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Initial assessment and management of acute stroke

Jamary Oliveira Filho, MD, MS, PhD
Michael T Mullen, MD
Section Editor
Scott E Kasner, MD
Deputy Editor
John F Dashe, MD, PhD


The subacute and long-term assessment and management of patients who have suffered a stroke includes physical therapy and testing to determine the precise etiology of the event so as to prevent recurrence. The acute management differs. Immediate goals include minimizing brain injury, treating medical complications, and moving toward uncovering the pathophysiologic basis of the patient's symptoms.

Patient assessment and management during the acute phase (first few hours) of an ischemic stroke will be reviewed here. Use of thrombolytic therapy, treatment of patients not eligible for thrombolytic therapy, the clinical diagnosis of various types of stroke, and the subacute and long-term assessment of patients who have had a stroke are discussed separately. (See "Intravenous fibrinolytic (thrombolytic) therapy in acute ischemic stroke: Therapeutic use" and "Reperfusion therapy for acute ischemic stroke" and "Antithrombotic treatment of acute ischemic stroke and transient ischemic attack" and "Clinical diagnosis of stroke subtypes" and "Overview of the evaluation of stroke".)


Sudden loss of focal brain function is the core feature of the onset of ischemic stroke. However, patients with conditions other than brain ischemia may present in a similar fashion (table 1). (See "Differential diagnosis of transient ischemic attack and stroke".)

In addition, patients suffering a stroke may present with other serious medical conditions. Thus, the initial evaluation requires a rapid but broad assessment [1].

The goals in the initial phase include:

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Literature review current through: Nov 2017. | This topic last updated: Sep 11, 2017.
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  1. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870.
  2. Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016; 47:581.
  3. Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2032.
  4. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012; 43:1711.
  5. Kothari R, Hall K, Brott T, Broderick J. Early stroke recognition: developing an out-of-hospital NIH Stroke Scale. Acad Emerg Med 1997; 4:986.
  6. Goldstein LB, Simel DL. Is this patient having a stroke? JAMA 2005; 293:2391.
  7. Generalized efficacy of t-PA for acute stroke. Subgroup analysis of the NINDS t-PA Stroke Trial. Stroke 1997; 28:2119.
  8. Adams HP Jr, Davis PH, Leira EC, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 1999; 53:126.
  9. Adams HP Jr, del Zoppo G, Alberts MJ, 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; 38:1655.
  10. Michaels AD, Spinler SA, Leeper B, et al. Medication errors in acute cardiovascular and stroke patients: a scientific statement from the American Heart Association. Circulation 2010; 121:1664.
  11. Rodriguez GJ, Cordina SM, Vazquez G, et al. The hydration influence on the risk of stroke (THIRST) study. Neurocrit Care 2009; 10:187.
  12. Burns JD, Green DM, Metivier K, DeFusco C. Intensive care management of acute ischemic stroke. Emerg Med Clin North Am 2012; 30:713.
  13. Weir CJ, Murray GD, Dyker AG, Lees KR. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study. BMJ 1997; 314:1303.
  14. Bruno A, Biller J, Adams HP Jr, et al. Acute blood glucose level and outcome from ischemic stroke. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators. Neurology 1999; 52:280.
  15. Capes SE, Hunt D, Malmberg K, et al. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 2001; 32:2426.
  16. Dave JA, Engel ME, Freercks R, et al. Abnormal glucose metabolism in non-diabetic patients presenting with an acute stroke: prospective study and systematic review. QJM 2010; 103:495.
  17. Béjot Y, Aboa-Eboulé C, Hervieu M, et al. The deleterious effect of admission hyperglycemia on survival and functional outcome in patients with intracerebral hemorrhage. Stroke 2012; 43:243.
  18. Zonneveld TP, Nederkoorn PJ, Westendorp WF, et al. Hyperglycemia predicts poststroke infections in acute ischemic stroke. Neurology 2017; 88:1415.
  19. Allport L, Baird T, Butcher K, et al. Frequency and temporal profile of poststroke hyperglycemia using continuous glucose monitoring. Diabetes Care 2006; 29:1839.
  20. Lindsberg PJ, Roine RO. Hyperglycemia in acute stroke. Stroke 2004; 35:363.
  21. Parsons MW, Barber PA, Desmond PM, et al. Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol 2002; 52:20.
  22. Bruno A, Levine SR, Frankel MR, et al. Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology 2002; 59:669.
  23. European Stroke Initiative Executive Committee, EUSI Writing Committee, Olsen TS, et al. European Stroke Initiative Recommendations for Stroke Management-update 2003. Cerebrovasc Dis 2003; 16:311.
  24. Stroke Hyperglycemia Insulin Network Effort (SHINE) Trial. http://clinicaltrials.gov/ct2/show/NCT01369069 (Accessed on March 21, 2013).
  25. Bruno A, Durkalski VL, Hall CE, et al. The Stroke Hyperglycemia Insulin Network Effort (SHINE) trial protocol: a randomized, blinded, efficacy trial of standard vs. intensive hyperglycemia management in acute stroke. Int J Stroke 2014; 9:246.
  26. Bellolio MF, Gilmore RM, Ganti L. Insulin for glycaemic control in acute ischaemic stroke. Cochrane Database Syst Rev 2014; :CD005346.
  27. Summers D, Leonard A, Wentworth D, et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke 2009; 40:2911.
  28. Schwarz S, Georgiadis D, Aschoff A, Schwab S. Effects of body position on intracranial pressure and cerebral perfusion in patients with large hemispheric stroke. Stroke 2002; 33:497.
  29. Wojner-Alexander AW, Garami Z, Chernyshev OY, Alexandrov AV. Heads down: flat positioning improves blood flow velocity in acute ischemic stroke. Neurology 2005; 64:1354.
  30. Favilla CG, Mesquita RC, Mullen M, et al. Optical bedside monitoring of cerebral blood flow in acute ischemic stroke patients during head-of-bed manipulation. Stroke 2014; 45:1269.
  31. Toole JF. Effects of change of head, limb and body position on cephalic circulation. N Engl J Med 1968; 279:307.
  32. Caplan LR, Sergay S. Positional cerebral ischaemia. J Neurol Neurosurg Psychiatry 1976; 39:385.
  33. Anderson CS, Arima H, Lavados P, et al. Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. N Engl J Med 2017; 376:2437.
  34. Fernández-Crehuet R, Díaz-Molina C, de Irala J, et al. Nosocomial infection in an intensive-care unit: identification of risk factors. Infect Control Hosp Epidemiol 1997; 18:825.
  35. AVERT Trial Collaboration group, Bernhardt J, Langhorne P, et al. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet 2015; 386:46.
  36. Ginsberg MD, Busto R. Combating hyperthermia in acute stroke: a significant clinical concern. Stroke 1998; 29:529.
  37. Greer DM, Funk SE, Reaven NL, et al. Impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive meta-analysis. Stroke 2008; 39:3029.
  38. Saini M, Saqqur M, Kamruzzaman A, et al. Effect of hyperthermia on prognosis after acute ischemic stroke. Stroke 2009; 40:3051.
  39. Phipps MS, Desai RA, Wira C, Bravata DM. Epidemiology and outcomes of fever burden among patients with acute ischemic stroke. Stroke 2011; 42:3357.
  40. Prasad K, Krishnan PR. Fever is associated with doubling of odds of short-term mortality in ischemic stroke: an updated meta-analysis. Acta Neurol Scand 2010; 122:404.
  41. den Hertog HM, van der Worp HB, van Gemert HM, et al. The Paracetamol (Acetaminophen) In Stroke (PAIS) trial: a multicentre, randomised, placebo-controlled, phase III trial. Lancet Neurol 2009; 8:434.
  42. Den Hertog HM, van der Worp HB, Tseng MC, Dippel DW. Cooling therapy for acute stroke. Cochrane Database Syst Rev 2009; :CD001247.
  43. The Intravascular Cooling in the Treatment of Stroke 2/3 Trial (ICTuS2/3). http://clinicaltrials.gov/ct2/show/NCT01123161 (Accessed on June 15, 2011).
  44. Candelise L, Gattinoni M, Bersano A, et al. Stroke-unit care for acute stroke patients: an observational follow-up study. Lancet 2007; 369:299.
  45. Meretoja A, Roine RO, Kaste M, et al. Effectiveness of primary and comprehensive stroke centers: PERFECT stroke: a nationwide observational study from Finland. Stroke 2010; 41:1102.
  46. Di Carlo A, Lamassa M, Wellwood I, et al. Stroke unit care in clinical practice: an observational study in the Florence center of the European Registers of Stroke (EROS) Project. Eur J Neurol 2011; 18:686.
  47. Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2013; :CD000197.
  48. Alberts MJ, Latchaw RE, Jagoda A, et al. Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the brain attack coalition. Stroke 2011; 42:2651.
  49. Alberts MJ, Latchaw RE, Selman WR, et al. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke 2005; 36:1597.
  50. Alberts MJ. Stroke centers: proof of concept and the concept of proof. Stroke 2010; 41:1100.
  51. Middleton S, McElduff P, Ward J, et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet 2011; 378:1699.
  52. European Stroke Organisation (ESO) Executive Committee, ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25:457.
  53. Qureshi AI. Acute hypertensive response in patients with stroke: pathophysiology and management. Circulation 2008; 118:176.
  54. Aiyagari V, Gorelick PB. Management of blood pressure for acute and recurrent stroke. Stroke 2009; 40:2251.
  55. Wallace JD, Levy LL. Blood pressure after stroke. JAMA 1981; 246:2177.
  56. Leonardi-Bee J, Bath PM, Phillips SJ, et al. Blood pressure and clinical outcomes in the International Stroke Trial. Stroke 2002; 33:1315.
  57. Okumura K, Ohya Y, Maehara A, et al. Effects of blood pressure levels on case fatality after acute stroke. J Hypertens 2005; 23:1217.
  58. Bath PM. How to manage blood pressure in acute stroke. J Hypertens 2005; 23:1135.
  59. Berge E. Should high blood pressure be lowered in the acute stroke? J Hypertens 2011; 29:1478.
  60. Oliveira-Filho J, Silva SC, Trabuco CC, et al. Detrimental effect of blood pressure reduction in the first 24 hours of acute stroke onset. Neurology 2003; 61:1047.
  61. Vlcek M, Schillinger M, Lang W, et al. Association between course of blood pressure within the first 24 hours and functional recovery after acute ischemic stroke. Ann Emerg Med 2003; 42:619.
  62. Castillo J, Leira R, García MM, et al. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke 2004; 35:520.
  63. Saver JL. Time is brain--quantified. Stroke 2006; 37:263.
  64. He J, Zhang Y, Xu T, et al. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. JAMA 2014; 311:479.
  65. Sandset EC, Bath PM, Boysen G, et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet 2011; 377:741.
  66. Robinson TG, Potter JF, Ford GA, et al. Effects of antihypertensive treatment after acute stroke in the Continue or Stop Post-Stroke Antihypertensives Collaborative Study (COSSACS): a prospective, randomised, open, blinded-endpoint trial. Lancet Neurol 2010; 9:767.
  67. ENOS Trial Investigators, Bath PM, Woodhouse L, et al. Efficacy of nitric oxide, with or without continuing antihypertensive treatment, for management of high blood pressure in acute stroke (ENOS): a partial-factorial randomised controlled trial. Lancet 2015; 385:617.
  68. Wang H, Tang Y, Rong X, et al. Effects of early blood pressure lowering on early and long-term outcomes after acute stroke: an updated meta-analysis. PLoS One 2014; 9:e97917.
  69. Lee M, Ovbiagele B, Hong KS, et al. Effect of Blood Pressure Lowering in Early Ischemic Stroke: Meta-Analysis. Stroke 2015; 46:1883.
  70. Woodhouse LJ, Manning L, Potter JF, et al. Continuing or Temporarily Stopping Prestroke Antihypertensive Medication in Acute Stroke: An Individual Patient Data Meta-Analysis. Hypertension 2017; 69:933.
  71. National Institute for Health and Clinical Excellence. Stroke: The diagnosis and acute management of stroke and transient ischaemic attacks. Royal College of Physicians, London 2008. http://www.nice.org.uk/CG068 (Accessed on February 01, 2011).
  72. Jung SY, Choi NK, Kim JY, et al. Short-acting nifedipine and risk of stroke in elderly hypertensive patients. Neurology 2011; 77:1229.
  73. California Acute Stroke Pilot Registry Investigators. The impact of standardized stroke orders on adherence to best practices. Neurology 2005; 65:360.
  74. Blanco M, Nombela F, Castellanos M, et al. Statin treatment withdrawal in ischemic stroke: a controlled randomized study. Neurology 2007; 69:904.
  75. Flint AC, Kamel H, Navi BB, et al. Statin use during ischemic stroke hospitalization is strongly associated with improved poststroke survival. Stroke 2012; 43:147.
  76. Flint AC, Kamel H, Navi BB, et al. Inpatient statin use predicts improved ischemic stroke discharge disposition. Neurology 2012; 78:1678.
  77. Ní Chróinín D, Callaly EL, Duggan J, et al. Association between acute statin therapy, survival, and improved functional outcome after ischemic stroke: the North Dublin Population Stroke Study. Stroke 2011; 42:1021.
  78. Cappellari M, Bovi P, Moretto G, et al. The THRombolysis and STatins (THRaST) study. Neurology 2013; 80:655.
  79. Mead GE, Hsieh CF, Lee R, et al. Selective serotonin reuptake inhibitors (SSRIs) for stroke recovery. Cochrane Database Syst Rev 2012; 11:CD009286.
  80. Chollet F, Tardy J, Albucher JF, et al. Fluoxetine for motor recovery after acute ischaemic stroke (FLAME): a randomised placebo-controlled trial. Lancet Neurol 2011; 10:123.
  81. Mead GE, Hsieh CF, Hackett M. Selective serotonin reuptake inhibitors for stroke recovery. JAMA 2013; 310:1066.
  82. Chollet F. Selective serotonin reuptake inhibitors may be helpful in most patients with stroke. Stroke 2012; 43:3150.
  83. Marshall RS. Should every patient with stroke be on selective serotonin reuptake inhibitors? No. Stroke 2012; 43:3152.
  84. Selim MH, Molina CA. Poststroke treatment with selective serotonin reuptake inhibitors: a journey from sadness to motor recovery. Stroke 2012; 43:3154.
  85. Dávalos A, Alvarez-Sabín J, Castillo J, et al. Citicoline in the treatment of acute ischaemic stroke: an international, randomised, multicentre, placebo-controlled study (ICTUS trial). Lancet 2012; 380:349.
  86. Reza Noorian A, Nogueira R, Gupta R. Neuroprotection in acute ischemic stroke. J Neurosurg Sci 2011; 55:127.
  87. Sahota P, Savitz SI. Investigational therapies for ischemic stroke: neuroprotection and neurorecovery. Neurotherapeutics 2011; 8:434.
  88. Tymianski M. Can molecular and cellular neuroprotection be translated into therapies for patients?: yes, but not the way we tried it before. Stroke 2010; 41:S87.
  89. Ginsberg MD, Palesch YY, Hill MD, et al. High-dose albumin treatment for acute ischaemic stroke (ALIAS) Part 2: a randomised, double-blind, phase 3, placebo-controlled trial. Lancet Neurol 2013; 12:1049.
  90. Chamorro Á, Dirnagl U, Urra X, Planas AM. Neuroprotection in acute stroke: targeting excitotoxicity, oxidative and nitrosative stress, and inflammation. Lancet Neurol 2016; 15:869.
  91. Neuhaus AA, Couch Y, Hadley G, Buchan AM. Neuroprotection in stroke: the importance of collaboration and reproducibility. Brain 2017; 140:2079.
  92. Balami JS, Chen RL, Grunwald IQ, Buchan AM. Neurological complications of acute ischaemic stroke. Lancet Neurol 2011; 10:357.
  93. Shi Q, Presutti R, Selchen D, Saposnik G. Delirium in acute stroke: a systematic review and meta-analysis. Stroke 2012; 43:645.
  94. Oldenbeuving AW, de Kort PL, Jansen BP, et al. Delirium in the acute phase after stroke: incidence, risk factors, and outcome. Neurology 2011; 76:993.