Strokes can be classified as ischemic, due to an occluded artery, or as hemorrhagic, due to a ruptured artery. Ischemic stroke is by far the more common type. Patient presentation of stroke includes sudden onset of focal neurologic impairment, which depends on the particular brain region affected.³   Common deficits include dysphasia, dysarthria, hemianopia, weakness, ataxia, sensory loss, and neglect. Symptoms and signs are often unilateral, and consciousness is usually normal or impaired only slightly. Deficits should be assessed by careful neurologic examination. The initial assessment can identify candidates for acute treatment and provide an early prognosis of mortality or recovery. The National Institutes of Health (NIH) Stroke Scale is used by qualified practitioners as the initial examination. This scale is well validated and correlates with short and long term outcomes for patients. Performing the scale on all stroke patients is a common requirement for stroke center certification.⁴

In the acute setting, cerebral infarction cannot be distinguished from intracerebral hemorrhage on the basis of symptoms and physical exam alone. Non-contrast CT is the initial diagnostic test to evaluate for acute ischemia and rule out hemorrhage. Compared with MRI, CT is more widely available, faster, less susceptible to motion artifacts, and less expensive. MRI is recommended as a follow up test and can identify acute and subacute ischemia, vasogenic edema, hemorrhage, nonvascular lesions, or another underlying cause.  Laboratory data is also important to collect during initial evaluation including: blood glucose, complete blood count, basic metabolic panel, troponin, and a coagulation profile.

The effectiveness of thrombolysis with recombinant tissue plasminogen activator (rtPA) administered within 3 hours of acute ischemic stroke was examined in the National Institute of Neurological Diseases and Stroke trial. This study (NINDS rt-PA) was a multicenter, randomized trial.⁵ t-PA is a fibrinolytic agent that converts plasminogen to plasmin in the presence of fibrin to initiate fibrinolysis at the site of thrombus formation, this improves blood flow to areas of the brain that are ischemic but not yet infarcted (ischemic penumbra). Patients treated with t-PA had a favorable neurologic or functional outcome at 3 months, as compared with patients given placebo. Mortality rates were similar in the two groups. The most feared complication of t-PA is intracranial hemorrhage which occurred in 6.4% of patients treated with t-PA and in 0.6% of controls. ⁵ A small number of patients with acute ischemic stroke will be eligible for reperfusion therapy, as there are numerous exclusion criteria including: minor or improving symptoms, seizure at stroke onset, prior stroke within 3 months, major surgery within 14 days, history of intracerebral hemorrhage, sustained elevated blood pressure or aggressive medical treatment to correct blood pressure (see below), and suspicion of subarachnoid hemorrhage. There is some laboratory data which also excludes patient from receiving t-PA including: INR >1.7, platelet count <100,000/uL, plasma glucose < 50 or >400 (mg/dL). ⁴ Chronologic age is not among the definite exclusion criteria.

Treatment of blood pressure in the acute setting of stroke is also essential. In patients who are candidates for t-PA, blood pressure should be less than 185/110 mm Hg, which can be achieved by the continuous infusion of agents like labetalol or nicardipine. After t-PA infusion, blood pressure should be targeted to less than 180/105 mmHg and one can continue to treat with the agents mentioned above. In patients ineligible for intravenous rtPA, blood pressure parameters are liberalized (up to 220/120 mmHg) with the intention of maintaining cerebral perfusion to ischemic areas. Antithrombotic agents remain the most commonly used drugs for stroke prevention. Two large clinical trials showed a benefit of treatment with aspirin over placebo in short-term mortality and recurrent stroke risk when administered within 48 hours of ischemic stroke onset. Admission to a specialized stroke unit improves clinical outcomes after stroke, including the 1-year mortality rate. These types of facilities bring an interprofessional  approach to treatment, and are able to focus on the physical, medical, and emotional needs of affected patients. After recovering from a stroke, prevention of future events through risk factor reduction is the cornerstone of stroke management.⁴