What is the recommended acute and secondary management for an elderly patient presenting with an acute paralytic stroke?

Treatment of Paralytic Stroke in Elderly Patients

For elderly patients presenting with acute paralytic stroke, immediate emergency department evaluation with rapid brain imaging (CT within minutes of arrival) is mandatory, followed by intravenous alteplase (0.9 mg/kg, maximum 90 mg) if eligible within 4.5 hours of symptom onset, and endovascular thrombectomy for large vessel occlusion within 6-24 hours based on imaging selection. 1

Hyperacute Management (First Hours)

Immediate Assessment and Stabilization

• Airway, breathing, and circulation assessment must be performed immediately upon arrival, with supplemental oxygen provided to maintain saturation >94% 1
• Neurological examination using the National Institutes of Health Stroke Scale (NIHSS) should be conducted immediately to determine stroke severity and guide treatment decisions 1
• Vital signs monitoring is critical: heart rate, rhythm, blood pressure, temperature, oxygen saturation, and seizure activity assessment 1

Emergency Imaging Protocol

• Non-contrast CT brain imaging must be obtained immediately (ideally within 25 minutes of ED arrival) to differentiate ischemic from hemorrhagic stroke and rule out contraindications to thrombolysis 1
• CT angiography (CTA) should be performed simultaneously with initial non-contrast CT for all patients presenting within 24 hours, as this approach detects more large vessel occlusions, increases thrombectomy rates, and improves outcomes 2, 3
• MRI is more sensitive than CT for ischemic changes and equally accurate for detecting acute hemorrhage, but CT remains the standard due to speed and availability 1, 4

Blood Pressure Management

For thrombolysis candidates: Blood pressure must be reduced to <185/110 mmHg before initiating alteplase and maintained <180/105 mmHg for 24 hours post-treatment to prevent hemorrhagic complications 1

For non-thrombolysis patients: Only treat if systolic BP >220 mmHg or diastolic BP >120 mmHg, as aggressive lowering may worsen ischemia by decreasing cerebral perfusion 1

Intravenous Thrombolysis Decision

Eligibility criteria for alteplase 1:

• Time window: Within 4.5 hours of symptom onset or last known well
• Age considerations: Equally recommended for patients <80 and >80 years within 3 hours; for 3-4.5 hour window, recommended for patients ≤80 years without both diabetes and prior stroke history 1
• Dosing: 0.9 mg/kg (maximum 90 mg total), with 10% given as IV bolus over 1 minute, remaining 90% infused over 60 minutes 1
• Target door-to-needle time: <60 minutes in 90% of cases, with median of 30 minutes 1

Key contraindications 1:

• Intracranial hemorrhage on CT
• Blood pressure that cannot be safely lowered to <185/110 mmHg
• Unclear or unwitnessed symptom onset beyond treatment window

Endovascular Thrombectomy

Indications 1:

• Large vessel occlusion identified on CTA (internal carotid artery, M1/M2 middle cerebral artery segments)
• Treatment within 6 hours: All eligible patients should receive thrombectomy 1
• Extended window (6-24 hours): Select patients with favorable imaging (small core infarct, salvageable penumbra) may benefit 1
• Target time: CT to groin puncture <60 minutes 1
• Can be performed in patients who received or were ineligible for IV alteplase 1

Acute Inpatient Management (First 24-72 Hours)

Monitoring and Complication Prevention

• Cardiac monitoring for at least 24 hours to detect atrial fibrillation and serious arrhythmias that require intervention 1
• Neurological assessments every 15 minutes during and after thrombolysis, then hourly for 24 hours to detect hemorrhagic transformation or clinical deterioration 1
• Temperature management: Identify and treat sources of hyperthermia (>38°C) with antipyretics, as fever worsens outcomes 1

Glucose Management

• Hypoglycemia (<60 mg/dL) must be treated immediately to achieve normoglycemia 1
• Hyperglycemia should be managed to maintain blood glucose 140-180 mg/dL using subcutaneous or intravenous insulin protocols 1

Early Antiplatelet Therapy

• Aspirin 160-300 mg daily should be initiated within 48 hours of ischemic stroke onset (but not within 24 hours of thrombolysis) 1
• Anticoagulation with unfractionated heparin is NOT recommended as standard treatment due to increased bleeding risk without additional benefit 1

Deep Vein Thrombosis Prophylaxis

• Low molecular weight heparin (enoxaparin 40 mg subcutaneously once daily) is more effective than unfractionated heparin (5000 IU twice daily) for DVT prevention in immobilized stroke patients 1
• Early mobilization and external compression devices provide additional protection 1

Management of Cerebral Edema

• Close observation is required for 3-4 days post-stroke, as cytotoxic edema typically peaks during this period 1
• For malignant edema (particularly in large middle cerebral artery infarctions in patients 18-60 years): Urgent neurosurgical consultation for potential hemicraniectomy within 48 hours, which substantially reduces death and disability 1

Secondary Prevention and Rehabilitation

Risk Factor Management

Essential interventions 5:

• Antiplatelet therapy: Clopidogrel or aspirin for non-cardioembolic stroke 5
• Anticoagulation: Oral anticoagulants for cardioembolic stroke with atrial fibrillation 5
• Blood pressure control: Restart antihypertensive medications after 24 hours if neurologically stable 1
• Lipid management: Statin therapy for atherosclerotic stroke 5
• Diabetes control and smoking cessation 5

Carotid Evaluation

• Urgent carotid duplex ultrasound for patients with carotid territory symptoms who are potential candidates for revascularization 1
• Carotid endarterectomy for symptomatic stenosis >50-70% 5

Multidisciplinary Rehabilitation

Early assessment and intervention 1, 5:

• Swallowing evaluation before oral intake to prevent aspiration
• Physical therapy for motor impairments, hemiparesis, gait abnormalities
• Occupational therapy for activities of daily living, cognitive impairments
• Speech-language pathology for aphasia, dysarthria, cognitive-communication deficits

Discharge Planning

Critical elements 5, 6:

• Patient and family education on stroke warning signs (FAST: Face drooping, Arm weakness, Speech difficulty, Time to call 911)
• Medication adherence assessment and simplification of regimens
• Follow-up coordination: Primary care for risk factor management, neurology/stroke specialist, cardiology if atrial fibrillation present
• Outpatient rehabilitation referrals as needed

Common Pitfalls to Avoid

• Do not delay imaging or treatment to obtain extensive history—time is brain, and every 15-minute delay in thrombolysis reduces favorable outcomes 1, 6
• Do not withhold thrombolysis based solely on advanced age—patients >80 years benefit equally within 3 hours 1
• Do not aggressively lower blood pressure in non-thrombolysis candidates unless severely elevated (>220/120 mmHg), as this may worsen cerebral perfusion 1
• Do not assume small strokes don't need CTA—performing CTA on all patients within 24 hours detects more large vessel occlusions and expands treatment options 2
• Do not start antiplatelet therapy within 24 hours of thrombolysis due to increased hemorrhage risk 1