Stroke

Stroke as a Time-Critical Emergency

Stroke is a time-critical cardiovascular emergency that results from an interruption of blood flow to the brain, causing neurological deficit. For the Certified Emergency Nurse (CEN) exam, stroke management is a high-yield topic because early recognition, rapid assessment, and protocol-driven interventions directly impact patient outcomes.[1] Ischemic stroke accounts for approximately 87% of all strokes, while hemorrhagic stroke constitutes the remainder.[2] The emergency nurse must be proficient in stroke scales, door-to-needle time goals, thrombolytic administration, and post-thrombolytic monitoring.

Essential Stroke Terminology and Metrics

  • Ischemic stroke: Obstruction of a cerebral artery by a thrombus or embolus, leading to infarction of brain tissue.[1]
  • Hemorrhagic stroke: Rupture of a cerebral vessel causing intraparenchymal or subarachnoid hemorrhage.[2]
  • Transient ischemic attack (TIA): A transient episode of neurological dysfunction caused by focal brain ischemia without acute infarction. Often a warning sign for impending stroke.[3]
  • Penumbra: The area of ischemic brain tissue that is at risk of infarction but potentially salvageable if blood flow is restored quickly. Time is brain.
  • Thrombolytic therapy: Administration of alteplase (tPA) to dissolve the clot in acute ischemic stroke within a defined therapeutic window.
  • Mechanical thrombectomy: Endovascular removal of a large vessel occlusion using a stent retriever or aspiration catheter.[4]
  • National Institutes of Health Stroke Scale (NIHSS): A standardized, 15-item neurological assessment tool used to quantify stroke severity.[1]
  • Door-to-needle time: The time from ED arrival to initiation of thrombolytic infusion. Target ≤ 60 minutes; ideal ≤ 30 minutes.[5]

AHA/ASA Stroke Chain of Survival and Prehospital Assessment

Stroke Chain of Survival (AHA/ASA)[5]

  1. Immediate recognition and activation of EMS (using FAST or BE FAST).
  2. Rapid EMS dispatch, prehospital notification, and transport to a stroke center.
  3. Early triage, assessment, and CT head on arrival.
  4. Timely decision-making: review eligibility for tPA and/or thrombectomy.
  5. Door-to-needle administration of alteplase (if eligible).
  6. Admission to a stroke unit or neuro ICU.

Prehospital Assessment – FAST Mnemonic

  • Face: Ask patient to smile. Is one side drooping?
  • Arms: Ask patient to raise both arms. Does one drift downward?
  • Speech: Ask patient to repeat a simple phrase. Is speech slurred or strange?
  • Time: Time of symptom onset is critical. If any sign is present, activate stroke team.

Many centers now use BE FAST (adding Balance and Eyes) to capture posterior circulation strokes.[3]

Recognizing Stroke: Cardinal Neurological Signs

  • Sudden unilateral weakness or numbness of face, arm, or leg (especially one side of the body).
  • Sudden confusion, trouble speaking (aphasia) or understanding speech.
  • Sudden vision loss in one or both eyes (monocular blindness, hemianopsia).
  • Sudden severe headache of unknown cause (classic for hemorrhagic stroke).
  • Sudden dizziness, loss of balance, or coordination (ataxia, especially with posterior circulation strokes).
  • Other findings: dysphagia, neglect, nystagmus, altered level of consciousness.

Emergency Diagnostic Workup and tPA Eligibility Screening

Emergency Department Assessment

  • Primary survey (ABCDE) with emphasis on airway protection if GCS < 8 or signs of increased ICP.
  • Time of symptom onset (or last known well) – most critical piece of information for treatment decisions.[1]
  • NIHSS performed on arrival. Score correlates with stroke severity and prognosis.[4]
  • Blood glucose – rule out hypoglycemia (can mimic stroke).
  • CT head without contrast – mandatory within 25 minutes of arrival to differentiate ischemic vs. hemorrhagic stroke.[5]
  • CT angiography (if thrombectomy candidate) to identify large vessel occlusion.
  • MRI may be used if unclear after CT, but not typically performed in hyperacute phase.
  • Other labs: CBC, electrolytes, INR/PTT, creatinine, EKG (look for atrial fibrillation).

Exclusion Criteria for alteplase (tPA) – High-Yield[1][5]

  • Onset time > 4.5 hours (or 3 hours per older guidelines).
  • Intracranial hemorrhage on CT.
  • Recent major surgery or trauma within 14 days.
  • History of intracranial hemorrhage.
  • Uncontrolled hypertension (systolic > 185 mmHg or diastolic > 110 mmHg) that cannot be lowered.
  • INR > 1.7 or use of direct oral anticoagulants (with some exceptions).
  • Platelet count < 100,000.

Acute Stroke Management Protocols and Interventions

Acute Ischemic Stroke

  1. ABC management: maintain airway, oxygen if sat < 94%.
  2. Blood pressure management: For tPA candidates, BP must be < 185/110 mmHg before infusion and maintained < 180/105 mmHg for 24 hours post-tPA. Use labetalol, nicardipine, or clevidipine.[4]
  3. Alteplase (tPA) administration: 0.9 mg/kg (max 90 mg). Give 10% as bolus over 1 minute, then remaining over 60 minutes.[1]
  4. Mechanical thrombectomy: For eligible patients with large vessel occlusion within 6–24 hours (based on advanced imaging criteria).[4]
  5. Adjunctive therapy: Aspirin (325 mg) within 24–48 hours (not within 24 hours post-tPA).
  6. Admission: Stroke unit or NICU. Continuous neuro checks per protocol (q15min during tPA infusion, then hourly).

Hemorrhagic Stroke

  • Reverse any anticoagulation (vitamin K, PCC, protamine).
  • Strict BP control (target systolic < 160 mmHg for ICH).[2]
  • Neurosurgical consult for possible evacuation or external ventricular drain (EVD) for hydrocephalus.
  • Seizure prophylaxis and ICP monitoring as indicated.

Post-Stroke Care and Risk Mitigation During Treatment

  • Bleeding from tPA: monitor for any signs of hemorrhage (gingival, IV sites, urine, stool, neurological deterioration). Stop infusion if concern for intracranial hemorrhage (symptomatic ICH rate ~6%).[5]
  • Angioedema (0.5–1% of tPA cases) – usually resolves with diphenhydramine, corticosteroids, or epinephrine if severe.
  • Elevated ICP: common after large strokes or hemorrhagic conversion. Avoid hypercapnia; elevate head of bed 30°; consider mannitol or hypertonic saline.
  • Dysphagia: NPO until swallow screen passed – risk of aspiration pneumonia.
  • Hypotension/Hypertension: avoid aggressive BP lowering in ischemic stroke without tPA to maintain cerebral perfusion pressure.
  • Thrombosis prevention: sequential compression devices, early mobilization, and low-molecular-weight heparin after 24–48 hours (post-tPA).

Critical Exam-Relevant Stroke Knowledge

  • Time is brain: 1.9 million neurons lost per minute of untreated stroke. Memorize door-to-needle goal of 60 min; advanced centers aim < 30 min.
  • CT before tPA is mandatory to rule out hemorrhage.
  • Know tPA exclusion criteria inside out – this is heavily tested.
  • Blood pressure thresholds: 185/110 pre-tPA; 180/105 post-tPA. For non-tPA ischemic stroke, permissive hypertension (220/120) is acceptable unless other comorbidities.
  • Posterior circulation stroke may present with dizziness, dysarthria, and ataxia rather than hemiparesis – don’t miss it.
  • Nursing interventions post-tPA: frequent neuro checks (q15 min × 2h, q30 min × 6h, q1h × 16h), no arterial sticks or IM injections for 24 hours, avoid antiplatelets/anticoagulants for 24h.
  • Memorize the mnemonic “FAST” or “BE FAST” for prehospital/public education.
  • Read NIHSS scoring – not required to memorize all items, but know it is a 42-point scale (0 = no deficit, 42 = severe).
  • Newer evidence: Tenecteplase may be used off-label or in select protocols; be aware of ongoing trials.
  • Joint Commission Primary Stroke Center criteria: ensure you know components – stroke team, written protocols, CT availability 24/7, quality monitoring.

References & Sources

  1. American Heart Association / American Stroke Association. (2019). Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke, 50(12), e344–e418. https://doi.org/10.1161/STR.0000000000000211
  2. Hemphill, J. C., et al. (2015). Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke, 46(7), 2032–2060. https://doi.org/10.1161/STR.0000000000000069
  3. Kleindorfer, D. O., et al. (2021). 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack. Stroke, 52(7), e364–e467. https://doi.org/10.1161/STR.0000000000000375
  4. Powers, W. J., et al. (2019). AHA/ASA Focused Update of the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke, 50(12), e344–e418. https://doi.org/10.1161/STR.0000000000000211
  5. Emergency Nurses Association. (2020). Core Curriculum for Emergency Nursing (7th ed.). Des Plaines, IL: ENA. (Relevant chapter on stroke – see also ENA Clinical Practice Guidelines: Stroke). https://www.ena.org/ [ENA website; specific guideline: ENA CPG: Acute Ischemic Stroke, 2019.]

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