Acute stroke: what the first 72 hours should — and should not — look like

1. Case. Consider the following hypothetical patient. Monday, day 1 post-admission. A 68-year-old woman presents with a left middle cerebral artery ischemic stroke. NIH Stroke Scale 9. She received IV alteplase at 90 minutes and is now in the stroke unit. Right hemiparesis (UE worse than LE), mild expressive aphasia, no dysphagia on bedside screen. Vitals stable. The nursing team asks whether you should get her out of bed today.

2. CPG section in plain English. The AHA/ASA 2016 guideline (Winstein et al., *Stroke*, 47:e98–e169) endorses early stroke-unit rehabilitation as standard care. However, the guideline does not endorse very early, high-dose out-of-bed activity within the first 24 hours. The AVERT trial (Bernhardt et al., *Lancet*. 2015;386:46–55) randomized 2,104 patients to very early mobilization (median start 18.5 hours post-stroke, higher dose) versus usual care; the very early group had lower odds of a favorable mRS 0–2 at 3 months (adjusted OR 0.73; 95% CI 0.59–0.90; p=0.004). The dose-response analysis (Bernhardt et al., *Neurology*. 2016;86:2138–2145) supports shorter, more frequent sessions over longer, less frequent very-early sessions. AHA/ASA 2016 places organized stroke-unit rehabilitation at Class I, Level B.

3. Reasoning walkthrough. Day 1 at less than 24 hours post-tPA is the AVERT high-risk window. Apply the AVERT signal: avoid prolonged upright, high-dose out-of-bed sessions. Prioritize bed positioning to protect the hemiparetic shoulder (subluxation prevention), passive and active-assisted ROM, postural changes every 2 hours, and short (3–5 minute) out-of-bed transfers as tolerated once 24 hours from tPA have elapsed and the medical team clears. Carvalho et al. (*J Cereb Blood Flow Metab*. 2020) found head-of-bed elevation can reduce ipsilesional cerebral blood flow in patients with large vessel occlusion; coordinate positioning with the stroke team, especially in LVO patients before reperfusion is confirmed stable. Screen for dysphagia before any oral intake (AHA/ASA Class I).

4. Outcome measure. Use the Stroke Rehabilitation Assessment of Movement (STREAM, Daley K, Mayo N, Wood-Dauphinée S. *Phys Ther*. 1999;79:8–23) when the patient tolerates assessment. STREAM total 0–70 across three subscales (UE 0–20, LE 0–20, basic mobility 0–30 with the 2x weighting). Interrater ICC 0.96. STREAM is appropriate from acute through chronic stages. For day-1 documentation, record bed mobility level, sitting tolerance, and resting and active vitals.