Management of Stroke

1. Immediate Assessment (All Stroke Types)

• Protect the airway - avoid obstruction, hypoventilation, aspiration
• Pulse oximetry or ABGs; supplemental oxygen if SpO2 < 94%
• Avoid hyperthermia (worsens ischemic outcome); treat fever aggressively
• Head of bed > 30 degrees to reduce aspiration risk
• Cardiac monitoring for at least 48 hours (cardiac arrhythmias complicating stroke are common); 12-lead ECG and troponin on admission

"Rapid diagnosis of stroke and initiation of treatment are important to maximize recovery, prevent recurrence of stroke, and prevent complications." - Bradley and Daroff's Neurology in Clinical Practice

2. Ischemic Stroke

2a. Blood Pressure Management

• Labetalol 10 mg IV over 1-2 min (repeat q10-20 min, max 300 mg)
• Nicardipine infusion 5 mg/h, titrate up to 15 mg/h
• If uncontrolled: sodium nitroprusside

2b. Reperfusion Therapy

IV Thrombolysis (Alteplase / Tenecteplase)

• Age ≤ 80
• No prior stroke + diabetes combination
• NIHSS ≤ 25
• Not on anticoagulants
• No extensive early ischemic changes on CT

DWI-FLAIR mismatch (top) vs. no mismatch (bottom) - used for extending thrombolysis eligibility

Mechanical Thrombectomy (Endovascular)

• No significant pre-stroke disability (mRS ≤ 1)
• Occlusion of ICA or MCA M1 segment
• NIHSS ≥ 6
• ASPECTS ≥ 6

"Mechanical thrombectomy is now indicated for patients with acute ischemic stroke with large artery occlusion in the anterior circulation who meet selected criteria and who present within 24 hours of last known to be well regardless of whether they receive IV alteplase." - Rosen's Emergency Medicine

2c. Antiplatelet Therapy

• Aspirin 160-325 mg should be given within 24-48 hours of ischemic stroke (not if given alteplase - delay 24 hours)
• IST and CAST trials established modest mortality and recurrence reduction
• Dual antiplatelet therapy (aspirin + clopidogrel) for 21 days is recommended after minor stroke/high-risk TIA (CHANCE trial; POINT trial). Benefit is greatest in the first 3 weeks; extending beyond 90 days increases hemorrhage risk without added benefit.

2d. Prevention of Complications

3. Intracerebral Hemorrhage (ICH)

Blood Pressure

• For SBP 150-220 mmHg: acutely lowering to 140 mmHg is safe and reduces hematoma expansion
• Use IV labetalol, nicardipine, or clevidipine for smooth control

Reversal of Coagulopathy

• Elevated INR (warfarin): reverse with 4-factor PCC (prothrombin complex concentrate) + Vitamin K
• Heparin: protamine sulfate
• DOACs: specific reversal agents (idarucizumab for dabigatran; andexanet alfa for Xa inhibitors)

Elevated ICP

• Intubation + sedation, HOB elevation, hypertonic saline/mannitol
• Ventriculostomy (EVD) for hydrocephalus
• Decompressive hemicraniectomy in refractory cases

Seizures

• Treat clinical seizures with antiepileptics
• Prophylactic AEDs are not routinely recommended

Surgical Evacuation

• Benefit clearest for cerebellar hematoma > 3 cm or with brainstem compression
• Supratentorial hematoma: role of surgery remains debated (STICH trials showed no clear benefit for routine surgery)

4. Subarachnoid Hemorrhage (SAH)

Immediate Steps

• Transfer to high-volume center (> 35 SAH cases/year) - associated with lower mortality
• Ventriculostomy (EVD) if hydrocephalus present
• Control BP: target SBP < 160 mmHg pre-aneurysm securing (titratable IV nicardipine preferred)

Aneurysm Obliteration

• Endovascular coiling vs microsurgical clipping - decision by multidisciplinary team based on aneurysm location, patient grade, and institutional expertise
• The ISAT trial showed coiling was associated with better 1-year outcomes for aneurysms amenable to both approaches
• Early treatment (within 24-72 hours) is preferred to reduce rebleeding risk

Rebleeding Prevention (pre-treatment)

• Short-term tranexamic acid or aminocaproic acid (< 72 hours) reduces rebleeding when there is unavoidable delay to aneurysm treatment, but increases thromboembolic risk

Delayed Cerebral Ischemia (Vasospasm)

• Peaks at days 4-14 post-SAH
• Oral nimodipine (60 mg q4h x 21 days) is the standard treatment - reduces vasospasm-related neurological deficit
• Maintain euvolemia; avoid hypovolemia
• Induced hypertension (Triple-H therapy: Hypertension, Hypervolemia, Hemodilution) or endovascular angioplasty/intra-arterial vasodilators for refractory vasospasm

5. Secondary Prevention (Post-Stroke)

6. Rehabilitation

Summary Diagram

ACUTE STROKE
     |
     |----> Non-contrast CT brain (immediate)
     |
     ├── ISCHEMIC (~85%)
     │     |
     │     ├─ Within 4.5h + eligible → IV Alteplase 0.9 mg/kg
     │     ├─ LVO detected → Mechanical Thrombectomy (up to 24h)
     │     ├─ BP management (permissive unless >185/110 pre-tPA)
     │     ├─ Aspirin 24h post-tPA (or immediately if no tPA)
     │     └─ Stroke unit care + complication prevention
     │
     ├── ICH (~10-15%)
     │     ├─ BP → target SBP 140 mmHg
     │     ├─ Reverse anticoagulation
     │     ├─ Treat elevated ICP
     │     └─ Neurosurgery if cerebellar hematoma > 3 cm
     │
     └── SAH (~5%)
           ├─ BP → SBP < 160 mmHg
           ├─ EVD if hydrocephalus
           ├─ Secure aneurysm (coiling or clipping)
           └─ Nimodipine x 21 days for vasospasm

• Bradley and Daroff's Neurology in Clinical Practice (General Management of Acute Ischemic Stroke, p.1405-1408)
• Rosen's Emergency Medicine (Reperfusion Therapy, p.1437-1439)
• Adams and Victor's Principles of Neurology, 12th ed. (Secondary Prevention, p.826)
• Frameworks for Internal Medicine (Intracerebral Hemorrhage, p.577)
• ESO 2024 PFO Guidelines [PMID 38752755]

Stroke - Clinical CT/MRI Imaging Findings

1. Acute Ischemic Stroke - CT (Non-Contrast)

Ultra-Early Signs (within 3-6 hours)

"Patients with a hyperdense artery sign and acute hypodensity of one-third of the MCA distribution tend to have a poorer prognosis. Their outcomes are still better with tPA treatment than without." - Rosen's Emergency Medicine

2. MRI - DWI/FLAIR for Ischemic Stroke

DWI-FLAIR Mismatch (Unknown Onset / "Wake-Up Stroke")

• Left pair (DWI bright, FLAIR dark = mismatch): The DWI shows restricted diffusion (acute infarct) but FLAIR is still negative - this indicates the infarct is likely < 4.5 hours old, making the patient potentially eligible for thrombolysis even with unknown time of onset.
• Right pair (DWI bright, FLAIR also bright = no mismatch): Both sequences positive - the infarct is older (> 4.5h), and thrombolysis carries higher hemorrhagic risk.

3. Intracerebral Hemorrhage (ICH) - CT

Deep and Lobar Hemorrhages

• Acute (0-72h): Hyperdense (bright white), 40-80 Hounsfield Units, round or oval
• Subacute (days-weeks): Progressively isodense as clot retracts, rim enhancement possible
• Chronic: Hypodense (dark), slit-like defect

Right Temporal ICH (Arrow Sign)

4. Subarachnoid Hemorrhage (SAH) - CT + CT Angiography

SAH from Ruptured Anterior Communicating Artery Aneurysm

• Sensitivity: ~98% within 12 hours of onset
• Falls to ~85-90% by 24 hours (blood becomes isodense)
• If CT negative but high clinical suspicion: LP for xanthochromia (CSF yellow discoloration from bilirubin)
• Grading: Fisher grade correlates blood burden with vasospasm risk

5. Bilateral Temporal Lobe Infarcts - CT

Cortical Deafness from Bilateral MCA Territory Strokes

6. Intracranial Angiography - MCA Stenting

Pre- and Post-Wingspan Stent for M1 MCA Stenosis

Summary: What to Look for on Imaging