Approach to Managing Stroke

Immediate Recognition and Response

• The American Heart Association recommends rapid recognition of stroke symptoms as the first critical step in the stroke chain of survival 1
• Emergency medical services (EMS) should be activated immediately by calling 911 when stroke symptoms are identified, as recommended by the American Heart Association 1
• EMS should use validated stroke screening tools to assist in rapid and accurate assessment, according to the International Journal of Stroke 2
• Local protocols should include early notification by paramedic staff, high-priority transportation, rapid triage, and expedited access to imaging, as suggested by the International Journal of Stroke 2

Emergency Department Management

• The American Heart Association recommends that all patients with suspected stroke should undergo urgent brain CT or MRI within 24 hours of symptom onset, but ideally as soon as possible 2
• A standardized stroke severity evaluation should be performed to assess prognosis and rehabilitation potential, according to the American Heart Association 3
• Written hospital protocols defining processes and responsibilities should be established according to American Heart Association guidelines 4
• Emergency department staff should use validated stroke screening tools for rapid assessment, as recommended by the International Journal of Stroke 2

Diagnostic Evaluation

• Essential investigations that should be obtained routinely in all patients include: full blood picture, electrocardiogram, electrolytes, renal function, fasting lipids, erythrocyte sedimentation rate and/or C-reactive protein, and glucose, according to the International Journal of Stroke 2
• All patients with carotid territory symptoms who would potentially be candidates for carotid revascularization should have an urgent carotid duplex ultrasound, as recommended by the International Journal of Stroke 2
• A repeat brain CT or MRI should be performed urgently when a patient's condition deteriorates, according to the International Journal of Stroke 2

Acute Treatment for Ischemic Stroke

• The American Heart Association strongly recommends intravenous recombinant tissue plasminogen activator (rtPA) for carefully selected patients who can receive the medication within 3 hours of stroke onset 5
• Aspirin can be administered within the first 48 hours due to its reasonable safety profile and modest benefit, according to the Stroke journal 5
• Anticoagulation (e.g., intravenous unfractionated heparin) is not recommended as standard treatment due to increased bleeding risk, as stated by the International Journal of Stroke 2

Management of Intracerebral Hemorrhage (ICH)

• ICH due to anticoagulation should be urgently reversed, according to the International Journal of Stroke 2
• Blood pressure lowering in ICH patients with a history of hypertension is indicated to keep mean arterial pressure below 130 mmHg, as recommended by the International Journal of Stroke 2
• Surgical intervention may be considered in specific situations, such as craniotomy for superficial ICH less than 1 cm from surface or stereotactic surgery for deep ICH, according to the International Journal of Stroke 2
• Surgery is particularly beneficial for patients with cerebellar hemorrhages that are leading to brain stem compression and hydrocephalus, as stated by the Stroke journal 5

Stroke Unit Care

• The American Heart Association recommends that all stroke patients should be admitted to a geographically defined stroke unit with specialized staff 6, 7
• Stroke unit care is characterized by an interdisciplinary stroke team with expertise in stroke management, according to the Stroke journal 7
• The multidisciplinary team should include physicians, nurses, physiotherapists, occupational therapists, speech-language pathologists, and pharmacists, as recommended by the Stroke journal 7

Prevention and Management of Complications

• Early screening and management of swallowing difficulties, nutrition, cognition, perception, and communication should be performed by appropriate members of the multidisciplinary team, according to the International Journal of Stroke 2
• Complications such as deep venous thrombosis, pyrexia, pressure ulcers, falls, and pain should be actively prevented, as recommended by the International Journal of Stroke 2
• For patients with significant brain edema and increased intracranial pressure, osmotherapy and hyperventilation are recommended, according to the Stroke journal 5
• Hemicraniectomy within 48 hours has been shown to substantially reduce death and disability in selected patients (18-60 years old) with extensive hemispheric infarcts, as stated by the International Journal of Stroke 2

Early Rehabilitation

• Early mobilization is strongly recommended to prevent complications, according to the Praxis Medical Insights 3
• Assessment and management of mobility, activities of daily living, incontinence, and mood should be undertaken early after stroke, as recommended by the International Journal of Stroke 2
• Speech and language pathologists should evaluate and treat all stroke patients for residual communication difficulties, according to the Praxis Medical Insights 3

Secondary Prevention

• Appropriate antithrombotic therapy should be prescribed based on stroke etiology, as recommended by the Praxis Medical Insights 3
• Blood pressure and cholesterol should be managed appropriately, according to the Praxis Medical Insights 3
• All modifiable risk factors should be addressed as part of secondary prevention, as recommended by the Praxis Medical Insights 3

Quality Improvement

• In-hospital stroke performance and quality data should be examined specifically and used to drive focused quality improvement efforts, according to the Stroke journal 4
• Reviewing metrics such as the number of stroke alerts, true stroke rates with subtypes, response times, imaging acquisition times, treatment rates, treatment times, and outcomes will support quality improvement, as recommended by the Stroke journal 4
• Reporting all stroke cases to a registry may help with monitoring the true incidence of stroke and provide data for future research, according to the Stroke journal 4

Management of Ischemic Stroke

Acute Treatment

• Blood pressure management is crucial, with antihypertensive agents avoided unless systolic blood pressure is >220 mm Hg or diastolic blood pressure is >120 mm Hg, according to the American Heart Association 8
• Sublingual nifedipine and other antihypertensive agents causing precipitous reductions in blood pressure should be avoided, as recommended by the American Heart Association 8
• Hypoglycemia can mimic stroke symptoms and requires prompt measurement and correction of serum glucose, as stated by the American Diabetes Association 8

Stroke Unit Care

• Comprehensive specialized stroke care units incorporating comprehensive rehabilitation are recommended by the American Heart Association 9

Prevention and Management of Complications

• Early screening and management of swallowing difficulties is essential to prevent aspiration pneumonia, as recommended by the American Heart Association 9
• Pneumonia is an important cause of death following stroke and requires prompt antibiotic therapy when identified, according to the Infectious Diseases Society of America 9
• Deep vein thrombosis prevention through subcutaneous anticoagulants or intermittent external compression stockings is strongly recommended for immobilized patients by the American College of Chest Physicians 9
• Indwelling bladder catheters should be avoided when possible due to infection risk, as stated by the Centers for Disease Control and Prevention 9

Nutrition and Hydration

• Sustaining nutrition is important as malnutrition can interfere with recovery, according to the American Heart Association 9
• Swallowing assessment is crucial before allowing oral intake, as recommended by the American Speech-Language-Hearing Association 9
• When necessary, nasogastric or nasoduodenal tubes can be inserted to provide feedings and medication administration, as stated by the American Gastroenterological Association 9
• Percutaneous endoscopic gastric tube placement is superior to nasogastric tube feeding if prolonged feeding support is anticipated, according to the American Society for Gastrointestinal Endoscopy 9

Secondary Prevention

• Continuation of statin therapy during the acute period is reasonable for patients already taking statins at the time of stroke onset, as recommended by the American College of Cardiology 10
• Neuroprotective agents have not demonstrated efficacy in improving outcomes after ischemic stroke and are not recommended by the American Heart Association 10