Comprehensive Management of Stroke

Definition and Recognition

• The FAST mnemonic is an effective tool for public recognition of stroke symptoms, which has been shown to increase awareness and prompt earlier medical attention, according to the International Journal of Stroke 1.
• All patients with suspected stroke should undergo immediate neurological evaluation and brain imaging studies within 24 hours to rule out hemorrhage and determine eligibility for reperfusion therapies, as recommended by the American Heart Association 2, 3.

Acute Management

Pre-hospital and Emergency Department Care

• Immediate activation of emergency medical services and rapid transport to a stroke-capable hospital is essential for optimal stroke outcomes, as stated by the American Heart Association 3.
• Local protocols should include early notification by paramedic staff, high-priority transportation, rapid referrals from ED staff to stroke specialists, and rapid access to imaging, according to the International Journal of Stroke 4.
• Emergency department staff should use validated stroke screening tools for rapid assessment, as recommended by the American Heart Association 4, 5.

Initial Assessment and Stabilization

• Airway, breathing, and circulation should be monitored and maintained, with tracheal intubation indicated for patients with compromised airway, according to the American Heart Association 2.
• Supplemental oxygen should be provided only to maintain oxygen saturation >94%, as recommended by the American Heart Association 2, 5.

Brain Imaging

• All patients with suspected stroke should have an urgent brain CT or MRI within 24 hours, as stated by the International Journal of Stroke 4, 5.
• A repeat brain CT or MRI should be considered urgently when a patient's condition deteriorates, according to the International Journal of Stroke 4.

Reperfusion Therapies

Intravenous Thrombolysis

• Intravenous alteplase is recommended for selected patients within 4.5 hours of symptom onset, as recommended by the American Heart Association 2.

Mechanical Thrombectomy

• Mechanical thrombectomy is recommended for patients with large vessel occlusion within 6-24 hours, according to specific imaging criteria, as stated by the American Heart Association 2.

Blood Pressure Management

• For patients not receiving thrombolysis, antihypertensive treatment should be avoided unless systolic blood pressure is >220 mmHg or diastolic >120 mmHg, as recommended by the American Heart Association 2.

Management of Complications

Cerebral Edema

• Corticosteroids are not recommended for cerebral edema and increased intracranial pressure, according to the American Heart Association 2.
• Osmotic therapy and hyperventilation are recommended for patients who deteriorate, as stated by the American Heart Association 2.

Other Complications

• Fever, hyperglycemia, and swallowing dysfunction should be actively monitored and managed, according to the American Heart Association 5.
• Swallowing screening should be performed within 24 hours of admission using a validated tool before giving food, fluids, or oral medications, as recommended by the American Heart Association 5.

Stroke Unit Care

• All stroke patients should be admitted to a geographically defined stroke unit with specialized staff, as recommended by the American Heart Association 5, 6.
• Stroke unit care should be provided by an interdisciplinary team with expertise in stroke management, according to the American Heart Association 5.

Rehabilitation and Recovery

• Initial assessment by rehabilitation professionals should be performed within 48 hours of admission, as recommended by the American Heart Association 2.
• Rehabilitation therapy should begin as soon as possible once the patient is medically stable, according to the American Heart Association 2, 5.

Secondary Prevention

• Aspirin 160-300 mg/day should be commenced within 48 hours of onset of acute ischemic stroke, as recommended by the American Heart Association 5.
• Anticoagulation is not recommended as standard treatment due to increased bleeding risk, according to the American Heart Association 5.

Optimal Stroke Care

Immediate Recognition and Response

• The "Stroke Chain of Survival" includes detection, dispatch, delivery, door, data, decision, drug, and disposition as key links in optimal stroke care 7

Emergency Department Management

• Standardized stroke orders or integrated stroke pathways improve adherence to best practices for treatment of stroke patients 8
• Neurological status and vital signs should be assessed frequently during the first 24 hours after admission 8

Acute Treatment for Ischemic Stroke

• Patients receiving thrombolytic therapy require close monitoring for bleeding complications 9
• A combined endovascular therapy approach using stent-retrievers and aspiration is the most effective way to achieve fast first-pass complete reperfusion 9

Stroke Unit Care

• Stroke units significantly reduce mortality and morbidity after stroke, with positive effects persisting for years 8
• The benefits from treatment in a stroke unit are comparable to the effects achieved with intravenous administration of rtPA 8

Prevention and Management of Complications

• Early mobilization is favored because it lessens the likelihood of complications such as pneumonia, deep vein thrombosis, pulmonary embolism, and pressure sores 8
• Frequent turning, use of alternating pressure mattresses, and close surveillance of the skin help prevent pressure sores 8

Nutrition and Hydration

• Sustaining nutrition is important as dehydration or malnutrition may slow recovery 8
• Dehydration is a potential cause of deep vein thrombosis after stroke 8

Early Rehabilitation

• If ongoing inpatient rehabilitation is needed, care should be provided in either a stroke rehabilitation unit or a general rehabilitation unit 10
• Rehabilitation in the community is equally effective if delivered in the hospital via outpatients, day hospital, or in the community, and should be offered to all stroke patients as needed 10

Secondary Prevention

• Carotid endarterectomy is recommended for patients with recent (within 6 months) non-disabling carotid artery territory ischemic stroke or TIA with ipsilateral carotid stenosis measured at 70-99% 10
• Carotid endarterectomy may be considered for select patients with stenosis of 50-69% 10
• Eligible patients should undergo carotid endarterectomy as soon as possible after the event, ideally within 2 weeks 10

Quality Improvement

• Participation in programs like Get With The Guidelines-Stroke has produced improved care processes and sustained increased adherence to stroke performance measures 8
• Transport and admission to a Primary Stroke Center compared with non-designated hospitals leads to lower overall 30-day mortality rates and increased use of fibrinolytic therapy 8