Management of Stroke

1. Initial Assessment and Stabilization

• Patients with TIA or acute stroke presenting within 72 hours of onset should be admitted - preferably to a stroke unit or ICU, where specialized care reduces mortality, hospital stays, and nursing home discharge rates.
• Establish a stroke team to expedite emergency care.
• Airway: Protect the airway, avoid obstruction, hypoventilation, and aspiration. Use pulse oximetry or ABG as needed. Add supplemental oxygen and ventilatory support if required.
• Hyperthermia worsens ischemic outcomes; mild hypothermia is neuroprotective. Treat fever aggressively.
• Aspiration risk is significant: >33% in brainstem strokes, ~25% in bilateral hemispheric strokes. Keep head of bed >30°, frequent suctioning. Nil by mouth until swallowing evaluated by speech pathology.
• Cardiac monitoring: Recommended for at least 48 hours. Obtain 12-lead ECG and troponin immediately. Concomitant cerebral and myocardial ischemia occurs in ~3-20% of cases.
• Blood pressure: Monitor continuously for the first 48-72 hours. Optimal SBP post-stroke is 160-200 mmHg. Do not over-treat - hypotension worsens outcome.

2. Acute Ischemic Stroke - Reperfusion Strategies

A. Intravenous Thrombolysis (IV tPA / Alteplase)

• Standard treatment: IV thrombolysis within 4.5 hours of stroke onset.
• If the patient wakes up with stroke symptoms (unknown onset time), a DWI-FLAIR mismatch on MRI can identify those still eligible - tissue viability, not the clock, is the guide.
• Absolute contraindications include: active intracranial hemorrhage, prior intracranial surgery <3 months, severe head trauma, blood glucose <50 mg/dL, active infective endocarditis, use of glycoprotein IIb/IIIa inhibitors, intra-axial intracranial neoplasm.
• Relative/conditional considerations: arteriovenous malformation, recent surgery or major trauma <14 days, malignancy, pregnancy, seizure at onset, unruptured intracranial aneurysm.
• Symptomatic intracranial hemorrhage risk with IV tPA: ~3-6%.

B. Endovascular Thrombectomy (Mechanical Thrombectomy)

• Indicated when large vessel occlusion is confirmed on vascular imaging (distal ICA or proximal MCA).
• Can be performed with or without preceding IV thrombolysis.
• Time window:
  • Up to 6 hours based on standard criteria.
  • 6-24 hours in selected patients where advanced imaging (CT/MRI perfusion) shows a mismatch between infarcted core and salvageable penumbra (DAWN and DEFUSE-3 trial criteria).
• For basilar artery occlusion: trials like BASICS and subsequent studies show endovascular treatment is superior to medical therapy, though overall outcomes remain poor.

C. Blood Pressure During Thrombolysis

• Before IV tPA: Reduce BP to <185/110 mmHg.
• During and after IV tPA: Maintain <180/105 mmHg for at least 24 hours.

3. General Medical Management (All Strokes)

Anticoagulation in Acute Ischemic Stroke

• UFH and LMWH have no proven benefit in reducing stroke mortality or morbidity in the acute phase (IST and FISS trials).
• Exception: Cerebral venous thrombosis - anticoagulation IS indicated.
• IV heparin may be used for small cardioembolic infarcts with intracardiac thrombus confirmed on echo (limited evidence).
• LMWH reduces DVT risk more than UFH in hemiparetic patients.

4. Intracerebral Hemorrhage (ICH) - Specific Management

Initial Steps

1. Immediate vital sign stabilization and airway protection.
2. If GCS ≤ 8: Endotracheal intubation (pretreat with IV fentanyl 2-3 mcg/kg to blunt ICP rise).
3. Emergent CT scan to define location and size of hemorrhage.
4. Labs: CBC, coagulation studies, toxicology screen, serum glucose, DOAC timing.
5. Neurosurgical consultation.

Blood Pressure Control in ICH

• Treat if BP >180/105 mmHg; goal is cerebral perfusion pressure of 50-70 mmHg.
• IV nicardipine is commonly used for rapid BP control.
• Reducing SBP to <140 mmHg - current evidence is unclear regarding additional benefit (INTERACT2 and ATACH-2 trials).

Anticoagulation Reversal

• Coagulopathy must be reversed emergently to prevent hematoma expansion.
• For DOACs: use specific reversal agents (idarucizumab for dabigatran, andexanet alfa for Xa inhibitors).
• For warfarin: IV vitamin K + 4-factor PCC (prothrombin complex concentrate).

ICP Management

• Head of bed elevation, mannitol or hypertonic saline for osmotherapy.
• Avoid hyperthermia, hypoglycemia, hyponatremia.
• Hyperventilation as a short-term bridge only.

Surgical Intervention

• Cerebellar ICH >3 cm with neurological deterioration or brainstem compression: urgent surgical evacuation.
• Supratentorial ICH: surgical benefit less clear; standard craniectomy not routinely recommended.

5. Rehabilitation

• Physical therapy, occupational therapy, and speech therapy.
• Early mobilization reduces complications (pneumonia, DVT, pressure ulcers).
• Screen and treat post-stroke depression.
• Social and environmental factors determine rehabilitation candidacy.

6. Secondary Prevention

Antiplatelet Therapy

• Aspirin (given within 48 hours of ischemic stroke): modest reduction in mortality and recurrence (IST and CAST trials).
• Dual antiplatelet therapy (DAPT) - aspirin + clopidogrel for 21-90 days after minor stroke or high-risk TIA:
  • CHANCE trial (Chinese population): reduced 90-day recurrence, no increase in hemorrhage.
  • POINT trial (larger, non-Asian population): reduced 90-day recurrence but slightly higher systemic hemorrhage with 90-day DAPT vs. 21-day DAPT.
• Warfarin vs. aspirin: In non-cardioembolic stroke, warfarin is not superior to aspirin (WARSS trial). For intracranial stenosis, aspirin not inferior to warfarin (WASID trial).

Anticoagulation

• Atrial fibrillation: Anticoagulation is superior to aspirin for stroke prevention.
  • DOACs (apixaban, rivaroxaban, dabigatran) are first-line over warfarin - fewer strokes, fewer intracranial hemorrhages.
  • Use CHA₂DS₂-VASc score to stratify risk.
• Initiate anticoagulation carefully after acute ischemic stroke due to risk of hemorrhagic transformation - especially with large infarcts or hypertension.

Statins

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

Risk Factor Control

• Hypertension: the single most important modifiable risk factor.
• Smoking cessation, glucose control (diabetes), weight management.
• Carotid endarterectomy (CEA) for symptomatic stenosis >70% (moderate benefit for 50-69% stenosis).

Summary Algorithm

STROKE ONSET
     |
     ├─ Ischemic (CT: no blood)?
     │       |
     │       ├─ Within 4.5h → IV tPA (if no contraindications)
     │       ├─ Large vessel occlusion → Thrombectomy (up to 24h with imaging selection)
     │       └─ General supportive care → Secondary prevention
     |
     └─ Hemorrhagic (CT: blood)?
             |
             ├─ Reverse anticoagulation if applicable
             ├─ BP control (target <180/105, goal CPP 50-70 mmHg)
             ├─ ICP management
             └─ Neurosurgical consult (cerebellar ICH >3cm → surgery)

• Bradley and Daroff's Neurology in Clinical Practice (General Management of Acute Ischemic Stroke, p. 1405-1408; ICH Management, p. 1438)
• Adams and Victor's Principles of Neurology, 12th Edition (Treatment of Ischemic Stroke, p. 820-826)
• Tintinalli's Emergency Medicine (General Treatment of Acute Ischemic Stroke)
• Fuster and Hurst's The Heart, 15th Edition (Subacute Medical Management)