Stroke Pathophysiology
Stroke = sudden disruption of cerebral blood flow → brain tissue ischemia/infarction. Time is brain: 1.9 million neurons die every minute without treatment. Ischemic penumbra: area of salvageable tissue surrounding infarct core — target for thrombolysis. Cerebral autoregulation: normally maintains CBF despite BP changes; impaired after stroke — avoid overly aggressive BP lowering.
Ischemic vs Hemorrhagic
Ischemic (87%): thrombotic (atherosclerosis) or embolic (A-fib most common cardioembolic source), or lacunar (small vessel). Treatment: tPA within 4.5 hours (if criteria met), mechanical thrombectomy within 24 hours for large vessel occlusion. Hemorrhagic (13%): intracerebral hemorrhage (HTN most common cause) or subarachnoid hemorrhage ("thunderclap headache"). Treatment: blood pressure control, reversal of anticoagulation, surgical evaluation.
BE-FAST Recognition
BE-FAST mnemonic: Balance (sudden loss), Eyes (vision change), Face drooping (asymmetrical smile), Arm weakness (one arm drifts), Speech difficulty (slurred/confused), Time to call 911. NIHSS (NIH Stroke Scale): standardized neurological assessment (0–42); higher score = more severe. "Time is Brain" — every 15 minutes of delay in treatment = 1 month less functional recovery.
Acute Management
tPA (alteplase): 0.9 mg/kg (max 90 mg) — 10% IV push over 1 minute, rest over 60 minutes. Exclusions: BP >185/110 (must lower before tPA), recent surgery, bleeding disorder, hemorrhagic stroke (CT first!), anticoagulation. Post-tPA: monitor q15 min × 2 hrs, q30 min × 6 hrs, q1hr × 16 hrs. Hold antihypertensives for ischemic stroke unless BP >220/120. Dysphagia screen before any oral intake.
Stroke Rehabilitation
Begin rehabilitation 24–48 hours post-stroke when medically stable. Multidisciplinary team: PT (mobility), OT (ADLs), SLP (speech, swallowing, cognition). Nursing role: consistent positioning (affected side), ROM exercises, skin care, bowel/bladder program, fall prevention, emotional support, caregiver education. Neuroplasticity: brain's ability to reorganize — intensive early rehabilitation maximizes recovery. Discharge planning begins on admission.
Important Notes
- ALWAYS obtain CT scan before tPA — hemorrhagic stroke is an absolute contraindication to tPA.
- DO NOT lower BP aggressively in acute ischemic stroke unless BP >220/120 — maintain penumbra perfusion.
Clinical Tips
- "Time is brain" — document exact time of symptom onset (or last known well) — critical for tPA eligibility window.
- Dysphagia screen (bedside swallowing test) must be performed before ANY oral intake after stroke — aspiration pneumonia is a leading cause of post-stroke mortality.
Summary
Stroke is a time-critical emergency. Rapid recognition using BE-FAST, immediate CT imaging, timely tPA/thrombectomy, vigilant acute nursing care, and early rehabilitation maximize functional recovery and prevent secondary complications.
