How should I manage a patient with an acute stroke?

Acute Stroke Management

Immediate Stabilization and Triage

Treat acute stroke as a medical emergency with the same priority as acute myocardial infarction or major trauma, immediately securing airway, breathing, and circulation (ABCs) upon patient arrival. 1, 2

• Assess and stabilize ABCs first - most acute ischemic stroke patients do not require emergency airway management, but this must be verified immediately 1, 2
• Administer supplemental oxygen only if oxygen saturation <94% to prevent hypoxemia-related secondary brain injury 1, 2, 3
• Check fingerstick glucose immediately - hypoglycemia is a common stroke mimic that can be rapidly reversed with IV glucose 1, 2, 3
• Establish IV access and obtain blood samples for complete blood count, electrolytes, glucose, coagulation studies (PT/INR), and creatinine, but do not delay imaging for these results 2, 3

Rapid Neurological Assessment

• Perform rapid neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to determine focal deficits and quantify stroke severity 2, 3
• Determine the exact time the patient was last known to be well - this is the single most important determinant of treatment eligibility 1
• Repeat neurological assessments at least hourly for the first 24 hours, as approximately 25% of patients deteriorate during this period 1, 3

Emergency Neuroimaging

Obtain immediate non-contrast CT or MRI brain imaging to distinguish ischemic from hemorrhagic stroke before any treatment decisions. 2, 3

• Imaging must not be delayed by laboratory results or other diagnostic tests 2
• Teleradiology systems are recommended for sites without in-house imaging interpretation expertise 1

Blood Pressure Management

For Ischemic Stroke (Non-Thrombolytic Candidates):

• Only lower blood pressure if systolic >220 mmHg or diastolic >120 mmHg - aggressive reduction may decrease cerebral perfusion and worsen ischemia 2, 3

For Ischemic Stroke (Thrombolytic Candidates):

• Blood pressure must be reduced to systolic <185 mmHg and diastolic <110 mmHg before administering thrombolytics to avoid hemorrhagic complications 2

For Hemorrhagic Stroke:

• Acutely lower systolic BP to 140 mmHg if initial systolic is 150-220 mmHg without contraindications 2

Thrombolytic Therapy

Administer IV alteplase (0.9 mg/kg, maximum 90 mg) within 3-4.5 hours of symptom onset for eligible ischemic stroke patients. 3, 4, 5

• Intravenous thrombolysis remains the cornerstone of acute ischemic stroke management and should not be delayed for interhospital transfer in eligible patients 1, 4
• Tenecteplase is emerging as an alternative to alteplase with similar efficacy 4, 6

Endovascular Thrombectomy

• Mechanical thrombectomy is standard of care for large vessel occlusions in anterior and posterior circulation when performed by experienced operators 4, 5
• Multiple randomized trials demonstrate substantial recanalization rates and improved outcomes compared to IV rtPA alone for proximal artery occlusions 5

Reversal of Coagulopathy

• For patients on vitamin K antagonists with elevated INR: withhold medication, administer therapy to replace vitamin K-dependent factors, correct the INR, and give intravenous vitamin K 2

Hospital Admission and Specialized Care

Admit all acute stroke patients to a geographically defined stroke unit with interdisciplinary specialized staff, as this reduces mortality and morbidity comparable to the benefits of IV rtPA. 1, 3

• Transport to Primary Stroke Centers (PSC) or Comprehensive Stroke Centers (CSC) reduces 30-day mortality (10.1% vs 12.5% at non-designated hospitals) and increases thrombolytic use 1
• EMS should bypass hospitals without stroke treatment capabilities and transport to the closest stroke-capable facility 1

Positioning and Fluid Management

• Position head flat if patient is hypotensive and administer isotonic saline to improve cerebral perfusion 2
• For hemorrhagic stroke, elevate head of bed 20-30 degrees to facilitate venous drainage and manage increased intracranial pressure 2
• Avoid excessive IV fluids and do not administer dextrose-containing fluids in non-hypoglycemic patients 1

Seizure Management

• Treat new-onset seizures occurring within 24 hours of stroke onset with short-acting anticonvulsants if not self-limited 2

Prevention of Complications

Venous Thromboembolism:

• Implement intermittent pneumatic compression beginning the day of hospital admission for VTE prevention 2, 3
• Do NOT use graduated compression stockings alone - they are less effective than intermittent pneumatic compression 2

Aspiration Pneumonia:

• Perform formal dysphagia screening using validated tools before allowing any oral intake to reduce pneumonia risk 2, 3
• Keep patient NPO until swallowing assessment is completed 1

Infection Surveillance:

• Fever after stroke should prompt immediate search for pneumonia, which is a leading cause of post-stroke mortality 3

Surgical Considerations for Hemorrhagic Stroke

Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus should undergo surgical removal of the hemorrhage as soon as possible. 2

Critical Pitfalls to Avoid

• Do NOT delay CT scan or thrombolytic therapy for blood work results 2
• Do NOT use corticosteroids for cerebral edema management - they are not recommended 2
• Do NOT initiate interventions for hypertension in the prehospital setting unless directed by medical command 1
• Do NOT administer medications by mouth - maintain NPO status until dysphagia screening is complete 1
• Do NOT delay transport for prehospital interventions 1

Quality Improvement

• Healthcare institutions should organize multidisciplinary quality improvement committees to review stroke care benchmarks and outcomes 1
• Standardized stroke orders and integrated care pathways improve adherence to best practices 1