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Acute Management of Stroke

Initial Treatment

The goal for the acute management of patients with stroke is to stabilize the patient and to complete initial evaluation and assessment, including imaging and laboratory studies, within 60 minutes of patient arrival.
(See Table 1, below.) Critical decisions focus on the need for intubation, blood pressure control, and determination of risk/benefit for thrombolytic intervention.

Table 1. NINDS* and ACLS** Recommended Stroke Evaluation Time Benchmarks for Potential Thrombolysis Candidate (Open Table in a new window)

Time Interval

Time Target

Door to doctor

10 min

Access to neurologic expertise

15 min

Door to CT scan completion

25 min

Door to CT scan interpretation

45 min

Door to treatment

60 min

Admission to stroke unit or ICU

3 h

*National Institute of Neurological Disorders and Stroke

**Advanced Cardiac Life Support guidelines

Hypoglycemia and hyperglycemia need to be identified and treated early in the evaluation. Not only can both produce symptoms that mimic ischemic stroke, but they can also aggravate ongoing neuronal ischemia. Administration of glucose in hypoglycemia produces profound and prompt improvement, while insulin should be started for patients with stroke and hyperglycemia. Ongoing studies will help to determine the optimal level of glycemic control.

Hyperthermia is infrequently associated with stroke but can increase morbidity. Administration of acetaminophen, by mouth or per rectum, is indicated in the presence of fever (temperature >100.4° F [38° C]).

Supplemental oxygen is recommended when the patient has a documented oxygen requirement. To date, there is conflicting evidence whether supernormal oxygenation improves outcome.

Optimal blood pressure targets remain to be determined. Many patients are hypertensive on arrival. American Stroke Association guidelines have reinforced the need for caution in lowering blood pressures acutely.

In the small proportion of patients with stroke who are relatively hypotensive, pharmacologically increasing blood pressure may improve flow through critical stenoses.

Serial monitoring and interventions when necessary early in the clinical course and eventual stroke rehabilitation and physical and occupational therapy are the ideals of management. (See Table 2, below.)

In patients with transient ischemic attacks (TIAs), failure to recognize the potential for near- term stroke, failure to perform a timely assessment for stroke risk factors, and failure to initiate primary and secondary stroke prevention exposes the patient to undue risk of stroke and exposes clinicians to potential litigation. TIAs confer a 10% risk of stroke within 30 days, and one half of the strokes occurring after a TIA, occurred within 48 hours.

Table 2. General Management of Patients With Acute Stroke
(Open Table in a new window)

Blood glucose

Treat hypoglycemia with D50

Treat hyperglycemia with insulin if serum glucose >200 mg/dL

Blood pressure

See recommendations for thrombolysis candidates and noncandidates (Table 3)

Cardiac monitor

Continuous monitoring for ischemic changes or atrial fibrillation

Intravenous fluids

Avoid D5W and excessive fluid administration

IV isotonic sodium chloride solution at 50 mL/h unless otherwise indicated

Oral intake

NPO initially; aspiration risk is great, avoid oral intake until swallowing assessed

Oxygen

Supplement if indicated (Sa02< 94%)

Temperature

Avoid hyperthermia; use oral or rectal acetaminophen and cooling blankets as needed

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