Acute Stroke — Diagnosis & Management Protocol

Stroke is defined by WHO as 'rapidly developing clinical signs of focal (or global) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than of vascular origin.' Two major types: ischemic (87%) due to arterial occlusion, and hemorrhagic (13%) due to vessel rupture (intracerebral or subarachnoid). The distinction is critical — thrombolysis is life-saving in ischemic stroke but catastrophic in hemorrhagic.

Time is brain. The golden hour for stroke is 4.5 hours (thrombolysis window) and 24 hours (mechanical thrombectomy window in selected patients). Public awareness of stroke symptoms and rapid transport to a stroke-ready hospital are the most modifiable factors in stroke outcome. India's first dedicated stroke units were established in the 2000s at AIIMS Delhi, NIMHANS Bengaluru, and Christian Medical College Vellore.

The BEFAST campaign (Balance, Eyes, Face, Arm, Speech, Time) helps the public recognise stroke and call emergency services immediately:

• B — Balance: Sudden loss of balance or coordination
• E — Eyes: Sudden vision loss in one or both eyes, double vision
• F — Face: Facial droop on one side (ask patient to smile)
• A — Arm: Arm drifts down when raised (test both arms)
• S — Speech: Slurred or inappropriate speech (ask patient to repeat a sentence)
• T — Time: Note the time of symptom onset. Call 108/102 immediately. Every minute counts.

If any of F, A, or S is positive, the probability of stroke is > 70%. Transport to the nearest stroke-ready hospital (preferably a Comprehensive Stroke Centre capable of mechanical thrombectomy).

Immediate investigations: Non-contrast CT brain (rule out hemorrhage), blood glucose (rule out hypoglycaemia mimicking stroke), ECG (rule out atrial fibrillation as cause), CBC, PT/INR, electrolytes, creatinine, troponin.

CT brain is the first imaging — it rapidly differentiates ischemic (normal or subtle hypodensity) from hemorrhagic (hyperdense area). MRI brain is more sensitive for early ischemia (DWI sequence shows infarct within minutes) but takes longer and is not universally available.

NIHSS (NIH Stroke Scale): 15-item neurological examination scoring system (0-42). Higher score = more severe stroke. Used for: triage (NIHSS > 6 suggests large vessel occlusion — consider thrombectomy), communication between clinicians, outcome prediction. Score < 5 = mild, 5-15 = moderate, 16-20 = moderate-severe, > 20 = severe.

IV Thrombolysis (rt-PA / Alteplase):

• Window: Within 4.5 hours of symptom onset (some guidelines extend to 4.5 hr exactly; beyond is off-label)
• Dose: 0.9 mg/kg (max 90 mg); 10% as bolus over 1 min, rest over 60 min
• Absolute contraindications: intracranial haemorrhage on CT, subarachnoid haemorrhage, recent intracranial surgery, active bleeding, platelets < 1 lakh, INR > 1.7, glucose < 50 or > 400
• Relative contraindications: seizure at onset, major surgery < 14 days, recent GI bleed, pregnancy, BP > 185/110 (lower with labetalol/nicardipine first)
• Outcome: 30% relative reduction in death/disability if given within 3 hours; 15% if 3-4.5 hours

Mechanical Thrombectomy:

• Window: Within 6 hours of symptom onset for large vessel occlusion (LVO) in anterior circulation (ICA, M1, M2)
• Extended window: 6-24 hours for patients with favourable CT perfusion profile (DAWN/DEFUSE-3 criteria) — small core, large penumbra
• Eligibility: NIHSS ≥ 6, LVO on CT angiography, no extensive early infarct changes (ASPECT score ≥ 6)

Antiplatelet therapy: Aspirin 300 mg within 24 hours (after ruling out hemorrhage), continue 75 mg OD. For minor stroke (NIHSS ≤ 3) or TIA: dual antiplatelet (Aspirin + Clopidogrel) for 21 days, then Aspirin alone. Anticoagulation instead of antiplatelet if atrial fibrillation is the cause (after 14 days, earlier if large vessel not involved).

Intracerebral Haemorrhage (ICH): Most common cause is hypertension (60%), with bleeds in basal ganglia, thalamus, pons, cerebellum. Other causes: amyloid angiopathy (lobar bleeds in elderly), AVM, aneurysm, anticoagulants, tumours.

Management:

• BP control: Lower SBP to 140 mmHg (not below) within 1 hour using IV Labetalol, Nicardipine, or Clevidipine. Rapid reduction limits haematoma expansion.
• Reverse anticoagulation: If on warfarin (INR elevated), give Vitamin K 10 mg IV + Prothrombin Complex Concentrate (PCC) 25-50 IU/kg. If on NOAC, give specific reversal agent (Idarucizumab for Dabigatran, Andexanet alfa for Apixaban/Rivaroxaban) or PCC.
• Surgery: Cerebellar haemorrhage > 3 cm or with brainstem compression — emergency surgical evacuation. Supratentorial lobar haemorrhage > 30 mL within 1 cm of cortex — consider surgical evacuation (STICH II). Deep haemorrhages usually managed medically.
• ICP management: Head elevation 30°, normoglycaemia, normothermia, osmotic therapy (Mannitol 0.5-1 g/kg or Hypertonic saline 3% bolus) if signs of raised ICP.

Subarachnoid Haemorrhage (SAH): Sudden thunderclap headache ('worst of my life'), brief loss of consciousness, meningismus. Cause: ruptured berry aneurysm (85%) or AVM. Management: secure aneurysm (surgical clipping or endovascular coiling within 24 hours), Nimodipine 60 mg PO 4-hourly x 21 days (prevents vasospasm), BP control, monitor for hydrocephalus (may need EVD).

Stroke is a neurological emergency where every minute determines outcome. For UPSC CMS aspirants, BEFAST recognition, the 4.5-hour thrombolysis window, NIHSS interpretation, and BP management in ICH are extremely high-yield clinical topics.