Stroke Recognition and Management

Initial Assessment

• The American Heart Association recommends using the FAST assessment as the most validated tool for initial stroke recognition, which includes checking for facial droop, arm drift, and speech difficulties 1
• Sudden severe headache, trouble seeing, trouble walking, dizziness, loss of balance, or coordination are symptoms of stroke 2
• The following assessment tool can be used to assess patients with suspected stroke:

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Pediatric Considerations

• The American Heart Association notes that pediatric stroke can present differently than adult stroke and adult stroke scores are not validated in the pediatric population 4

Prehospital Care

• The American Heart Association recommends activating emergency medical services immediately and noting the time of symptom onset for treatment decisions 1, 2
• Performing the FAST assessment and communicating findings to EMS is recommended 2
• Providing supplementary oxygen to hypoxemic stroke patients (oxygen saturation <94%) is recommended, but blood pressure should not be lowered in the prehospital setting unless systolic BP <90 mmHg 2

Telemedicine Evaluation

• The American Heart Association recommends using the NIH Stroke Scale (NIHSS) for telemedicine evaluation when in-person neurological assessment is not immediately available 5
• Vascular imaging with CTA or contrast-enhanced MRA is superior to ultrasound for vertebral artery stenosis, with sensitivity and specificity of 94% and 95%, respectively 6, 7

Diagnostic Imaging

• The American Heart Association recommends performing non-contrast CT scan to distinguish ischemic from hemorrhagic stroke, as well as CT angiography (CTA) from aortic arch to vertex to identify large vessel occlusions 1
• The American College of Radiology recommends urgent non-contrast CT scan within 25 minutes of arrival, with a strength of evidence classified as high 1, 8

Treatment

• The American Heart Association recommends IV thrombolysis (alteplase) for eligible patients within 4.5 hours of symptom onset, with a dose of 0.9 mg/kg (maximum 90 mg) and ensuring BP <185/110 mmHg before administration, with a strength of evidence classified as high 1, 9, 10, 11
• The American Stroke Association suggests endovascular thrombectomy for large vessel occlusion, which can be considered up to 24 hours with evidence of salvageable brain tissue, with a strength of evidence classified as moderate 8, 9, 10, 12
• Antiplatelet therapy options include aspirin alone, combination of aspirin plus dipyridamole, ticlopidine, or warfarin, and anticoagulation with heparin followed by warfarin for at least 3 months is recommended for acute ischemic syndromes with angiographic evidence of thrombus in extracranial vertebral artery 6, 7

Surgical and Endovascular Treatment

• Surgical approaches for vertebral artery occlusive disease include trans-subclavian vertebral endarterectomy, transposition of vertebral artery to ipsilateral common carotid artery, and reimplantation with vein graft extension 6, 7
• Endovascular treatment may be considered for patients with contraindications to anticoagulation, ineffective anticoagulation, or progressive symptoms despite medical therapy 6, 7

Post-Stroke Care

• Patients should be transferred to a specialized stroke unit as soon as possible, with transfer protocols to ensure direct admission to the stroke unit 13
• Continuous monitoring of vital signs, neurological status, and potential complications should be performed, and mobilization should be initiated by rehabilitation professionals within 48 hours of admission 1
• Implementing lifestyle modification guidance, including smoking cessation, diet, and exercise, is suggested to help prevent future stroke events, and statin therapy should be initiated for lipid management, and hypertension should be controlled with diet, exercise, and medication 14, 10, 15, 11