The cerebral hemispheres are affected most, followed by the cerebellum and the brain stem. The severity of deficits however depends more on the region affected than the volume of tissue destroyed. Even small infarctions of the brain stem cause profound deficits, and often coma, whereas relatively large strokes in the cerebral cortex may cause only minor functional impairment. Infarctions of the cerebellum are often not recognized.

The most important consideration for the stroke patient is the heart. Myocardial infarction may be the underlying precipitant of a stroke, and can be far more threatening to the patient than his cerebral infarction, if not recognized. Rhythm disturbance is particularly important. Atrial fibrillation, especially intermittent, may be responsible for embolization. Stroke may also induce a number of rhythm disturbances, including heart block and tachyarrhythmias, which can compromise circulation and worsen the stroke. With this in mind, when a capable intensive care unit is available, the patient should be there within the first 24 to 48 hours if possible.

Oxygen and airway management are the most important care factors. If there is any question of maintaining the airway, as there may be with brain stem or cerebellar lesions, the patient should be intubated. Supplemental oxygen should be given, taking care to avoid respiratory suppression in patients with chronic lung disease.

Blood pressure has to be managed carefully. Hypertension may precipitate an infarction or may contribute to secondary hemorrhage. As a result, very high pressures should be lowered. However, the brain loses autoregulation in the region of an infarction, so if the pressure drops excessively, perfusion may suffer, resulting in extension of the ischemic zone. If the pressure is above 180/110 mmHg, efforts should be made to lower it gradually to this level. Aggressive measures are not desirable in an acute infarction.

The head of the bed should be elevated 30 degrees to facilitate venous return. This will also diminish brain edema, which peaks on about the third day following infarction. The doctor should anticipate this problem because edema in the area of the infarction may appear to be an extension of the lesion. Fluid intake and output must be measured carefully, to assure that intake does not exceed output. Only isotonic, non-glucose containing solutions should be used in intravenous fluids. Corticosteroids are not helpful for the edema due to an infarction. Usually the local edema subsides within 2 to 3 days. If treatment is necessary for local swelling, hyperventilation or osmotic agents may be used.

Watch out for urinary retention. Intermittent or indwelling urinary catheters may be necessary, but an indwelling catheter is most reliable for the patient who will be transported any significant distance.

Two often overlooked principles are rectal impaction and range of motion. A rectal examination must be done every day, and digital disimpaction may be necessary every few days to prevent significant difficulty later. For the patient with paresis or paralysis, passive range of motion in all affected extremities, twenty to thirty repetitions, are necessary from the very first day, even in an isolated setting while awaiting transport. Frequent movements or massage of the calves and ankles may be necessary to prevent venous stasis. When possible, a stable patient should be out of bed several times a day from the very first day, and if cardiac stability permits, the patient should walk a few steps with assistance every day.

As in all neurological conditions, the stroke patient should not be transported until hemodynamically stable. Do not initiate transport until a receiving physician has reviewed the case and assured that the place to which the patient is being transported will be able to provide the required care and testing. Ascertain clearly the time that will be required for transport. If this is longer than the patient can tolerate, consider delaying transfer until a shorter route can be obtained.

The patient should travel with supplemental oxygen. An indwelling catheter is almost always necessary. IV fluids through two secure indwelling catheters should run at a minimal rate with non-glucose containing isotonic solutions. A detailed record that describes the entire situation, detailed initial neurological examination, and record of care must accompany the patient. The medical escort should be capable of rapid endotracheal intubation. Equipment should include a bag for mechanically assisted ventilation, vials of mannitol, and spare IV apparatus. If possible, an ECG monitor, percutaneous oximeter, defibrillator and ACLS medications. The medical escort must plan to stay with the patient at the receiving site long enough to give a thorough brief.