Immediate Management of Suspected Acute Stroke

Immediate Actions

The American Heart Association recommends immediate activation of EMS for any patient with sudden neurological symptoms, including unilateral weakness, sensory loss, visual disturbances, speech difficulties, or coordination problems 1, 3, 4
Left-sided neglect combined with headache and dizziness strongly suggests right hemisphere stroke, particularly in the middle cerebral artery territory 5
EMS dispatch should be notified that this is a suspected stroke for high-priority response 1

The American Heart Association recommends that EMS personnel perform the Cincinnati Prehospital Stroke Scale, assessing facial droop, arm drift, and abnormal speech—if any one of these is abnormal, stroke probability is 72% 1
Supplementary oxygen should be provided only if oxygen saturation is less than 94% 3
The American Heart Association recommends not treating elevated blood pressure in the prehospital setting unless systolic BP is less than 90 mm Hg 3

The American Heart Association recommends direct transport to a designated stroke center with capacity for advanced imaging and thrombolytic therapy on-site 1, 4, 6
Prehospital notification to the receiving hospital is mandatory to activate the stroke team 1, 3

The American Heart Association recommends brain imaging, preferably MRI with diffusion-weighted imaging, or CT if MRI is unavailable, to be completed immediately upon arrival 6
Vascular imaging, such as CTA or MRA from aortic arch to vertex, should be performed without delay 6
An ECG should be performed immediately upon arrival 6

The patient meets the highest risk criteria for acute stroke, requiring immediate ED evaluation, due to presenting with unilateral neurological deficit, acute and potentially fluctuating symptoms, and left-sided neglect indicating right hemisphere involvement 6, 2, 7, 5

The American College of Cardiology recommends not discharging patients with crescendo or fluctuating symptoms under any circumstances 2
The American College of Cardiology recommends not delaying carotid imaging in patients with anterior circulation symptoms 2
The American College of Cardiology recommends not relying solely on ABCD2 scores for disposition decisions—clinical judgment and imaging findings are paramount 2