Assessment and Management of Subacute Stroke

Initial Assessment

The American Heart Association recommends that all patients with suspected subacute stroke should undergo urgent brain CT or MRI within 24 hours of symptom onset to confirm diagnosis and rule out hemorrhage 1, 2
A standardized stroke severity evaluation using validated tools (e.g., National Institutes of Health Stroke Scale) should be performed to assess prognosis and rehabilitation potential 3, 2
Emergency department staff should use validated stroke screening tools to assist in rapid and accurate assessment 1, 4
Essential laboratory investigations should include full blood picture, electrocardiogram, electrolytes, renal function, fasting lipids, erythrocyte sedimentation rate and/or C-reactive protein, and glucose 1, 3
Patients with carotid territory symptoms who would potentially be candidates for carotid revascularization should have urgent carotid duplex ultrasound 1, 2

Blood pressure should be closely monitored in the first 48 hours after stroke onset 4
For patients not receiving thrombolysis, blood pressure should only be lowered if systolic BP exceeds 220 mmHg or diastolic exceeds 120 mmHg 4
For patients who received thrombolysis, maintain BP below 180/105 mmHg in the first 24 hours 4
Body temperature should be monitored at least 4 times per day for 3 days with treatment of temperature >37.5°C (99.5°F) with acetaminophen 4
Oxygen saturation should be monitored, with supplemental oxygen provided only to maintain oxygen saturation >94% 4

Fever, hyperglycemia, and swallowing dysfunction (FeSS) should be actively monitored and managed 4, 5
Swallowing screening should be performed within 24 hours of admission using a validated tool before giving food, fluids, or oral medications 4, 5
Blood glucose should be measured on admission and at least 4 times per day for 3 days, with elevated glucose >180 mg/dL (10 mmol/L) treated with insulin 4
Measures to prevent pneumonia should be implemented, including good pulmonary toileting and early mobility 5
Indwelling urinary catheters should be avoided when possible to reduce risk of urinary tract infections 5
Assess for urinary retention in the first 72 hours after stroke using bladder scanning to obtain post-void residual volume 5
Implement fall prevention protocols, especially during transfers and toileting 5

Aspirin 160-300 mg/day should be commenced within 48 hours of onset of acute ischemic stroke 1
Anticoagulation (e.g., intravenous unfractionated heparin) is not recommended as standard treatment due to increased bleeding risk 1, 2

All stroke patients should receive a standardized screening evaluation during initial hospitalization to identify those with residual impairments requiring rehabilitation 6
Early, short, frequent exercise sessions should be implemented to prevent complications and improve outcomes 5
Daily stretching of hemiplegic limbs should be performed to prevent contractures 5
Positioning of the hemiplegic shoulder in maximum external rotation for 30 minutes daily can help prevent shoulder contracture 5
Early mobilization should be encouraged to help prevent venous thromboembolism 3, 5

All stroke patients should be admitted to a geographically defined stroke unit with specialized staff 7, 2
Stroke unit care should be provided by an interdisciplinary team with expertise in stroke management 7, 2
The multidisciplinary team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists 2
Clinical pathways should be used consistently to ensure organized application of interventions to prevent stroke progression or secondary complications 7

All modifiable risk factors should be addressed as part of secondary prevention 2
Appropriate antithrombotic therapy should be prescribed based on stroke etiology 2
Blood pressure and cholesterol should be managed appropriately 2

A stroke system should ensure a smooth transition from inpatient to outpatient care 6
Timely transfer of hospital discharge information to the subsequent treating physician should be arranged 6
A clear method of appropriate follow-up should be established 6
Patient and family education about stroke risk factors, warning signs, and prevention strategies should be provided 6

Failure to monitor for and treat fever can worsen outcomes; temperature should be actively monitored and treated if >37.5°C 4
Delaying swallowing assessment increases risk of aspiration pneumonia; screening should be completed within 24 hours 4, 5
Inadequate blood pressure management can lead to complications; follow specific parameters based on whether the patient received thrombolysis 4
Overlooking urinary retention, which occurs in 21-47% of patients in the first 72 hours after stroke 5
Neglecting early mobilization and rehabilitation can lead to preventable complications like deep vein thrombosis and contractures 5, 3