourly for the first 24 hours 1
• Maintain continuous cardiac monitoring for at least 24 hours to detect arrhythmias, especially atrial fibrillation 2
• Position the patient's head flat if hypotensive and administer isotonic saline to improve cerebral perfusion 1
• For hemorrhagic stroke, elevate the head of the bed by 20-30 degrees to facilitate venous drainage and manage increased intracranial pressure 1

Management of Specific Complications

Coagulopathy

• For patients on vitamin K antagonists with elevated INR, withhold medication, administer therapy to replace vitamin K-dependent factors, correct the INR, and give intravenous vitamin K 1

Seizures

• Treat new onset seizures occurring immediately before or within 24 hours of stroke onset with short-acting medications if not self-limited 1

Temperature and Glucose Control

• Treat fever aggressively, as hyperthermia worsens neurological damage 2, 5
• Normalize glucose levels below 50 mg/dL or above 400 mg/dL, as glucose levels >8 mmol/L predict poor prognosis 2, 5
• Insulin therapy in critically ill stroke patients is safe and determines lower mortality and complication rates 5

Cerebral Edema

• Monitor closely for signs of increased intracranial pressure, as edema typically peaks 3-4 days post-stroke but may accelerate with early reperfusion 2
• Do NOT use corticosteroids for cerebral edema management, as they are not recommended 1

Prevention of Complications

Venous Thromboembolism

• Implement intermittent pneumatic compression beginning the day of hospital admission 1
• Do NOT use graduated compression stockings, as they are less effective than intermittent pneumatic compression 1

Aspiration Prevention

• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 1, 2

Early Mobilization

• Initiate early mobilization when appropriate to prevent complications including pneumonia, urinary tract infections, deep vein thrombosis, and pressure ulcers 2

Secondary Prevention

• Initiate antiplatelet therapy within the first 48 hours in patients who did not receive thrombolytics 2

Surgical Considerations

Hemorrhagic Stroke

• Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus should undergo surgical removal of the hemorrhage as soon as possible 1

Carotid Endarterectomy (CEA)

• The usefulness of emergent or urgent CEA is not well established, even when imaging suggests small infarct core with large penumbra or in patients with unstable neurological status 4
• Emergent CEA generally is not performed outside specific settings due to high perceived risks, including increased brain edema and hemorrhagic transformation 4

Critical Pitfalls to Avoid

• Time is brain tissue—any delay in starting therapy results in progressive, irreversible loss of brain tissue 6, 5
• Do not delay CT imaging or treatment decisions for completion of laboratory tests 1
• Do not use corticosteroids for cerebral edema 1
• Do not use graduated compression stockings for VTE prophylaxis 1
• Avoid aggressive blood pressure lowering in ischemic stroke patients not receiving thrombolytics, as this may worsen perfusion 1