What is the immediate management for a stable patient with a recent stroke, with no signs of acute deterioration, while awaiting referral to a neurologist?

Immediate Management of Stable Stroke Patient Pending Neurology Referral

Admit the patient to a specialized stroke unit immediately, as this single intervention reduces mortality and improves functional outcomes more than any other acute management strategy. 1, 2, 3

Admission and Monitoring

• Transfer to a stroke unit with multidisciplinary care (neurologists, specialized nurses, physiotherapists, occupational therapists, speech therapists) rather than general medical ward. 2
• Perform neurological assessments using NIHSS every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours to detect hemorrhagic transformation, cerebral edema, or seizures. 1
• Monitor vital signs continuously, particularly blood pressure, temperature, and oxygen saturation. 2
• Approximately 25% of patients deteriorate neurologically in the first 24-48 hours, making this intensive monitoring essential. 3

Blood Pressure Management

• If the patient received thrombolysis: Maintain BP <180/105 mmHg for at least 24 hours, checking every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly. 1, 2
• If no reperfusion therapy was given: Allow permissive hypertension unless BP exceeds 220/120 mmHg or there are comorbidities requiring intervention (acute MI, heart failure, aortic dissection). 2
• After 24 hours post-thrombolysis, restart antihypertensive medications with target <140/90 mmHg. 1

Aspiration Prevention and Nutrition

• Keep patient NPO until formal swallowing screen is completed. 1, 2
• Patients with brainstem infarcts, multiple strokes, large hemispheric lesions, or depressed consciousness are at highest aspiration risk. 4, 2
• If swallowing is impaired, place nasogastric tube for nutrition and medications; consider PEG tube if prolonged need anticipated. 4

Antiplatelet Therapy

• Start aspirin 160-300 mg within 48 hours of stroke onset (typically 24 hours after thrombolysis if given). 2, 3
• For minor-to-moderate stroke, initiate dual antiplatelet therapy (aspirin + clopidogrel) for 21 days, then continue single antiplatelet therapy. 1

Deep Vein Thrombosis Prophylaxis

• Administer subcutaneous anticoagulation (low molecular weight heparin or unfractionated heparin) for all immobilized patients. 4, 2
• If anticoagulation is contraindicated, use intermittent pneumatic compression stockings. 4, 2

Temperature and Oxygenation

• Aggressively treat fever >37.5°C (99.5°F) with antipyretics, as hyperthermia worsens neurological outcomes. 2
• Maintain oxygen saturation ≥92-94%; provide supplemental oxygen only if hypoxia documented. 2, 3

Secondary Prevention Initiation

• Start high-intensity statin (atorvastatin 80 mg daily) regardless of baseline cholesterol levels. 1, 3
• Optimize glycemic control if diabetic, targeting HbA1c <7%. 1
• Address cardiovascular risk factors including smoking cessation and dietary modifications. 5

Complication Surveillance

• Monitor for aspiration pneumonia, urinary tract infections, pressure ulcers, and contractures. 4, 2
• If fever develops, investigate for pneumonia or urinary tract infection and treat with appropriate antibiotics. 4
• Avoid indwelling bladder catheters when possible due to infection risk; use intermittent catheterization if needed. 4

Early Mobilization

• Begin early mobilization when medically stable with daily stretching of hemiplegic limbs to prevent contractures. 2, 3
• Early, short, frequent exercise sessions are essential. 2

Patient and Family Education

• Educate on stroke warning signs using FAST mnemonic (Face drooping, Arm weakness, Speech difficulty, Time to call 911). 1
• Emphasize medication adherence and risk factor modification. 1
• Provide family support and assess for depression in patient. 4

Critical Pitfalls to Avoid

• Do not lower blood pressure aggressively in the acute phase unless specific indications exist, as this may compromise cerebral perfusion. 2
• Do not give oral intake before swallowing assessment - aspiration pneumonia is a leading cause of post-stroke death. 4, 1
• Do not use corticosteroids for cerebral edema management in ischemic stroke. 4
• Do not delay stroke unit admission - comprehensive stroke unit care is as effective as thrombolysis in reducing mortality and morbidity. 3