What is the initial management of an acute stroke?

Initial Management of Acute Stroke

Treat acute stroke as a medical emergency with the same priority as acute myocardial infarction or major trauma, initiating immediate evaluation and stabilization of airway, breathing, and circulation (ABCs) upon patient arrival. 1

Immediate Stabilization (First Minutes)

Airway, Breathing, and Circulation:

• Assess and secure airway, breathing, and circulation immediately, though most acute ischemic stroke patients do not require emergency airway management 2, 1
• Administer supplemental oxygen only if oxygen saturation <94% to prevent hypoxemia-related secondary brain injury 2, 1
• Avoid routine oxygen supplementation in nonhypoxic patients, as it provides no benefit 1

Glucose Assessment:

• Check fingerstick glucose immediately upon arrival, as hypoglycemia is a common stroke mimic that can be rapidly reversed with IV glucose 2, 1
• If blood glucose <60 mg/dL, administer intravenous glucose immediately to resolve potential neurological deficits 2, 1

Vascular Access and Laboratory Testing:

• Establish IV access and obtain blood samples for complete blood count, electrolytes, random glucose, coagulation status (INR, aPTT), and creatinine 2, 1
• Critical pitfall: These tests should not delay imaging or treatment decisions—blood work must be obtained but cannot delay CT scan or thrombolytic therapy 2, 1

Neurological Assessment

Stroke Scale and Timing:

• Perform rapid neurological examination using a standardized stroke scale (National Institutes of Health Stroke Scale - NIHSS) to determine focal deficits and assess stroke severity 2, 1
• Accurately determine the exact time the patient was last known to be well—this is the single most important factor for eligibility for reperfusion therapies 1
• Repeat neurological examinations at least hourly during the first 24 hours, as approximately 25% of patients experience clinical deterioration in this period 1

Immediate Neuroimaging

Brain Imaging:

• Obtain immediate neuroimaging with CT or MRI to confirm diagnosis, location, and extent of hemorrhage or ischemia 1
• Use teleradiology systems at hospitals lacking in-house imaging interpretation expertise to ensure rapid image review 1
• If initial CT is negative but clinical suspicion remains high, consider MRI with diffusion-weighted imaging 1

Blood Pressure Management

The approach differs dramatically based on thrombolytic eligibility:

For patients NOT receiving thrombolytic therapy:

• Lower blood pressure only if systolic >220 mmHg or diastolic >120 mmHg 2, 1
• Aggressive blood pressure reduction may decrease perfusion pressure and worsen ischemia 2
• Do not initiate antihypertensive treatment in the prehospital setting unless directed by medical command, to prevent inadvertent cerebral hypoperfusion 1

For patients who ARE candidates for thrombolytic therapy:

• Blood pressure must be reduced to systolic <185 mmHg and diastolic <110 mmHg before administering thrombolytics to avoid hemorrhagic complications 2, 1
• Elevated blood pressure (systolic ≥185 mmHg or diastolic ≥110 mmHg) is a contraindication to thrombolytics 2

Positioning and Fluid Management

Patient Positioning:

• For hypotensive patients (systolic blood pressure <120 mmHg), place the head of the stretcher flat and administer isotonic saline to improve cerebral perfusion 2, 1
• Place nonhypoxic patients who tolerate lying flat in the supine position to optimize cerebral perfusion 1
• Elevate the head of bed 15-30° in patients at risk for airway obstruction, aspiration, or suspected elevated intracranial pressure 1

Fluid Administration:

• Use normal saline (isotonic fluids) if rehydration is required 2, 1
• Avoid excessive intravenous fluid administration and do not give dextrose-containing fluids to patients who are not hypoglycemic, as excessive dextrose has the potential to exacerbate cerebral injury 2, 1

Seizure Management

Acute Seizure Treatment:

• Treat new onset seizures occurring immediately before or within 24 hours of stroke onset with short-acting medications (e.g., lorazepam IV) if they are not self-limited 2, 1
• A single, self-limiting seizure occurring at onset or within 24 hours should not be treated with long-term anticonvulsant medications 2
• Monitor patients with immediate post-stroke seizures for recurrent seizure activity during routine vital signs monitoring 2

Coagulopathy Management

For patients on anticoagulation:

• 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 1

Transport and Triage

Prehospital Considerations:

• Emergency medical services should bypass facilities without stroke-treatment capability and transport the patient to the nearest Primary or Comprehensive Stroke Center 1
• Advance notification of stroke patient arrival by EMS shortens time to initial evaluation, brain imaging, and increases use of intravenous thrombolysis 2
• Transport to a Primary Stroke Center or Comprehensive Stroke Center lowers 30-day mortality (10.1% vs 12.5% at non-designated hospitals) and increases use of thrombolytic therapy 1

Admission and Specialized Care

Stroke Unit Admission:

• Admit every acute stroke patient to a geographically defined stroke unit staffed by an interdisciplinary team—this reduces mortality and morbidity to an extent comparable with the benefit of IV alteplase 1
• Maintain NPO status until a formal dysphagia screening is completed using validated tools before allowing any oral intake to prevent aspiration pneumonia 1

Prevention of Complications

Venous Thromboembolism Prevention:

• Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 1
• Do not use graduated compression stockings, as they are less effective than intermittent pneumatic compression 1

Aspiration Prevention:

• Perform formal screening procedure for dysphagia before initiating oral intake to reduce the risk of pneumonia 1
• Do not administer oral medications until dysphagia screening is completed 1

Critical Pitfalls to Avoid

• Do NOT delay imaging or treatment for diagnostic tests—blood work should be obtained but must not delay CT scan or thrombolytic therapy 2, 1
• Do NOT use corticosteroids for management of cerebral edema and increased intracranial pressure 1
• Do NOT routinely lower blood pressure in ischemic stroke unless it exceeds 220/120 mmHg (or 185/110 mmHg if thrombolytic candidate) 2, 1
• Do NOT give dextrose-containing fluids to nonhypoglycemic patients 2, 1
• Do NOT initiate prehospital antihypertensive treatment without medical command direction 1