Early management of patients with suspected stroke

David Goldemund M.D.
Updated on 07/05/2024, published on 07/06/2022

  • any patient experiencing rapidly evolving neurological deficits should be evaluated as a potential candidate for recanalization therapy and transported ASAP to the nearest Stroke Center (SC) or Comprehensive Stroke Center (CSC) for urgent diagnostic evaluation and treatment

Definition and clinical presentation of acute stroke

  • stroke is a cerebrovascular emergency typically characterized by the sudden loss of neurological functions
  • it can be classified into 2 main categories:
    • ischemic
      • arterial occlusion (ischemic stroke)    Cerebellar infarct caused the PICA occlusion
      • venous thrombosis (cerebral sinus or vein thrombosis)  Hyperdense sign in the right sigmoid and straight sinus thrombosis (80 HU)
    • hemorrhagic
      • intracerebral hemorrhage Density of an acute hematoma on non-contrast CT (NCCT)
      • subarachnoid hemorrhage  SAH caused by the rupture of a posterior communicating artery (PComA) aneurysm
  • sudden onset of neurological deficit
    • not all stroke subtypes meet this criterion (mild SAH, the early phase of cerebral sinus thrombosis, etc.)
    • conversely, not all acute-onset focal symptoms are stroke-related stroke mimics (tumor, migraines, trauma, epileptic seizures, hypoglycemia, etc.)
      • other cause at age < 50 years ~ 21%
      • other cause at age > 50 years ~ 3%
  • several prehospital tests have been developed to facilitate rapid stroke detection (FAST, 3-ISS, C-STAT, LAMS, PASS, RACE, FAST+)
Typical clinical course
  • sudden onset, with the deficit usually reaching its maximum severity initially; the undulating and progressive course is possible (due to thrombus dynamics, quality of collateral circulation, etc.)
  • focal, negative symptoms (hemiparesis, hemihypesthesia, dysarthria, aphasia, hemianopsia, etc.-)
    • common in ischemic stroke or ICH
    • usually absent in SAH and during the early phases of cerebral sinus thrombosis
  • associated symptoms: headache, vertigo, and nausea
Common signs and symptoms
  • hemiparesis
  • hemihypesthesia
  • hemianopsia, monocular visual disturbances
  • hemiparesthesias
  • aphasia
  • dysarthria, dysphonia, dysphagia
  • vestibular and cerebellar syndrome
  • oculomotor disorders
Less likely stroke symptoms
  • isolated diplopia
  • isolated dysphagia
  • isolated tinnitus/hearing loss
  • vertigo
  • isolated imbalance and falls
  • isolated confusion (don’t mistake confusion for aphasia)
  • the original concepts of transient Ischemic Attack (TIA) and Reversible Ischemic Neurological Deficit (RIND) are now considered obsolete
  • according to the old definition, a TIA was defined as a sudden focal neurological deficit of presumed vascular origin lasting < 24 hours; however, ~30-50% of such TIAs had evidence of infarction on MR-DWI
  • a new definition of TIA: a short-term impairment of neurological function caused by the cerebral, spinal cord, or retinal ischemia (with clinical symptoms usually lasting < 1h) unless there is evidence of cerebral infarction [Albers, 2002] [Furie, 2011]
  • cerebral infarction – persistent clinical symptoms and/or positive imaging studies (i.e., even if neurological findings are normal)

From a practical point of view, both stroke and TIA are serious conditions with significant prognostic implications, that require urgent diagnosis and treatment → TIA see here

  • triage positive patient = at least 1 major or 2 minor symptoms (see table)
Major stroke symptoms
Minor stroke symptoms
  • hemiparesis or monoparesis
  • central paresis of the facial nerve
  • speech disorder (aphasia, dysarthria)
  • altered level of consciousness (LOC)
    • quantitative (somnolence – sopor – coma)
    • qualitative (delirium)
  • visual disturbance (visual field defects, sudden loss of vision in one eye, diplopia)
  • balance and gait disturbance
  • unilateral sensory impairment (hypesthesia, anesthesia, paresthesias)
  • symptoms suggestive of potential SAH
    • sudden onset of a severe, atypical headache (“worst headache ever”)
    • gradual development of neck stiffness (meningeal syndrome)
  • the scale reflects acute stroke severity and predicts proximal MCA occlusion with reasonable accuracy (Singer, 2005)
  • it evaluates 3 parameters:
    • level of consciousness (LOC)
    • gaze
    • motor functions
  • each item is graded from 0 to 2, with 0 representing normal findings and 2 indicating severe abnormalities
  • the worst score is 6 (i.e., profound drowsiness or worse, forced gaze deviation, and severe hemiparesis, respectively)
  • a score of ≥4 predicts proximal vessel occlusion (T-segment of ICA or M1 segment) almost as accurately as an NIHSS score ≥14

Pre-hospital management and triage

Monitoring vital signs, symptomatic therapy

  • perform a rapid assessment of vital signs (ABC) – A – airway, B – breathing, C – circulation
    • maintain arterial blood oxygen saturation >94%, and do not administer oxygen to nonhypoxic patients  (AHA/ASA 2018 I/C-LD)
    • secure the airway if necessary
    • monitor blood pressure (BP) – correct hypotension; hypertension should be treated cautiously (→ hypertension in the acute stage of stroke see here)
  • secure venous access
    • a green cannula (18G, inner diameter 1.3 mm) if CTP is a standard part of the imaging protocol
    • a pink cannula  (20G, inner diameter 1.1 mm) if CTA alone is planned
  • check glycemia and avoid glucose infusions (except for hypoglycemia)
  • avoid any oral intake
  • perform an ECG
  • initiate symptomatic therapy as needed (such as antiemetics, antiseizure medications, etc.)

Triage of patients with suspected stroke

  • emergency services should recognize the clinical signs of stroke (using FAST, FAST PLUS, 3I-SS, etc.), obtain relevant medical history and the exact time of onset, and look for contraindications to thrombolysis (see below)
  • patients eligible for recanalization treatment should be urgently transported to a Stroke Center or Comprehensive Stroke Center) (AHA/ASA 2019 I/B-NR)
    • for patients with suspected Large Vessel Occlusion (LVO), direct transport to the nearest CSC may be preferable  (AHA/ASA 2019 IIb/B-NR)
    • data analysis from the DAWN trial showed no significant difference in outcome between patients transferred to a Stroke Center with secondary transport to a CSC and those with direct transport to a CSC [Aghaebrahim,2019]
    • patients with suspected LVO for whom IVT is contraindicated should be transferred directly to a CSC after prior consultation (AHA/ASA 2019 IIb/C-EO)
    • if symptomatic LVO is detected in the SC, the nearest CSC should be consulted immediately
When the patient should be primarily transferred to a center providing endovascular treatment
presumed LVO < 4.5h from the onset of symptoms if the time of IVT initiation would not differ significantly between SC and CSC
an acute stroke patient with a known absolute contraindication to  IVT (anticoagulant therapy, endocarditis, aortic dissection, recent delivery, etc.)
signs and symptoms of SAH
When to transfer the patient from the SC to the CSC
selected patients with LVO < 24h after symptoms onset mechanical recanalization
patients at risk of malignant ischemia for whom decompressive craniectomy is considered
patients with arterial dissection indicated for interventional procedure
patients with ICH, SAH, or IVH who are candidates for surgical intervention
patients with cerebral sinus thrombosis who are likely candidates for endovascular or surgical intervention

Relevant information to obtain

  • determine the time of stroke onset:
    • ascertain the exact time of stroke onset or establish when the patient was last seen well, or at least when a witness found the patient
    • in wake-up stroke (WUS), try to narrow down the onset time (determine when the patient went to sleep, whether they woke up during the night, etc.)
  • contact information and history:
    • obtain phone contact with someone who can specify the circumstances of the stroke
  • collect a detailed personal and medical history
    • focus on known contraindications to thrombolysis
      • use of anticoagulants (warfarin, DOACs) and the time of the last dose
      • recent surgery or bleeding
      • predisposition to bleeding
      • allergies and adverse reactions (to iodinated contrast media, drugs, food, etc.)
      • history of renal insufficiency
    • paramedics should obtain a list of the patient’s diagnoses and medications from family members and bring any available medical records
  • assess the patient’s pre-stroke biological status and life expectancy

Initial hospital management

Following basic procedures should be performed as quickly as possible. Many of them can be done simultaneously, either before or during thrombolysis

  • recanalization therapy should begin ASAP after the patient arrives at the hospital
  • it is recommended to follow the approved in-house stroke protocol
    • the patient is taken to the emergency department, stroke unit, or directly to the CT department
    • brain and vascular imaging (± perfusion) are performed
  • none of the following procedures (except for stabilizing vital signs, correcting blood pressure, and performing non-contrast CT scan) should delay recanalization therapy
  • monitor baseline vital signs during transport and diagnostic evaluation (at least oximetry. BP, and pulse rate during the CT scan)

Initial assessment and stabilization of vital functions

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Intravenous access and laboratory testing

  • collect blood samples for the following tests:
    • blood glucose – the only test required before starting IVT (AHA/ASA 2019 I/B-NR)
    • bilirubin, osmolality, liver panel (AST, ALT, GMT)
    • urea (BUN), creatinine, estimated glomerular filtration rate (eGFR) or CrCl
    • ionogram (Na, K, Cl)
    • inflammatory markers
    • cardiac enzymes (CK, CKMB, LD) + high-sensitivity troponin T (hs-troponin T) (AHA/ASA 2019 I/C-LD)
      • elevation seen in 5-34% of patients
      • MI can cause stroke, and conversely, stroke can provoke MI
      • ~ 10% of mild troponin T elevations are not due to MI (potential causes include hypertensive crisis, tachycardia, cardiac failure, pulmonary embolism, renal failure, aortic dissection)
      • even borderline elevations of hs-troponin T may be associated with MI (in cryptogenic stroke with suspected cardioembolism, TTE or cardiac MRI should be performed)
    • complete blood count (CBC)
    • coagulation tests
      • APTT, prothrombin time, AT III, fibrinogen
      • specific tests to assess DOAC activity
      • INR (if the patient is using warfarin) can be quickly determined with a bedside coagulometer (CoaguChek)
    • other tests
      • ASTRUP
      • toxicology screen (alcohol, drugs)
      • pregnancy test
      • D-dimer
  • insert IV cannula (2 cannulas are required if thrombolysis is planned)
    • if a peripheral vein cannot be secured, cannulate the femoral or jugular vein
  • consider placing a urinary catheter
    • palpate the bladder for fullness; urinary retention may cause agitation
  • in patients not receiving anticoagulant therapy or without known thrombocytopenia or bleeding abnormality, IVT may be initiated without awaiting INR, aPTT, and platelet count (if their evaluation and determination would postpone the initiation of thrombolysis)
  • if tests reveal an INR > 1.7 or aPTT above the upper laboratory limit, or a platelet count is < 100 000/μL, IVT must be stopped immediately
  • the risk of unexpected thrombocytopenia or coagulopathy is very low (~ 0.3-0.4%) [Rost, 2009], [Cucchiara, 2007]

AHA/ASA guidelines 2019

Medical history, clinical examination, symptomatic therapy

  • medical history (from patient or witnesses)
    • time of stroke symptom onset or when the patient was last seen well
    • duration of transient symptoms, as longer durations increase the likelihood of detecting a DWI lesion.
    • circumstances of stroke onset, including signs of possible epileptic seizure
    • history of previous stroke, myocardial infarction (MI), hypertension (HT), dyslipidemia (DLP), or diabetes
    • history of coagulation disorders, recent bleeding, or surgery
    • medications (especially anticoagulants), comorbidities, allergies, previous reaction to an iodinated contrast agent
    • history of smoking, drug or alcohol abuse
  • clinical examination
  • start symptomatic therapy (e.g., analgesics, antiemetics)

Brain and vascular imaging

  • perform all tests as quickly as possible (AHA/ASA 2019 I/B-NR)
  • do not administer antiplatelets/anticoagulants prior to brain imaging; only provide necessary symptomatic therapy
    • IV midazolam bolus if the patient is agitated or IV antiemetics for vomiting
  • start with non-contrast brain CT (NCCT) or MRI (FLAIR, DWI, GRE) – sufficient for IVT indication
    • distinguish ischemia from hemorrhage and other etiology (tumor, inflammatory involvement, trauma)
    • MRI is as effective as NCCT in differentiating hemorrhage (AHA/ASA 2019 I/B-NR)
    • assess the location and extent of the infarct
  • vascular imaging – perform CT angiography/MR angiography in all candidates for mechanical recanalization therapy (usually after tPA bolus) (AHA/ASA 2019 I/A)
    • examine extra- and intracranial circulation and assess the aortic arch (exclude dissection!) Aortic dissection on CTA
    • consider extending emergency CTA to the level of the heart to detect left atrial appendage (LAA) thrombus or pulmonary embolism Pulmonary embolism on CTA LAA thrombus on CTA CTA showing thrombus in LAA  (Popkirov, 2019)
    • assess vascular pathology (occlusion, extra-/intracranial stenosis) and route to the site of occlusion and collateral circulation
    • vascular imaging is also useful in TIA patients to exclude occlusion or high-risk stenosis
    • do not wait for a creatinine level in patients with no history of renal impairment; the risk of CIN is low (AHA/ASA 2019 IIa/B-NR)
    • management of patients with a history of renal insufficiency is not specified in the recent guidelines
  • evaluation of tissue viability (via multimodal imaging techniques such as CT perfusion, MR DWI/PWI mismatch)
    • testing should not delay IVT administration and is not necessary for patients within the 4.5h window (AHA/ASA 2018 III/B-NR)
    • in patients < 6h after stroke onset and with ASPECTS ≥ 6, CTP is unnecessary to indicate mechanical recanalization (THRACE and MR CLEAN trials showed positive results without CTP). Further RCTs will decide whether stratification by CTP is helpful in this time window
    • expanded indications for recanalization therapy are discussed here
    • multimodal imaging may also be considered after secondary transport to CSC to avoid futile endovascular procedure  see the discussion here

Clinical-radiologic correlation

  • a vascular neurologist (strokologist or stroke specialist) should be able to correctly indicate and interpret various imaging modalities and ultimately make clinical-imaging correlations
  • after integrating all this knowledge together with a careful risk-benefit assessment, they can decide on the optimal therapeutic approach
  • the decision-making process is most complex in acute ischemic stroke, where the diagnostic evaluation should help to address the following questions:
  • is it a stroke/TIA?
  • what type of stroke is it (ischemic, hemorrhagic)?
  • which part of the brain and what arterial territory is affected?
  • is a relevant artery occluded?
  • can the affected part of the brain be salvaged (e.g., through IVT or thrombectomy)?
  • what is the most likely cause of the stroke, and what measures should be taken to prevent its recurrence?
  • what is the patient’s prognosis and goals?

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Early management of patients with suspected stroke