---
title: Acute Stroke Assessment and Treatment
description: A comprehensive guide to the clinical assessment and evidence-based management of acute ischemic and hemorrhagic stroke.
keywords: [stroke, ischemic, hemorrhagic, thrombolysis, thrombectomy, cerebrovascular]
category: clinical
---

## Acute Stroke Presentation and Diagnostic Criteria

Acute stroke is a medical emergency characterized by the sudden onset of focal neurological deficits resulting from an interruption of cerebral blood flow. Ischemic stroke, caused by arterial occlusion, accounts for 87% of cases, while the remaining 13% are hemorrhagic strokes resulting from intracerebral or subarachnoid bleeding. Common presenting symptoms include unilateral weakness, sensory loss, ataxia, visual disturbances, aphasia, and altered mental status.

The diagnosis of acute stroke is primarily clinical, based on a thorough history and physical examination. The ROSIER (Recognition of Stroke in the Emergency Room) scale can be used to rapidly screen for stroke, with a score ≥1 indicating a high likelihood. Immediate neuroimaging with non-contrast CT or MRI is essential to differentiate ischemic from hemorrhagic stroke and guide treatment. Laboratory testing should include a complete blood count, electrolytes, renal function, and coagulation studies.

## Ischemic Stroke: Thrombolytic Therapy

For patients with acute ischemic stroke, intravenous tissue plasminogen activator (IV-tPA) is the first-line pharmacologic treatment. Eligible patients must receive tPA within 4.5 hours of symptom onset. Contraindications include recent surgery or trauma, active bleeding, uncontrolled hypertension, and history of intracranial hemorrhage.

The recommended tPA dose is 0.9 mg/kg (maximum 90 mg), with 10% given as a bolus and the remaining 90% infused over 60 minutes. Patients should be monitored closely for bleeding complications, with blood pressure maintained <180/105 mmHg. Repeat imaging is warranted if neurological status deteriorates.

## Ischemic Stroke: Endovascular Thrombectomy

For patients with large vessel occlusion (LVO) of the internal carotid, middle cerebral, or basilar arteries, endovascular thrombectomy is the standard of care. Eligible patients must meet specific criteria, including a National Institutes of Health Stroke Scale (NIHSS) score ≥6 and the ability to initiate the procedure within 6-24 hours of symptom onset.

The procedure involves the use of mechanical devices (stent retrievers, aspiration catheters) to physically remove the occluding thrombus. Intravenous tPA should be administered prior to thrombectomy when possible. Antiplatelet therapy with aspirin 325 mg is typically started within 24 hours of the procedure.

## Hemorrhagic Stroke: Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes and is associated with high morbidity and mortality. Common risk factors include hypertension, anticoagulant use, and cerebral amyloid angiopathy. Patients typically present with sudden-onset headache, vomiting, and decreased level of consciousness.

Immediate management focuses on controlling blood pressure, reversing any coagulopathy, and minimizing hematoma expansion. Recommended blood pressure targets are systolic <140 mmHg and diastolic <90 mmHg. Prothrombin complex concentrate (PCC) or fresh frozen plasma can be used to rapidly correct INR in patients on warfarin. Surgical evacuation of the hematoma may be considered for select patients with large, accessible ICH.

## Hemorrhagic Stroke: Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH) accounts for 5-10% of all strokes and is most commonly caused by the rupture of an intracranial aneurysm. Patients typically present with sudden-onset "thunderclap" headache, nausea, vomiting, and altered mental status.

Initial management includes securing the airway, supporting ventilation, and controlling blood pressure to prevent further bleeding. Non-contrast CT of the head is the initial diagnostic test, with a sensitivity of 93-98% within the first 6 hours. If CT is negative but clinical suspicion remains high, lumbar puncture should be performed to assess for xanthochromia.

Definitive treatment involves securing the ruptured aneurysm, either through surgical clipping or endovascular coiling. Nimodipine, a calcium channel blocker, is given to prevent cerebral vasospasm, a major cause of secondary brain injury. Close monitoring in a neurointensive care unit is essential.

## Stroke Rehabilitation and Prognosis

All patients with acute stroke should be admitted to a dedicated stroke unit for comprehensive care and early mobilization. Rehabilitation services, including physical, occupational, and speech therapy, should be initiated as soon as the patient is medically stable.

The overall prognosis for stroke depends on the type, severity, and location of the cerebrovascular event. Ischemic stroke patients treated with tPA or thrombectomy have a better functional outcome compared to those who do not receive reperfusion therapy. Intracerebral hemorrhage is associated with higher mortality, particularly in the setting of large hematoma volume, intraventricular extension, and underlying coagulopathy.

Long-term management focuses on secondary prevention, including strict blood pressure control, antiplatelet or anticoagulant therapy, and management of other vascular risk factors. Patients should be monitored for post-stroke complications, such as depression, spasticity, and aspiration pneumonia.