Acute management of Stroke, Emergency management of stroke. Stroke management guidelines.

Today's topic is Emergency management of stroke.


As with any emergency start with the Stabilization of the patient.


Brain stem strokes can cause loss of consciousness, in which case, intubation is required to maintain the airway patency.
Stroke patients are usually stable, but for the sake of completeness, I'll mention the breathing as well.
How ever it is very important to measure the blood pressure of the patient. Most of strokes patients have elevated pressure levels.
Measure the GCS under the disability.
If there's a history of a fall, check the entire body for secondary injuries.


Following the stabilization,
take a quick history.
Time of onset of symptoms is important, to find out if the patient is within the thrombolytic window, which is 4.5 hours.
Then ask about the progression, as rapid recovery of weakness is indicating Transient ischemic attack, rather than a stroke.
The history is followed up with a quick neurological examination.

After the assessment, Get done a non-contrast CT scan of the brain.
Look for hemorrhagic changes, as the management of hemorrhagic strokes completely differs from that of ischemic strokes.

If you were able to exclude hemorrhagic stroke, consider it as an ischemic stroke and proceed with the algorithm.
Remember that ischemic features in the CT scan are delayed features and we can't wait that long. CT scan is used only to exclude hemorrhagic strokes.

Revascularization is the treatment of ischemic strokes.
Fibrinolytic therapy with altepase is the most commonly used method of revascularization.
But new methods like vascular interventions or stenting are also gaining rapid popularity.

Altepase dose is 0.9mg/kg, although the maximum dose is 90mg.
10% of the dose is given as the loading dose and the rest is given within an hour.

But before you give altepase, you have to check whether the patient fulfills the inclusion criteria and exclusion criteria for thrombolysis.

Inclusion criteria includes that
the patient is within the thrombolytic window, which is 4.5 hours from the onset of symptoms,
presence of a measurable degree of weakness. scores like NIHSS score can be used for this.a NIHSS score between 5 and 25 is considered ideal for thrombolysis.
And the symptoms should not be rapidly resolving, as we don't thrombolyse patients with Transient ischemic attacks.

Please pause and go through the exclusion criteria for thrombolysis.


Following thrombolysis, patient should be monitored at an intensive care unit. after 24 hours another non contrast CT is taken to exclude hemorrhagic transformation in the brain.

After excluding this, we start anti platelet drugs and stains. We also investigate to find the etiologies for the stroke and and manage those risk factors.

Physiotherapy and occupation therapies are also considered at this stage.

The management of hemorrhagic stroke is usually controlling the blood pressure. I'll make another video in the future, to discuss the hypertensive emergencies.


I'd love to hear your feedback. I hope you liked the video. I plan on making more emergency videos in the future. You can subscribe if you are interested. Thanks.

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