What is the approach to acute management of stroke?

Answer

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.^[3]

Table 2. General Management of Patients With Acute Stroke^{[1, 4]} (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

Did this answer your question?

Yes No

Additional feedback? (Optional)

Thank you for your feedback!

[Guideline] Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007 May. 38(5):1655-711. [Medline].
Bruno A, Kent TA, Coull BM, Shankar RR, Saha C, Becker KJ, et al. Treatment of hyperglycemia in ischemic stroke (THIS): a randomized pilot trial. Stroke. 2008 Feb. 39(2):384-9. [Medline].
Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke. 2011 Jan. 42(1):227-76. [Medline].
Adams H, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update a scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke. 2005 Apr. 36(4):916-23. [Medline].
[Guideline] Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, et al. 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015 Oct. 46 (10):3020-35. [Medline].
Obach V, Oleaga L, Urra X, Macho J, Amaro S, Capurro S, et al. Multimodal CT-Assisted Thrombolysis in Patients With Acute Stroke: A Cohort Study. Stroke. 2011 Apr. 42(4):1129-31. [Medline].
Albers GW, Thijs VN, Wechsler L, Kemp S, Schlaug G, Skalabrin E, et al. Magnetic resonance imaging profiles predict clinical response to early reperfusion: the diffusion and perfusion imaging evaluation for understanding stroke evolution (DEFUSE) study. Ann Neurol. 2006 Nov. 60(5):508-17. [Medline].
Hacke W, Albers G, Al-Rawi Y, et al. Stroke. The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with IV desmoteplase. 2005. 36:66 -73.
Albers GW, von Kummer R, Truelsen T, Jensen JK, Ravn GM, Grønning BA, et al. Safety and efficacy of desmoteplase given 3-9 h after ischaemic stroke in patients with occlusion or high-grade stenosis in major cerebral arteries (DIAS-3): a double-blind, randomised, placebo-controlled phase 3 trial. Lancet Neurol. 2015 Jun. 14 (6):575-84. [Medline].
Muchada M, Rubiera M, Rodriguez-Luna D, Pagola J, Flores A, Kallas J, et al. Baseline National Institutes of Health stroke scale-adjusted time window for intravenous tissue-type plasminogen activator in acute ischemic stroke. Stroke. 2014 Apr. 45(4):1059-63. [Medline].
Abilleira S, Cardona P, Ribó M, Millán M, Obach V, Roquer J, et al. Outcomes of a contemporary cohort of 536 consecutive patients with acute ischemic stroke treated with endovascular therapy. Stroke. 2014 Apr. 45(4):1046-52. [Medline].
Jovin TG, Liebeskind DS, Gupta R, Rymer M, Rai A, Zaidat OO, et al. Imaging-Based Endovascular Therapy for Acute Ischemic Stroke due to Proximal Intracranial Anterior Circulation Occlusion Treated Beyond 8 Hours From Time Last Seen Well: Retrospective Multicenter Analysis of 237 Consecutive Patients. Stroke. 2011 Aug. 42(8):2206-11. [Medline].
González RG. Imaging-guided acute ischemic stroke therapy: From "time is brain" to "physiology is brain". AJNR Am J Neuroradiol. 2006 Apr. 27(4):728-35. [Medline].
Ingall TJ, O'Fallon WM, Asplund K, Goldfrank LR, Hertzberg VS, Louis TA, et al. Findings from the reanalysis of the NINDS tissue plasminogen activator for acute ischemic stroke treatment trial. Stroke. 2004 Oct. 35(10):2418-24. [Medline].
Sims JR, Rordorf G, Smith EE, Koroshetz WJ, Lev MH, Buonanno F, et al. Arterial occlusion revealed by CT angiography predicts NIH stroke score and acute outcomes after IV tPA treatment. AJNR Am J Neuroradiol. 2005 Feb. 26(2):246-51. [Medline].
Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, Broderick JP, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004 Mar 6. 363(9411):768-74. [Medline].
Saposnik G, Fang J, Kapral MK, Tu JV, Mamdani M, Austin P, et al. The iScore predicts effectiveness of thrombolytic therapy for acute ischemic stroke. Stroke. 2012 May. 43(5):1315-22. [Medline].
Milhaud D, Popp J, Thouvenot E, Heroum C, Bonafé A. Mechanical ventilation in ischemic stroke. J Stroke Cerebrovasc Dis. 2004 Jul-Aug. 13(4):183-8. [Medline].
Krieger D, Hacke W. The intensive care of the stroke patient. In: Stroke: Pathophysiology, Diagnosis and Management. 3rd ed. New York, NY: Churchill Livingstone; 1998.
Bruno A, Levine SR, Frankel MR, Brott TG, Lin Y, Tilley BC, et al. Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology. 2002 Sep 10. 59(5):669-74. [Medline].
Bruno A, Biller J, Adams HP Jr, Clarke WR, Woolson RF, Williams LS, et al. Acute blood glucose level and outcome from ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Neurology. 1999 Jan 15. 52(2):280-4. [Medline].
Baird TA, Parsons MW, Phanh T, Butcher KS, Desmond PM, Tress BM, et al. Persistent poststroke hyperglycemia is independently associated with infarct expansion and worse clinical outcome. Stroke. 2003 Sep. 34(9):2208-14. [Medline].
Anderson CS, Arima H, Lavados P, Billot L, Hackett ML, Olavarría VV, et al. Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. N Engl J Med. 2017 Jun 22. 376 (25):2437-2447. [Medline].
Wojner-Alexander AW, Garami Z, Chernyshev OY, Alexandrov AV. Heads down: flat positioning improves blood flow velocity in acute ischemic stroke. Neurology. 2005 Apr 26. 64(8):1354-7. [Medline].
Castillo J, Leira R, García MM, Serena J, Blanco M, Dávalos A. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. 2004 Feb. 35(2):520-6. [Medline].
Sandset EC, Bath PM, Boysen G, Jatuzis D, Kõrv J, Lüders S, et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet. 2011 Feb 26. 377(9767):741-50. [Medline].
Sandset EC, Murray GD, Bath PM, Kjeldsen SE, Berge E. Relation between change in blood pressure in acute stroke and risk of early adverse events and poor outcome. Stroke. 2012 Aug. 43(8):2108-14. [Medline].
The NINDS rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995 Dec 14. 333(24):1581-7. [Medline].
Cumming TB, Thrift AG, Collier JM, Churilov L, Dewey HM, Donnan GA, et al. Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial. Stroke. 2011 Jan. 42(1):153-8. [Medline].
Baker WL, Colby JA, Tongbram V, Talati R, Silverman IE, White CM, et al. Neurothrombectomy devices for the treatment of acute ischemic stroke: state of the evidence. Ann Intern Med. 2011 Feb 15. 154(4):243-52. [Medline].
Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet. 2008 May 10. 371(9624):1612-23. [Medline].
Derex L, Tomsick TA, Brott TG, Lewandowski CA, Frankel MR, Clark W, et al. Outcome of stroke patients without angiographically revealed arterial occlusion within four hours of symptom onset. AJNR Am J Neuroradiol. 2001 Apr. 22(4):685-90. [Medline].

Media Gallery

of 0

Author

Edward C Jauch, MD, MS, FAHA, FACEP Chief of System Research, Mission Research Institute, Mission Health; Adjunct Professor, Department of Bioengineering, Clemson University

Edward C Jauch, MD, MS, FAHA, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, American Medical Association, National Stroke Association, Society for Academic Emergency Medicine, South Carolina Medical Association

Disclosure: Received grant/research funds from Genentech for site pi.

Coauthor(s)

Brett Kissela, MD, MS Professor and Chair, Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine

Brett Kissela, MD, MS is a member of the following medical societies: American Academy of Neurology, American Heart Association, Phi Beta Kappa

Disclosure: Received honoraria from Medscape Education for an educational activity; Received fees for adjudication of adverse events for clinical trial, payment per event reviewed from AbbVie and Janssen. Work performed as anindependent contractor.

Brian Stettler, MD Assistant Professor, Program Director, Emergency Medicine Residency Program, Department of Emergency Medicine, and Faculty Greater Cincinnati/Northern Kentucky Stroke Team, University of Cincinnati

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Abbott Laboratories, advisory group.

Acknowledgements

Thomas A Kent, MD Professor and Director of Stroke Research and Education, Department of Neurology, Baylor College of Medicine; Chief of Neurology, Michael E DeBakey Veterans Affairs Medical Center

Thomas A Kent, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, New York Academy of Sciences, Royal Society of Medicine, Sigma Xi, and Stroke Council of the American Heart Association

Disclosure: Nothing to disclose.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Acknowledgments

The authors would like to thank Dr. Jennifer Franklin for her assistance in the updating of this article.

What is the approach to acute management of stroke?

Answer

Related Questions:

References

Tables

Contributor Information and Disclosures