What is the recommended acute and secondary management for a patient presenting with an acute cerebrovascular accident (stroke)?

Acute Cerebrovascular Accident Management

Immediate Emergency Department Evaluation

All patients with suspected acute stroke require immediate clinical evaluation with rapid assessment of airway, breathing, and circulation, followed by urgent brain imaging within 45 minutes to determine stroke type and eligibility for reperfusion therapy. 1

Initial Assessment Protocol

• Perform rapid ABC assessment immediately upon arrival to identify life-threatening conditions 1
• Conduct neurological examination using a standardized stroke scale (NIHSS) to determine focal deficits and stroke severity 1
• Assess vital parameters including heart rate/rhythm, blood pressure, temperature, oxygen saturation, hydration status, and seizure activity 1
• Obtain acute bloodwork including electrolytes, random glucose, complete blood count, coagulation status (INR, aPTT), and creatinine—but do not delay imaging or treatment for these results 1

Urgent Neuroimaging

Brain imaging with non-contrast CT (NCCT) or MRI must be completed immediately to distinguish ischemic from hemorrhagic stroke and determine treatment eligibility 1

• For patients arriving within 4.5 hours: Perform immediate NCCT without delay to determine thrombolysis eligibility 1
• For patients arriving within 6 hours: Perform NCCT plus CT angiography (CTA) from arch-to-vertex to identify large vessel occlusions eligible for endovascular thrombectomy (EVT) 1
• Imaging interpretation must occur within 45 minutes of ED arrival by a physician with expertise in neuroimaging 1

Acute Management Based on Stroke Type

For Ischemic Stroke

Intravenous thrombolysis with rtPA is highly effective for selected patients presenting within 4.5 hours of symptom onset and should be administered immediately after confirming eligibility 1, 2

Blood Pressure Management (Pre-Thrombolysis)

• If thrombolysis candidate: Blood pressure must be reduced below SBP 185 mmHg or DBP 110 mmHg before administering thrombolytics to avoid hemorrhagic complications 1
• If NOT thrombolysis candidate: Only lower blood pressure when SBP exceeds 220 mmHg or DBP exceeds 120 mmHg, as aggressive reduction may worsen ischemia 1

Antiplatelet Therapy

• Aspirin 160-300 mg/day should be commenced within 48 hours of acute ischemic stroke onset 1

Endovascular Thrombectomy Considerations

• EVT should be considered for patients with large vessel occlusions presenting within 6 hours, with recent evidence suggesting potential benefit up to 24 hours in selected patients 3, 2
• Use validated triage tools (such as ASPECTS) to rapidly identify EVT candidates who may require transfer 1

For Hemorrhagic Stroke

Patients with intracerebral hemorrhage require immediate blood pressure control and reversal of coagulopathy 4

Blood Pressure Management

• For ICH patients with SBP 150-220 mmHg: Acute lowering of systolic BP to 140 mmHg is safe and can improve functional outcomes 4
• Avoid cerebral vasodilators (such as sodium nitroprusside) in patients with elevated intracranial pressure 4
• Nicardipine is superior to labetalol for achieving and maintaining goal blood pressure 4

Coagulopathy Reversal

• Patients on vitamin K antagonists with elevated INR: Withhold medication, administer therapy to replace vitamin K-dependent factors, correct INR, and give intravenous vitamin K 4
• Patients with severe thrombocytopenia or coagulation factor deficiency: Receive appropriate factor replacement therapy or platelets 4

Vascular Imaging

• Perform vascular imaging (CTA, MRA, or catheter angiography) to exclude underlying lesions such as aneurysms or arteriovenous malformations 4

Seizure Management

New onset seizures occurring at stroke onset or within 24 hours should be treated with short-acting medications (e.g., lorazepam IV) only if not self-limited 1, 4

• A single self-limiting seizure should NOT be treated with long-term anticonvulsants as there is evidence suggesting possible harm with negative effects on neural recovery 1
• Prophylactic anticonvulsants are not recommended in acute stroke patients 1
• Recurrent seizures should be treated as per standard seizure management protocols 1, 4

Acute Inpatient Care

All stroke patients should be admitted to a dedicated stroke unit as soon as possible, ideally within 24 hours of hospital arrival 1

• Stroke unit care significantly reduces mortality (OR 0.76), death or institutionalization (OR 0.76), and death or dependency (OR 0.80) compared to general medical ward care 1
• Initial monitoring should occur in an ICU or stroke unit with neuroscience expertise, maintaining nurse-patient ratio of 1:2 for first 24 hours 4
• Neurological assessments using validated scales should be performed at baseline and repeated at least hourly for the first 24 hours 4

Prevention of Complications

• Implement intermittent pneumatic compression for venous thromboembolism prevention beginning day of admission 4
• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 4
• Avoid hypo-osmolar fluids (such as 5% dextrose in water) as they may worsen cerebral edema 4

Critical Pitfalls to Avoid

• Do not delay imaging or thrombolysis while waiting for laboratory results 1
• Do not treat frank hypodensity involving more than one-third of MCA territory with IV rtPA due to increased hemorrhage risk 1
• Recognize that early deterioration is common in ICH, with over 20% experiencing decreased consciousness between prehospital and ED evaluation 4
• Hematoma expansion occurs in 30-40% of ICH patients within first hours and predicts poor outcome 4
• Do not use graduated compression stockings for VTE prophylaxis as they are less effective than intermittent pneumatic compression 4

Secondary Prevention Evaluation

Patients with TIA or non-disabling stroke presenting within 48 hours with motor weakness or speech disturbance require comprehensive evaluation within 24 hours due to high recurrent stroke risk 1

• Brain imaging and vascular imaging (CTA or MRA from aortic arch to vertex) should be completed based on triage category 1
• 12-lead ECG to identify atrial fibrillation or structural heart disease 1
• Carotid imaging to identify significant symptomatic stenosis requiring revascularization 1