Acute Stroke Management

Initial Assessment and Stabilization

The American Heart Association recommends rapid evaluation of airway, breathing, and circulation (ABCs) should be performed immediately upon patient arrival, with a focus on assessing stroke severity using a validated stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) 1, 2
The American College of Cardiology suggests that vital signs assessment including heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity should be conducted to determine the patient's overall condition 1, 2
Establishing the time of symptom onset is crucial, defined as when the patient was last at their previous baseline or symptom-free state, to determine eligibility for thrombolytic therapy and endovascular treatment 3

The American Heart Association recommends that brain imaging (CT or MRI) should be completed immediately to assess for intracranial hemorrhage and ischemic stroke, with CT angiography (CTA) from aortic arch to vertex performed at the time of initial brain CT when possible to assess both extracranial and intracranial circulation 1, 2, 4, 5
Initial blood work should include complete blood count, electrolytes, coagulation studies (INR, aPTT), and renal function (creatinine, eGFR) to assess for any underlying conditions that may affect treatment decisions 1, 2, 5, 6

The American Heart Association recommends that intravenous tissue plasminogen activator (tPA) at 0.9 mg/kg (maximum 90 mg) should be administered to eligible patients within 3-4.5 hours of symptom onset, with strict adherence to patient selection criteria to ensure safe administration 7
Blood pressure management is critical, with the American College of Cardiology recommending that blood pressure must be below 185/110 mmHg before thrombolytic therapy, and consensus-based recommendations suggesting lowering blood pressure only when systolic pressure exceeds 220 mmHg or diastolic pressure exceeds 120 mmHg in patients not receiving thrombolytic therapy 1

The American Heart Association suggests that swallowing screening should be completed as early as possible by a trained practitioner using a validated tool, ideally within 24 hours of hospital arrival, to assess for dysphagia and prevent aspiration 2
Temperature management is important, with the American College of Cardiology recommending that temperature should be monitored every 4 hours for the first 48 hours, and temperature-reducing measures initiated if temperature exceeds 37.5°C 8
The American Academy of Neurology recommends that new-onset seizures should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limiting, but prophylactic use of anticonvulsants is not recommended 1, 8

The American Heart Association recommends that early mobilization and adequate hydration should be encouraged to help prevent venous thromboembolism, with low-molecular-weight heparin (e.g., enoxaparin) considered for patients at high risk 8
Anti-embolism stockings alone for post-stroke venous thromboembolism prophylaxis are not recommended, with the American College of Cardiology suggesting that other methods such as intermittent pneumatic compression devices or pharmacological prophylaxis should be used instead 8