What is the recommended acute management and secondary prevention for a patient with suspected ischemic stroke?

Acute Management and Secondary Prevention of Ischemic Stroke

All patients with suspected acute ischemic stroke require immediate hospital admission to a specialized stroke unit with continuous cardiac and neurologic monitoring for at least 24 hours, followed by urgent initiation of antiplatelet therapy, high-intensity statin therapy, and comprehensive secondary prevention measures. 1

Immediate Prehospital and Emergency Department Management

Time-Critical Assessment

• Establish the exact "last known well" time immediately—this single determination dictates all treatment eligibility, particularly for thrombolysis (effective within 4.5 hours) and mechanical thrombectomy (up to 24 hours for selected patients). 2, 3
• Activate emergency medical services (EMS) rather than private transport, as EMS reduces time to stroke team activation by approximately 8 minutes. 3
• Stabilize airway, breathing, and circulation (ABCs) in the field; provide supplemental oxygen only if oxygen saturation falls below 94%. 2, 4
• Check blood glucose immediately and avoid glucose-containing fluids unless the patient is hypoglycemic. 2

Emergency Department Protocol (Target: First 60 Minutes)

• Obtain non-contrast CT or MRI within 30 minutes of arrival—this is the only definitive method to differentiate ischemic stroke from hemorrhagic stroke and stroke mimics. 3
• Perform CT angiography or MR angiography from aortic arch to vertex within 24 hours to identify large vessel occlusions amenable to mechanical thrombectomy. 3
• Complete essential laboratory tests: blood glucose, oxygen saturation, serum electrolytes/renal function, complete blood count with platelets, cardiac biomarkers, PT/INR, and aPTT. 2

Critical Pitfall: Do not delay thrombolytic therapy while awaiting laboratory results unless there is clinical suspicion of bleeding abnormality, thrombocytopenia, or the patient has received anticoagulants. 2

Acute Treatment Phase (First 24-72 Hours)

Reperfusion Therapy

• Administer intravenous tissue plasminogen activator (tPA) with door-to-needle time <60 minutes for eligible patients presenting within 4.5 hours of symptom onset—earlier treatment (0-90 minutes) provides number-needed-to-treat of 4.5 compared to 14.1 for later treatment. 3, 5
• Tenecteplase is now a safe and effective alternative to alteplase for intravenous thrombolysis. 6
• For large vessel occlusions, endovascular thrombectomy has become standard of care for both anterior and posterior circulation strokes, with extended time windows up to 24 hours in selected patients. 5, 6

Blood Pressure Management

• Avoid lowering blood pressure unless systolic BP >220 mmHg or diastolic BP >120 mmHg—aggressive reduction worsens ischemic injury by compromising penumbral perfusion. 4
• If blood pressure reduction is necessary, lower cautiously by approximately 15% during the first 24 hours using easily titratable parenteral agents such as labetalol or nicardipine. 4
• For patients receiving thrombolysis, maintain blood pressure below 180/105 mmHg for at least 24 hours to minimize hemorrhagic complications. 4

Specialized 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. 3
• Maintain nurse-patient ratio of 1:2 for the first 24 hours, then 1:4 if stable—up to 30% of stroke patients deteriorate in the first 24 hours. 2
• Monitor particularly closely for cerebral edema in patients with large hemispheric infarcts, right hemispheric strokes, or posterior fossa infarctions, as edema typically peaks at 3-5 days but can occur within 24 hours with reperfusion. 1, 3

Antiplatelet Therapy Initiation

• Administer oral aspirin 160-325 mg within 24-48 hours after stroke onset for patients not receiving thrombolytic therapy. 1, 4
• Delay aspirin administration until >24 hours after thrombolysis for patients who received intravenous alteplase to minimize hemorrhagic risk. 2, 4
• For minor stroke or high-risk TIA, initiate dual antiplatelet therapy within 12-24 hours and continue for exactly 21 days, then switch to monotherapy. 1

High-Intensity Statin Therapy

• Initiate atorvastatin 80 mg daily immediately for all ischemic stroke patients, regardless of baseline cholesterol levels—this is a Class I recommendation. 1, 4
• Target LDL-C <70 mg/dL or achieve ≥50% reduction from baseline for patients with atherosclerotic disease. 1

Prevention of Acute Complications

Venous Thromboembolism Prophylaxis

• Use subcutaneous anticoagulants (unfractionated heparin 5000 IU twice daily or low-molecular-weight heparin) for immobilized patients—anticoagulation provides superior VTE prophylaxis compared to mechanical methods alone. 2, 1
• Use intermittent pneumatic compression for immobile patients, as this reduces risk of VTE and possibly death. 2
• Routine use of antiembolic stockings is not recommended. 2

Aspiration Prevention

• Implement swallowing screening before any oral intake—this is a compulsory quality indicator to prevent aspiration pneumonia. 3
• For patients unable to swallow, consider initiating nasoenteric feeding within 24 hours; nasoenteric tube feeding is preferred over PEG tube feeding for the first 2-3 weeks. 2
• Provide oral hygiene at least 3 times daily and immediately after meals to reduce aspiration pneumonia risk. 2

Early Mobilization

• Mobilize neurologically and hemodynamically stable patients within 24 hours—early mobilization (within 52 hours) is associated with fewer complications. 2
• Patients with stable presentation can be mobilized to out-of-bed chair sitting even if level of consciousness is depressed. 2

Other Complications

• Maintain euvolemia using isotonic intravenous normal saline; volume expanders to achieve hemodilution are not recommended. 2
• Avoid routine use of indwelling urinary catheters due to infection risk. 2
• Provide pressure area care for high-risk patients using high-specification foam mattresses. 2

Critical Pitfall: Do not use corticosteroids for cerebral edema management following ischemic stroke—they are ineffective and potentially harmful. 4

Urgent Etiologic Evaluation and Secondary Prevention

Carotid Stenosis Evaluation

• Perform CT angiography, MR angiography, or carotid ultrasound urgently to identify ipsilateral carotid stenosis requiring intervention. 1
• For symptomatic carotid stenosis 70-99% (NASCET criteria), perform carotid endarterectomy urgently—ideally within the first few days and no later than 2 weeks post-stroke. 1, 4
• Carotid revascularization is also indicated for ≥50% symptomatic carotid stenosis. 3

Anticoagulation for Cardioembolic Stroke

• Initiate oral anticoagulation with direct oral anticoagulants (DOACs) preferred over warfarin for atrial fibrillation identified as stroke mechanism—this is a compulsory quality indicator at discharge. 1, 3
• Do not use urgent anticoagulation routinely for acute ischemic stroke—it increases hemorrhagic risk without proven benefit for preventing early recurrent stroke. 4

Blood Pressure Control for Secondary Prevention

• Begin antihypertensive therapy within 24 hours after the acute phase with target BP <130/80 mmHg for most patients, or <120/80 mmHg for optimal secondary prevention. 1

Glycemic Control

• Target HbA1c ≤7.0% for most diabetic patients. 1

Lifestyle Modifications

• Mandate complete smoking cessation, Mediterranean-style diet, and physical activity to reduce recurrent stroke risk. 1

Rehabilitation and Discharge Planning

• Initiate physical therapy, occupational therapy, and speech therapy during hospitalization—conduct standardized screening evaluation to identify patients with residual impairments requiring rehabilitation. 1, 3
• Involve caregivers in rehabilitation planning within 24 hours, as 50-70% of patients regain functional independence but 15-30% remain permanently disabled. 3
• Provide comprehensive discharge planning with written action plans detailing medications, follow-up appointments, warning signs of recurrent stroke, and lifestyle modifications. 1
• Provide structured patient and family education about stroke causes, risk factors, warning signs, secondary prevention strategies, and proper EMS activation before discharge. 3

Critical Interventions to AVOID

• Do not use glycoprotein IIb/IIIa inhibitors, volume expansion, vasodilators, or induced hypertension strategies outside clinical trials—these lack proven benefit. 4
• Do not use hyperbaric oxygen therapy except for air embolization. 4
• Do not use neuroprotective agents—they have not demonstrated efficacy in improving outcomes. 4

Quality Monitoring

• Implement hospital-based or outpatient quality monitoring programs to track adherence to secondary prevention guidelines. 1
• Ensure six compulsory quality indicators are met: door-to-needle time <60 minutes for thrombolysis, all acute stroke patients admitted to stroke unit or ICU, brain imaging in every suspected stroke, antiplatelet therapy at discharge for ischemic stroke, anticoagulation at discharge for atrial fibrillation patients, and swallowing disorder screening for all patients. 3