Management of Stroke

1. ACUTE STABILIZATION (All Stroke Types)

Airway, Breathing, Circulation

• Protect the airway: prevent obstruction, hypoventilation, and aspiration
• Pulse oximetry or ABG; supplemental oxygen if saturation is low
• Cardiac monitoring for at least 48 hours (arrhythmias occur in up to 20% of patients, and concomitant myocardial ischemia in 3-20%)
• Immediate 12-lead ECG and troponin level
• Admit to a stroke unit - this alone reduces mortality, shortens hospital stay, and reduces nursing-home discharge rates

Emergency Investigations

2. ISCHEMIC STROKE: ACUTE REPERFUSION THERAPY

A. Intravenous Thrombolysis - Alteplase (tPA)

• Age ≥18 years
• Measurable neurological deficit from acute ischemic stroke
• Symptom onset <3 hours (standard) or 3-4.5 hours (extended)

• Intracranial hemorrhage on CT (any type)
• Prior ischemic stroke or severe head trauma within 3 months
• Intracranial/intraspinal surgery within 3 months
• GI malignancy or GI bleeding within 21 days
• Pre-treatment SBP >185 mmHg or DBP >110 mmHg despite treatment
• Platelet count <100,000/mm³
• INR >1.7, aPTT >40s, or PT >15s
• Use of LMWH within 48 hours
• Current direct thrombin inhibitors or direct Xa inhibitors
• CT showing extensive hypoattenuation (>2/3 of MCA territory)
• NIHSS too low (mild/rapidly-improving deficit, score ≤3) or stroke too massive

Note: If tPA is given, blood pressure must be maintained below 185/110 mmHg.

B. Endovascular Thrombectomy (Mechanical)

• Standard window: up to 6-8 hours from onset
• Extended window: up to 16-24 hours with appropriate imaging selection (mismatch on CT perfusion/MRI)
• Main selection criterion: confirmed large-vessel occlusion on CTA
• The ASPECTS score gauges extent of infarction to guide eligibility
• A 2025 meta-analysis (PMID: 40245349) confirms endovascular thrombectomy benefit even for large ischemic core strokes

3. BLOOD PRESSURE MANAGEMENT IN ISCHEMIC STROKE

• Nicardipine 5 mg/hr IV (first-line, titrate to max 15 mg/hr)
• Labetalol 10 mg IV over 1-2 min (repeat/double every 10-20 min, max 300 mg)
• Sodium nitroprusside 0.3 mcg/kg/min IV (avoid if possible - causes cerebral vasodilation, can worsen edema)
• Sublingual calcium channel blockers are contraindicated (precipitous BP drops)

4. GLUCOSE AND TEMPERATURE MANAGEMENT

• Glucose: Keep close to euglycemia. Hyperglycemia worsens ischemic outcome. However, intensive glucose control (SHINE trial, GIST-UK, SELESTIAL) conferred no benefit and increased hypoglycemia risk. Use standard glucose control.
• Temperature: Mild hypothermia is neuroprotective; hyperthermia worsens ischemic outcome. Treat fever aggressively.
• Avoid supplemental oxygen in normoxic patients (large RCT showed no benefit from low-dose O₂ in acute stroke).

5. CEREBRAL EDEMA AND RAISED ICP IN ISCHEMIC STROKE

• Head of bed elevated 15-30 degrees
• Correct hypercarbia, hypoxia, hyperthermia, acidosis, hypotension, hypovolemia
• Avoid head/neck positions compressing jugular veins
• Hyperventilation to PaCO₂ 35±3 mmHg (if actively herniating - short-term bridge only)
• Mannitol 0.25-1 g/kg IV over 30 minutes (max 2 g/kg total; repeat every 6 hours); replace urinary losses with normal saline
• Hypertonic saline - alternative to mannitol
• IV fluids: isotonic (normal saline); avoid glucose-containing solutions

• Hemicraniectomy + durotomy for malignant MCA infarction (improves survival and functional outcome)
• Posterior fossa decompression for cerebellar stroke with herniation (can be life-saving)
• Ventriculostomy (risk of upward cerebellar herniation)

6. HEMORRHAGIC STROKE MANAGEMENT

Intracerebral Hemorrhage (ICH)

1. Reverse coagulopathy - correct elevated INR (fresh frozen plasma, vitamin K, prothrombin complex concentrate as indicated)
2. Blood pressure control - for SBP 150-220 mmHg, acutely lower to 140 mmHg (safe and effective)
3. Glucose - avoid both hyperglycemia and hypoglycemia
4. Seizures - treat with antiepileptic drugs
5. Raised ICP - intubation/sedation, head elevation, hypertonic fluids, hemicraniectomy if needed

7. PREVENTION OF COMPLICATIONS

8. SECONDARY PREVENTION

Antiplatelet Therapy

• Aspirin within 48 hours reduces mortality and recurrence (IST and CAST trials) - begin unless tPA was given
• Dual antiplatelet therapy (aspirin + clopidogrel) for 3 weeks after minor stroke/TIA (CHANCE trial) reduces 90-day recurrence without increasing major hemorrhage; extending to 90 days (POINT trial) showed some excess systemic bleeding but still effective
• Not indicated if anticoagulation is planned

Anticoagulation

• Indicated for cardioembolic stroke (especially atrial fibrillation) - DOACs are now preferred over warfarin
• Early anticoagulation after large stroke carries risk of hemorrhagic transformation - defer unless the infarct is small
• Warfarin is not superior to aspirin in non-cardioembolic stroke (WARSS, WASID trials)
• For AF: anticoagulation > aspirin (multiple trials)

Statins

• High-dose statin therapy reduces subsequent stroke by ~2% over 5 years (SPARCL trial)
• Target LDL <70 mg/dL for secondary prevention

Carotid Revascularization

• Carotid endarterectomy or stenting for symptomatic stenosis ≥50-70%
• Intracranial stenting is an option for recurrent stroke despite optimal medical therapy in focal intracranial stenosis

Risk Factor Modification

• Tight blood pressure control (long-term)
• Glycemic control in diabetics
• Smoking cessation
• Anticoagulation for AF
• Pioglitazone may reduce recurrent stroke/MI in insulin-resistant non-diabetic patients (IRIS trial, Kernan 2016)

9. REHABILITATION

• Multidisciplinary team: Neurology, physical therapy, occupational therapy, speech/language therapy, nutrition, social services
• Begin early mobilization as tolerated
• Feeding tube for oropharyngeal dysfunction pending swallow assessment
• Stroke units consistently outperform general wards for functional recovery outcomes

Summary: Time-Critical Actions

Recent evidence update (2025): A systematic review and meta-analysis (PMID: 40245349) confirms that endovascular thrombectomy benefits patients with large ischemic core strokes - expanding the pool of eligible candidates beyond earlier, more restrictive criteria.

Management of Acute Rise in BP (150/90) Before Surgery in a Normally Normotensive Patient

1. First: Understand the Clinical Context

1. Is this a true elevation or white-coat/anxiety hypertension?
2. Is there any end-organ damage (hypertensive emergency)?
3. Does the degree of elevation actually pose a perioperative risk?

2. The Critical Threshold - Does 150/90 Even Require Action?

A preoperative BP below 180 mmHg systolic / 110 mmHg diastolic has NOT been associated with increased perioperative cardiovascular risk and is NOT an indication to cancel or delay elective surgery.

• BP <180/110: No significant difference in perioperative outcomes vs. normotensives (2025 AHA/ACC Hypertension Guidelines; Morgan & Mikhail's Clinical Anesthesiology 7e)
• DBP <110 is not an independent risk factor for perioperative cardiovascular complications
• The 2024 AHA/ACC perioperative guideline explicitly states: "There is little evidence to defer surgery" for SBP/DBP <180/110 mmHg

• Barash, Cullen, and Stoelting's Clinical Anesthesia 9e; Morgan and Mikhail's Clinical Anesthesiology 7e

3. Step-by-Step Management

Step 1 - Identify the Cause (Rule Out Non-pathological Causes First)

• Morgan and Mikhail's Clinical Anesthesiology 7e

Step 2 - Non-pharmacological Measures (First-line for 150/90)

• Reassurance - address fear and anxiety; calm environment
• Adequate pre-operative analgesia if pain is a contributor
• Anxiolytic premedication - oral midazolam 0.5 mg/kg or IV midazolam 1-2 mg; this alone often normalizes the BP
• Rest - allow 10-15 minutes of supine rest and recheck BP
• Correct reversible factors - full bladder, cold environment, discomfort
• Refer to baseline ambulatory BP - if the patient's home BP readings are normal, this is almost certainly situational

Step 3 - Assess for End-Organ Damage (Rule Out Emergency)

Step 4 - Decision: Proceed vs. Postpone

Step 5 - If Pharmacological Treatment Is Deemed Necessary

• Oral labetalol 100-200 mg (also has antianxiety properties via beta-blockade)
• Oral amlodipine 5 mg (takes hours to work - not ideal for immediate pre-op use)
• Avoid sublingual nifedipine - causes precipitous, uncontrolled BP drop; dangerous and discouraged by all current guidelines

• 2025 AHA/ACC Hypertension Guidelines; 2024 AHA/ACC Perioperative Guideline

4. Intraoperative Considerations

• Patients with preoperative hypertension (even white-coat) are more prone to intraoperative BP lability - both hypertension AND hypotension
• The greatest BP surges occur during induction and laryngoscopy - a 20-30 mmHg systolic rise is expected even in normotensives
• An IV antihypertensive (labetalol or esmolol) should be on standby at induction
• Careful fluid management - avoid hypovolemia, which causes hypotension and then reflex tachycardia

5. Postoperative Plan

• If the elevated preoperative BP was an isolated finding and returns to normal after surgery, no further action is needed acutely
• If BP remains elevated postoperatively, arrange formal outpatient BP monitoring and workup for hypertension (ambulatory BP monitoring, ABPM)
• Address underlying risk factors: obesity, salt, alcohol, physical inactivity

Summary