What is the recommended approach to a patient presenting with an acute cerebral infarction and hemiplegia?

Approach to Patient with Cerebral Infarction and Hemiplegia

Immediately assess airway, breathing, and circulation, obtain non-contrast CT within 25 minutes of arrival to differentiate ischemic from hemorrhagic stroke, and initiate IV thrombolysis with alteplase 0.9 mg/kg if the patient presents within 4.5 hours of symptom onset and meets eligibility criteria. 1, 2

Immediate Emergency Department Assessment

Initial Stabilization and Vital Parameters

• Perform rapid ABC assessment to identify life-threatening airway obstruction, respiratory compromise, or hemodynamic instability 1, 2
• Monitor oxygen saturation continuously and provide supplemental oxygen at 2-3 L/min if saturation falls below 92% 1
• Position the patient appropriately: Keep head flat (0 degrees) if no hypoxia or aspiration risk to maximize cerebral blood flow; elevate head to 25-30 degrees if aspiration risk, increased intracranial pressure, or respiratory compromise is present 1
• Keep patient NPO until swallowing ability is formally assessed, as dysphagia occurs frequently with hemiplegia 1

Neurological Examination

• Conduct standardized neurological assessment using NIHSS to quantify stroke severity and focal deficits, recognizing that hemiplegia typically indicates anterior circulation involvement with middle cerebral artery territory infarction 1, 2
• Document specific deficits: motor weakness pattern, sensory changes, visual field defects, language disturbances, and level of consciousness 1
• Assess for seizure activity, which can complicate large cortical strokes causing hemiplegia 1

Vital Signs Monitoring

• Record heart rate and rhythm, blood pressure, temperature, oxygen saturation, and hydration status 1, 2
• For thrombolysis candidates: Reduce systolic BP <185 mmHg and diastolic BP <110 mmHg using labetalol, nitropaste, or nicardipine drip before administering tPA 1, 2
• For non-thrombolysis candidates: Only lower BP when systolic >220 mmHg or diastolic >120 mmHg, as aggressive reduction may worsen cerebral ischemia 1, 2
• Treat fever >99.6°F with acetaminophen, as hyperthermia worsens outcomes 1

Urgent Diagnostic Workup

Neuroimaging (Priority #1)

• Obtain non-contrast CT or MRI immediately (target: within 25-45 minutes of arrival) to differentiate ischemic from hemorrhagic stroke 1, 3, 2
• Perform CTA from aortic arch to vertex simultaneously with initial CT to identify large vessel occlusions amenable to endovascular thrombectomy 1, 3, 2
• Do not withhold IV tPA if frank hypodensity involves >1/3 of middle cerebral artery territory, as this increases hemorrhagic transformation risk 1, 2
• Complete imaging interpretation within 45 minutes by a physician experienced in neuroimaging 1

Laboratory Investigations (Do Not Delay Imaging)

• Draw acute bloodwork immediately but do not await results before imaging or treatment unless clinical suspicion exists for bleeding abnormality, thrombocytopenia, or known anticoagulant use 1, 3, 2
• Essential labs include: electrolytes, glucose (to exclude hypoglycemia as stroke mimic), CBC with platelets, coagulation studies (INR, aPTT), creatinine, eGFR, and troponin 1, 3, 2
• For patients on warfarin, INR is required before thrombolysis decisions 1

Cardiac Evaluation

• Obtain 12-lead ECG to detect atrial fibrillation, acute coronary syndrome, or structural heart disease, but defer until after thrombolysis decision if patient is hemodynamically stable 1, 3
• Initiate continuous cardiac monitoring for 24-72 hours to detect paroxysmal atrial fibrillation 1
• Defer chest X-ray unless acute cardiac or pulmonary disease is evident; it should not delay acute treatment 1

Acute Reperfusion Therapy

Intravenous Thrombolysis

• Administer IV alteplase 0.9 mg/kg (maximum 90 mg) within 4.5 hours of symptom onset for eligible patients, with 10% given as bolus and remainder over 60 minutes 1, 2
• Do not withhold thrombolysis for mild or rapidly improving symptoms, as hemiplegia represents disabling deficit 2
• Contraindications include: inability to control BP to target levels, frank hypodensity >1/3 MCA territory on CT, or coagulopathy 1, 2

Endovascular Thrombectomy

• Consider mechanical thrombectomy for large vessel occlusions presenting ≤6 hours (or up to 24 hours in selected patients with favorable imaging) 1, 2
• Do not delay IV tPA while arranging transfer for endovascular therapy 2

Antiplatelet Therapy

• Initiate aspirin 160-300 mg/day within 48 hours of ischemic stroke onset 2
• For thrombolysis patients: Hold aspirin, clopidogrel, heparin, and warfarin for 24 hours after tPA, then start antithrombotic therapy 1

Acute Monitoring and Complications Management

Neurological Monitoring Schedule

• For thrombolysis patients: Neurological assessment and vital signs every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours (total 24 hours) 1
• For non-thrombolysis patients: Hourly neurological checks in ICU, or minimum every 4 hours in non-ICU setting 1
• Monitor for hemorrhagic transformation with repeat CT or MRI at 24 hours after thrombolysis before starting anticoagulants or antiplatelets 1, 2

Cerebral Edema Management

• Anticipate cerebral edema peaking at 3-5 days after large hemispheric infarctions causing hemiplegia 1, 2
• Consider osmotic therapy with mannitol 0.25-0.50 g/kg IV every 6 hours if signs of increased intracranial pressure develop, though evidence for routine use is limited 1
• Surgical decompressive hemicraniectomy within 48 hours reduces mortality in malignant middle cerebral artery infarctions causing hemiplegia, though survivors have severe residual deficits 1

Seizure Management

• Treat only if seizure is not self-limited with short-acting agents like IV lorazepam 2
• Do not use prophylactic anticonvulsants, as they may impair neural recovery and are associated with worse outcomes 1, 2
• For recurrent seizures: Initiate maintenance anticonvulsant therapy according to standard protocols 1

Early Rehabilitation and Complication Prevention

Mobility and Positioning

• Begin early, short, frequent mobilization as soon as medically stable to prevent complications 1
• Perform daily stretching of hemiplegic limbs to prevent contractures, teaching patients and families proper techniques 1
• Position hemiplegic shoulder in maximum external rotation for 30 minutes daily to prevent shoulder contracture 1
• Use supportive devices and slings to prevent shoulder subluxation 1
• Apply resting ankle splints at night to prevent ankle contracture in hemiplegic limb 1

Aspiration and Dysphagia Prevention

• Assess swallowing before allowing oral intake using bedside swallowing assessment or videofluoroscopic modified barium swallow 1, 2
• Position on paretic side when significant hemiparesis present to facilitate communication and prevent aspiration 1
• Insert nasogastric or nasoduodenal tube if swallowing is impaired for feedings and medications 1, 2

Venous Thromboembolism Prophylaxis

• Initiate early mobilization as primary prevention strategy 1
• Apply intermittent pneumatic compression devices if no contraindications, in addition to routine care 1
• Maintain adequate hydration and consider aspirin once cleared after thrombolysis 1

Pressure Injury Prevention

• Perform regular skin assessment using Braden scale 1
• Turn regularly, minimize skin friction, provide support surfaces, maintain good skin hygiene, and ensure adequate nutrition and hydration 1
• Use specialized mattresses and wheelchair cushions until mobility returns 1

Cognitive and Mood Assessment

• Screen for depression early, as it occurs in up to one-third of ischemic stroke patients and impairs rehabilitation 1
• Assess for delirium using validated tools (4AT or CAM-ICU), avoiding sedative medications, regulating sleep/wake cycles, and promoting early mobilization 1
• Provide cognitive stimulation and consider having family member stay with patient for orientation and safety 1

Disposition and Ongoing Care

Stroke Unit Admission

• Admit all stroke patients to dedicated stroke unit within 24 hours of hospital arrival, as 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 2

Critical Pitfalls to Avoid

• Never discharge from ED without: diagnostic evaluation completion, functional assessment, secondary prevention therapy initiation, and ongoing management plan 1
• Never delay imaging or acute treatment while awaiting laboratory results unless specific clinical indication exists 1, 3, 2
• Never skip vascular imaging, as CTA identifies large vessel occlusions benefiting from endovascular therapy up to 24 hours from onset 3
• Never forget glucose testing, as hypoglycemia is the only stroke mimic requiring immediate exclusion 3