What is the recommended acute and secondary management for a patient with suspected acute ischemic stroke?

Acute Ischemic Stroke Management

Immediately activate emergency medical services (EMS) for direct transport to the nearest stroke-capable center with CT imaging, as time from symptom onset to reperfusion therapy is the single most critical determinant of outcome. 1, 2

Prehospital Recognition and Transport

Use a validated stroke screening tool (FAST: Face, Arms, Speech, Time) at first contact—any positive finding mandates immediate high-priority EMS activation. 1

• EMS personnel should perform a two-step assessment: first screen with FAST, then use a validated severity scale to identify potential large vessel occlusion candidates (look for aphasia, visual field deficits, neglect). 1
• Record the exact time of symptom onset or "last known well" time—this single data point determines all treatment eligibility. For wake-up strokes, the last known well time is when the patient went to sleep, not when they were discovered. 2, 3
• Limit on-scene time to ≤15-20 minutes maximum—the goal is "recognize and mobilize," not extensive field management. 1, 2
• Obtain capillary blood glucose immediately on scene; if <50-60 mg/dL, treat hypoglycemia with IV dextrose as it mimics stroke and contraindicates thrombolysis. 1, 2
• Establish IV access with normal saline (avoid dextrose-containing solutions unless hypoglycemic) and draw blood samples for CBC, electrolytes, creatinine, coagulation studies (INR/aPTT), and glucose. 2
• Document any anticoagulant use (warfarin, direct oral anticoagulants) or recent antiplatelet therapy—this directly affects reperfusion eligibility. 2

Transport directly to the nearest stroke-capable center, bypassing non-stroke hospitals, with detailed prenotification including onset time, FAST findings, vital signs, glucose level, anticoagulation status, and estimated arrival time. 1, 2

Blood Pressure Management During Transport

For patients potentially eligible for IV thrombolysis (≤4.5 hours from onset), maintain systolic BP <185 mmHg and diastolic BP <110 mmHg. 2

• If BP exceeds these thresholds, administer labetalol 10 mg IV bolus or start nicardipine infusion (5 mg/h, titrate by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h). 2
• Avoid aggressive BP reduction below target values—cerebral perfusion is pressure-dependent in acute stroke. 2
• For patients NOT candidates for thrombolysis, treat hypertension only if systolic >220 mmHg or diastolic >120 mmHg; if treatment required, lower BP by only 15-25% within the first 24 hours. 2
• Do not treat hypertension in the field unless systolic BP ≥220 mmHg and only after medical command consultation. 2

Airway and Supportive Care During Transport

• Administer supplemental oxygen only if oxygen saturation <94%—routine oxygen in non-hypoxic patients does not improve outcomes. 2, 3
• Intubate if Glasgow Coma Scale ≤8 or if bulbar dysfunction prevents airway protection. 2, 3
• Initiate continuous cardiac monitoring to detect arrhythmias (especially atrial fibrillation). 2, 3
• Treat active seizures with IV lorazepam; do not give prophylactic anticonvulsants (Class III recommendation—potential for harm). 2

Emergency Department Evaluation

Target door-to-CT time of ≤25 minutes and door-to-needle time of ≤30 minutes (median) or ≤60 minutes (90th percentile)—each 15-minute reduction in door-to-needle time decreases in-hospital mortality by 5%. 1, 2, 3

Immediate Actions Upon Arrival

• Triage as highest priority (equivalent to acute MI or major trauma) and activate stroke team immediately. 1, 3
• Perform rapid neurological assessment using NIH Stroke Scale (NIHSS) to quantify deficit severity. 2, 3
• Check vital signs every 15-30 minutes; treat fever >99.6°F as hyperthermia worsens outcomes. 3
• Position head of bed at 25-30 degrees unless contraindicated. 3

Imaging Protocol

Obtain non-contrast CT brain immediately to exclude hemorrhage and assess for early ischemic changes—do not delay imaging for laboratory results. 1, 3

• For patients presenting within 6 hours of onset, obtain CT angiography (CTA) from aortic arch to vertex to identify large vessel occlusion for potential mechanical thrombectomy. 2, 3
• Advanced imaging (CT perfusion or MRI with DWI-FLAIR mismatch) can identify candidates for extended-window thrombolysis in wake-up strokes or patients with unknown onset time. 2

Laboratory Testing

Order immediately but do not delay imaging: complete blood count, electrolytes, renal function, coagulation studies (PT/INR, aPTT), troponin, and blood glucose. 2, 3

Acute Reperfusion Therapy

Intravenous Thrombolysis

Administer IV alteplase (or tenecteplase) to eligible patients within 4.5 hours of symptom onset when no contraindications exist (Class I, Level A evidence). 1, 2

Key eligibility criteria:

• Time from symptom onset (or last known well) ≤4.5 hours 1, 2
• Blood pressure <185/110 mmHg (must be achieved before treatment) 2
• No intracranial hemorrhage on CT 1
• Glucose ≥50 mg/dL 2
• No recent major surgery, trauma, or GI/GU bleeding 1
• Not on therapeutic anticoagulation (INR ≤1.7, aPTT normal, or appropriate time since last DOAC dose) 1

During IV alteplase infusion, check vital signs every 15 minutes and maintain BP <180/105 mmHg. 3

Mechanical Thrombectomy

Perform endovascular thrombectomy for large vessel occlusion within 6 hours of symptom onset (Class I, Level A evidence); selected patients may benefit up to 24 hours with favorable imaging criteria. 2, 4

• Use "drip-and-ship" strategy: administer IV alteplase at primary stroke center and immediately transfer to comprehensive stroke center for thrombectomy—do not delay transfer to observe alteplase effect. 2
• Thrombectomy is highly effective even after thrombolysis and remains beneficial in both anterior and posterior circulation strokes. 2, 4

Critical Pitfalls to Avoid

• Never postpone transfer to obtain imaging at a non-CT facility—rapid transport supersedes any on-site intervention without imaging capability. 2
• Do not withhold transfer for "mild" or improving symptoms—large vessel occlusions can present with fluctuating deficits. 2
• Do not assume patients beyond 4.5 hours are ineligible for therapy—endovascular treatment may be offered up to 24 hours with appropriate imaging selection. 2
• Failure to establish accurate symptom onset time can inappropriately exclude patients from time-sensitive interventions. 3
• Posterior circulation strokes may present with atypical symptoms (vertigo, ataxia, diplopia) and require special attention to airway management. 3

Stroke Mimics

Be vigilant for conditions that mimic stroke: hypoglycemia (most common reversible mimic), seizure with Todd's paralysis, complex migraine with aura, conversion disorder, hypertensive encephalopathy, and CNS abscess or tumor. 3, 5

Early Inpatient Management

• Perform swallowing screening with a validated tool before any oral intake to prevent aspiration. 3
• Monitor for neurological deterioration, hemorrhagic transformation, and cerebral edema. 6
• Maintain normoglycemia, normothermia, and adequate oxygenation—avoid hyperglycemia and hyperthermia as both worsen outcomes. 3, 6
• Begin early mobilization and comprehensive rehabilitation planning. 6

Secondary Prevention

Initiate secondary prevention measures during hospitalization to prevent early recurrence (up to 20% risk at 90 days for high-risk patients). 1, 5

• Start antiplatelet therapy (aspirin 325 mg or dual antiplatelet therapy with aspirin plus clopidogrel for 21-90 days in minor stroke/high-risk TIA). 5, 6
• Initiate oral anticoagulation for cardioembolic stroke (atrial fibrillation, mechanical valve). 5, 6
• Start high-intensity statin therapy regardless of baseline cholesterol. 5, 6
• Optimize blood pressure control, diabetes management, and smoking cessation. 5, 6
• Consider carotid revascularization for symptomatic carotid stenosis ≥50% or patent foramen ovale closure in selected patients. 5