How should I manage a patient with an evolving acute stroke, where neurological deficits are worsening or new deficits appear within the first few hours?

Management of Stroke in Evolution

Admit the patient immediately to a specialized stroke unit or neurocritical care unit and perform urgent vascular imaging with CT angiography or transcranial Doppler to identify large-vessel occlusion or critical stenosis, as deterioration following initial improvement is strongly associated with persistent arterial occlusion and warrants consideration for endovascular thrombectomy even beyond standard time windows. 1, 2

Immediate Triage and Stabilization (First 10 Minutes)

• Treat as a medical emergency with the same priority as acute myocardial infarction or major trauma, regardless of whether deficits are worsening or fluctuating. 1, 3
• Secure airway, breathing, and circulation immediately; intubate if Glasgow Coma Scale ≤8 or the patient cannot protect the airway. 3, 4
• Administer supplemental oxygen only if SpO₂ <94%; routine oxygen in non-hypoxic patients offers no benefit and may be harmful. 3, 4
• Obtain finger-stick glucose immediately—hypoglycemia (typically <60 mg/dL) can mimic or worsen stroke symptoms and must be corrected with IV glucose before any other intervention. 3, 4
• Establish IV access and draw blood for complete blood count, electrolytes, coagulation profile (INR, aPTT), and creatinine, but do not delay imaging or treatment for results. 3, 4

Neurological Assessment and Documentation

• Document the exact "last known well" time immediately—this single datum determines all reperfusion therapy eligibility. 3
• Perform the NIH Stroke Scale (NIHSS) rapidly to quantify current severity and establish a baseline for detecting further deterioration. 3, 4
• Repeat NIHSS at least hourly for the first 24 hours, as approximately 25% of patients experience neurological worsening during this period. 1, 4, 5

Emergent Vascular Imaging

This is the critical step that distinguishes stroke-in-evolution management from stable stroke:

• Order non-contrast CT brain immediately (target ≤25 minutes from arrival) to exclude hemorrhage. 3
• Do not stop there—proceed immediately to CT angiography (CTA) or MR angiography (MRA) to identify large-vessel occlusion or high-grade stenosis, which is present in 62% of patients who deteriorate following initial improvement. 2
• Transcranial Doppler (TCD) at bedside is an alternative rapid vascular assessment tool that can detect occlusion or stenosis in real time and predict subsequent deterioration. 2
• Large-vessel occlusion or stenosis on vascular imaging is the strongest predictor of deterioration (62% with occlusion vs. 4% with normal vessels, P<0.001). 2

Blood Pressure Management

For Thrombolysis Candidates (Within 4.5 Hours of Last Known Well)

• Target BP <185/110 mmHg before administering rtPA to reduce hemorrhagic risk. 3, 4
• Use labetalol 10–20 mg IV over 1–2 minutes (may repeat once) or nicardipine infusion starting at 5 mg/hr, titrated by 2.5 mg/hr every 5–15 minutes. 3

For Non-Thrombolysis Candidates or Beyond Time Window

• Treat severe hypertension only if systolic >220 mmHg or diastolic >120 mmHg; aggressive lowering may worsen cerebral perfusion in the setting of evolving ischemia. 4
• Avoid antihypertensive agents that induce cerebral vasodilation (e.g., nitrates, hydralazine), as these can exacerbate edema and increase intracranial pressure. 1, 5

Reperfusion Therapy Decision Algorithm

If Within 4.5 Hours of Last Known Well:

• Administer IV rtPA (0.9 mg/kg, maximum 90 mg) if no contraindications exist, even if symptoms are fluctuating or improving. 3, 6, 7
• Do not withhold rtPA solely because deficits are "mild" or "improving"—large-vessel occlusions frequently present with fluctuating symptoms. 3

If Large-Vessel Occlusion Identified on CTA/MRA:

• Activate the endovascular stroke team immediately for consideration of mechanical thrombectomy, which has demonstrated substantial recanalization rates and improved outcomes compared to IV rtPA alone in proximal artery occlusions. 7
• Endovascular therapy can be considered up to 24 hours from last known well in select patients with favorable imaging profiles (small infarct core, large penumbra). 7
• The presence of large-vessel atherosclerotic stenosis or embolic occlusion is the mechanism underlying 31% and 23% of deterioration cases, respectively, making these patients prime candidates for endovascular intervention. 2

If Symptoms Resolved but Vascular Imaging Shows Occlusion/Stenosis:

• Do not assume the patient is stable—62% of patients with documented occlusion on TCD who initially improved subsequently deteriorated. 2
• Consider urgent carotid endarterectomy (CEA) or endovascular intervention in highly select cases with small infarct core, large territory at risk, and critical carotid stenosis, though the evidence is limited (Class IIb). 1

Management of Cerebral Edema (Anticipatory)

Stroke-in-evolution patients are at high risk for malignant edema, which can accelerate within 24 hours after reperfusion:

• Restrict free water and avoid hypotonic fluids; use isotonic normal saline for volume replacement. 1, 4, 5
• Avoid dextrose-containing fluids in non-hypoglycemic patients, as hyperglycemia exacerbates cerebral injury. 1, 4
• Treat hyperthermia aggressively with antipyretics; fever >37.5°C for >24 hours correlates with poor outcomes. 1
• Minimize hypoxemia and hypercarbia through adequate oxygenation and ventilation. 1, 5
• Elevate the head of the bed 20–30 degrees to assist venous drainage once blood pressure is controlled. 1, 5
• If frank hypodensity on CT involves ≥1/3 of the MCA territory within 6 hours, or if MRI diffusion-weighted imaging shows volumes ≥80 mL, anticipate rapid fulminant edema and consider early transfer to a neurosurgical center. 5

If Increased Intracranial Pressure Develops:

• Initiate standard ICP management: hyperventilation (target PaCO₂ 30–35 mmHg), hypertonic saline (23.4% bolus or 3% infusion), osmotic diuretics (mannitol 0.25–1 g/kg), and intraventricular drainage if hydrocephalus is present. 1, 5
• Do NOT use corticosteroids—they are ineffective for cerebral edema in ischemic stroke and may cause harm. 4
• Decompressive hemicraniectomy should be considered in patients <60 years old with malignant MCA infarction and deteriorating neurological status despite medical management. 1

Seizure Management

• Treat active seizures with IV lorazepam (0.1 mg/kg, maximum 4 mg per dose) if not self-limited. 3, 4
• Do not initiate prophylactic anticonvulsants for a single seizure at stroke onset—there is no evidence of benefit and potential for harm. 3
• Monitor for recurrent seizure activity during routine vital-sign checks in the first 24 hours. 4

Cardiac Monitoring

• Obtain a 12-lead ECG promptly to identify atrial fibrillation or acute myocardial infarction as potential stroke etiologies. 1, 3
• Initiate continuous cardiac monitoring for the first 24 hours to detect intermittent atrial fibrillation (present in up to 25% of cryptogenic strokes) and potentially lethal arrhythmias. 1, 3

Fluid Management and Positioning

• If hypotensive (systolic <120 mmHg), keep the head flat and administer isotonic saline to improve cerebral perfusion. 4
• Avoid excessive IV fluid administration; maintain euvolemia to prevent worsening edema. 4

Admission and Specialized Care

• Admit to a geographically defined stroke unit staffed by an interdisciplinary team (neurologists, neurointensivists, neurosurgeons, dedicated stroke nurses); this intervention reduces mortality and morbidity to an extent comparable with IV rtPA. 1, 4, 5
• If comprehensive stroke care or timely neurosurgical intervention is unavailable, arrange immediate transfer to a Comprehensive Stroke Center. 5
• Implement standardized stroke order sets and integrated care pathways to ensure adherence to best practices. 1, 4

Critical Pitfalls to Avoid

• Do not delay vascular imaging to obtain additional laboratory tests or wait for "stability"—deterioration is unpredictable and vascular imaging is the only way to identify treatable occlusions. 2
• Do not assume that symptom improvement means the patient is out of danger—normal vascular studies predict stable resolution, but occlusion/stenosis predicts deterioration in the majority of cases. 2
• Do not withhold reperfusion therapy because symptoms are "too mild" or "improving"—fluctuating deficits are a hallmark of large-vessel occlusion. 3
• Do not aggressively lower blood pressure in the absence of thrombolytic therapy—permissive hypertension (up to 220/120 mmHg) maintains collateral perfusion in evolving stroke. 4
• Do not use graduated compression stockings for VTE prophylaxis—they are ineffective; use intermittent pneumatic compression beginning on the day of admission. 4

Post-Acute Considerations (After Stabilization)

• Initiate aspirin 160–325 mg within 24–48 hours of stroke onset (delayed 24 hours if rtPA was given). 5
• Continue statin therapy if the patient was already taking statins prior to admission. 5
• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk. 4
• Begin early rehabilitation assessment to optimize functional recovery. 5