Acute Stroke Management

Initial Recognition and Pre-hospital Management

• Emergency Medical Services (EMS) should be contacted immediately when signs of stroke are recognized, using validated tools such as FAST (Face, Arms, Speech, Time) 1
• EMS dispatchers should be trained to recognize stroke symptoms and prioritize rapid response 1
• Paramedics should use validated stroke assessment tools on scene and implement a "recognize and mobilize" approach to minimize on-scene time 1
• Pre-notification of the receiving hospital by EMS is essential to activate stroke protocols and prepare the stroke team, imaging, and other necessary resources 1

Emergency Department Triage and Assessment

• Emergency departments should use validated stroke screening tools and follow local protocols developed jointly with pre-hospital services 2
• Patients should be evaluated immediately by clinicians experienced in stroke assessment 2
• Urgent vital signs monitoring should be initiated, with temperature checks every 4 hours for the first 48 hours 3
• Initial laboratory tests should include complete blood count, electrolytes, renal function, glucose, lipids, and coagulation studies 2

Immediate Imaging

• All suspected stroke patients should undergo urgent brain CT or MRI within 24 hours of symptom onset, but ideally as soon as possible 2
• Imaging is crucial to rule out intracranial hemorrhage, identify vessel occlusion and its location, and assess the risk/benefit ratio of potential treatments 4
• For patients eligible for thrombolysis or endovascular therapy, imaging should be performed without delay 4

Acute Treatment of Ischemic Stroke

• Intravenous rtPA (0.9 mg/kg, maximum 90 mg) is strongly recommended for carefully selected patients within 3 hours of stroke onset 5
• Blood pressure must be <185/110 mmHg before administering rtPA 6
• For large vessel occlusions, endovascular thrombectomy should be considered, particularly within 6 hours of symptom onset 7
• Combined approaches using stent retrievers and aspiration techniques achieve the best reperfusion rates 4

Management of Physiological Parameters

• Cautious approach to hypertension is recommended, with avoidance of treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg 6
• Monitor blood glucose regularly and treat hyperglycemia to maintain levels <300 mg/dL (<16.63 mmol/L) 6
• Treat sources of fever and use antipyretics for elevated temperatures 6
• For temperatures >37.5°C, increase monitoring frequency and investigate possible infections 3

Management of Complications

• Corticosteroids are not recommended for cerebral edema and increased intracranial pressure 5
• Osmotherapy and hyperventilation are recommended for deteriorating patients 5
• Surgical decompression may be life-saving for large cerebellar infarctions causing brainstem compression 5
• New-onset seizures should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limiting 3
• Prophylactic anticonvulsants are not recommended 3

Early Rehabilitation and Supportive Care

• Initial assessment by rehabilitation professionals should be conducted within 48 hours of admission 3
• Rehabilitation therapy should begin as early as possible once the patient is medically stable 3
• Frequent, brief, out-of-bed activity involving active sitting, standing, and walking should begin within 24 hours if no contraindications exist 3
• Swallowing, nutritional, and hydration status should be screened as early as possible, ideally on the day of admission 3
• Patients who cannot take food and fluids orally should receive appropriate feeding (nasogastric, nasoduodenal, or PEG) to maintain hydration and nutrition 8

Secondary Prevention

• Identify stroke etiology to guide secondary prevention strategies 8
• Initiate appropriate antithrombotic therapy before discharge 8
• Address modifiable risk factors including hypertension, diabetes, hyperlipidemia, and smoking 8
• Consider carotid imaging for patients with carotid territory symptoms who might be candidates for revascularization 2

Common Pitfalls and Caveats

• Delays in recognition and treatment significantly worsen outcomes - every 30-minute delay in recanalization decreases the chance of good functional outcome by 8-14% 4
• Overly selective treatment criteria may exclude patients who could benefit from therapy 4
• Inadequate blood pressure control before thrombolysis increases hemorrhagic risk 6
• Failure to monitor for and treat complications (swallowing difficulties, infections, venous thromboembolism) can worsen outcomes 3, 5
• Overlooking the need for early rehabilitation can delay recovery 3

Management of Acute Stroke

Acute Treatment of Ischemic Stroke

• The American Heart Association recommends that blood pressure must be <185/110 mmHg before administering rtPA, and for patients with blood pressure >185/110 mmHg who are candidates for acute reperfusion therapy, medications such as Labetalol, Nicardipine, or Clevidipine can be used to lower blood pressure 9
• The American Heart Association recommends maintaining BP ≤180/105 mmHg during and after thrombolysis treatment 9

Management of Physiological Parameters

• The American Heart Association suggests that sources of hyperthermia should be identified and treated, and antipyretic medications should be administered to lower temperature in hyperthermic patients 9
• The American Heart Association recommends that hypothermia should be offered only in the context of ongoing clinical trials 9
• The American Heart Association recommends monitoring blood glucose regularly and treating hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL, and close monitoring is essential to prevent hypoglycemia 9

Management of Complications

• The American Heart Association recommends that for patients selected for decompressive hemicraniectomy, proceed urgently to surgery prior to significant decline in GCS or pupillary change, ideally within 48 hours from stroke onset 10
• The American Heart Association recommends that stroke unit care significantly reduces mortality and dependency compared to general ward care, with an odds ratio of 0.76 for mortality and 0.80 for dependency 11

Stroke Unit Care

• The American Heart Association recommends that all stroke patients should be admitted to a geographically defined stroke unit with specialized staff as soon as possible, ideally within 24 hours of hospital arrival 11

Blood Pressure Management in Acute Ischemic Stroke

Patients Eligible for Reperfusion Therapy (IV rtPA or Mechanical Thrombectomy)

• Pre‑treatment blood pressure must be lowered to < 185/110 mmHg before initiating IV rtPA – the American Heart Association/American Stroke Association guideline recommends this threshold to qualify for thrombolysis. 12
• Labetalol 10–20 mg IV over 1–2 minutes (may repeat once) is an accepted rapid‑acting agent for achieving the pre‑treatment target. 12
• Nicardipine initiated at 5 mg/h IV and titrated by 2.5 mg/h every 5–15 minutes (max 15 mg/h) is another recommended option for rapid BP reduction. 12
• If the target < 185/110 mmHg cannot be achieved, IV rtPA should be withheld. 12
• During and for the first 24 hours after thrombolysis or thrombectomy, maintain blood pressure ≤ 180/105 mmHg to reduce the risk of hemorrhagic transformation. 12
• Blood pressure monitoring schedule after reperfusion therapy: every 15 minutes for the first 2 hours from rtPA start, then every 30 minutes for the next 6 hours, and hourly thereafter for the remaining 16 hours. 12
• If systolic BP rises to 180–230 mmHg or diastolic BP to 105–120 mmHg, treat with:
  
  • Labetalol 10 mg IV followed by a continuous infusion of 2–8 mg/min, or
  • Nicardipine 5 mg/h IV, titrated to the desired effect. 12
• If diastolic BP exceeds 140 mmHg, consider intravenous sodium nitroprusside as a rescue agent. 12

Patients Not Receiving Reperfusion Therapy

• Blood pressure reduction is only indicated when systolic BP > 220 mmHg or diastolic BP > 120 mmHg; otherwise permissive hypertension is acceptable. 13
• A reasonable goal is to lower blood pressure by 15–25 % within the first 24 hours when treatment is indicated. 13
• Rationale: acute stroke impairs cerebral autoregulation, so the brain may rely on elevated systemic pressure to perfuse the ischemic penumbra. 12
• Exceptions requiring BP lowering regardless of stroke type (due to concurrent critical conditions): acute myocardial infarction, acute heart failure, and acute aortic dissection. 13

Monitoring and Safety Considerations

• Avoid overly aggressive BP lowering in patients not undergoing thrombolysis, as this can worsen cerebral perfusion and enlarge the infarct. 12
• Arterial hypotension (systolic < 100 mmHg) is rare but dangerous, prompting evaluation for alternative diagnoses such as cardiac ischemia, aortic dissection, or shock, and necessitating immediate correction. 12
• Frequent BP monitoring during the acute phase is essential to detect dangerous fluctuations that require prompt intervention. 12