aha stroke module (final) · statistics 9 • 87% of strokes are ischemic & eligible for...

Stroke

2019

Introduction

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CREATING A HEALTHIER HAWAI ʻ I

Many advances have been made in stroke prevention, treatment, and rehabilitation.3,4

• Fibronlytic therapy can limit the extent of neurologic damage from stroke and improve outcome, but the time available for treatment is limited.4,5

• Healthcare providers, hospitals, and communities must develop systems to increase the efficiency and effectiveness of stroke care.

• The 8 D’s of Stroke Care - Detection, Dispatch, Delivery, Door, Data, Decision, Drug, and Disposition - highlight the major steps in diagnosis and treatment.6

795,000Every 40 seconds, someone in the US

has a stroke

people experience a new or recurrent stroke

Approx. 55,000 more women than men have a stroke annually. Blacks and Hispanics have twice the risk of

first-time strokes as whites. 1,2

The 8 D's of Stroke Care 3

The reperfusion concept was expanded to include patients with acute coronary syndromes (STEMI) and highly selected stroke patients.6


Detection: Rapid recognition of stroke symptoms

Dispatch: Early activation & dispatch of EMS via 9-1-1

Delivery: Rapid EMS ID, management, & transport

Door: Appropriate triage to stroke center

Data: Rapid triage, evaluation, & management within ED

Decision: Stroke expertise & therapy selection

Drug/Device: Fibrinolytic or endovascular therapy

Disposition: Rapid admission to stroke unit or ICU

Major steps in diagnosis & treatment

The 8 D's of Stroke Care (continued) 4


The Stroke Chain of Survival

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Goal of stroke care: Minimize brain injury & Maximize the patient’s recovery“Time is Brain”

The Stroke Chain of Survival

The AHA stroke guidelines focus on the initial out-of-hospital and ED assessment and management of the patient with acute stroke.

The target times and measurable goals are recommended by the National Institute of Neurological Disorders and Stroke (NINDS).

These targets or goals should be achieved for at least 80% of patients with acute stroke.


1. Rapid recognition and reaction to stroke warning signs

2. Rapid EMS dispatch

3. Rapid EMS system transport and prearrival

4. notification to the receiving hospital

5. Rapid diagnosis and treatment in hospital

All HPH stroke centers participate in rigorous quality and performance data reporting to the AHA

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Target: Stroke Phase II Target Stroke Phase III

Honor RollTime to thrombolytic therapy within 60

minutes in 50% or more of acute ischemic stroke patients treated with IV-tPA

DTN times within 60 minutes for at least 75% of applicable patients are

required

Honor Roll EliteTime to thrombolytic therapy within 60

minutes in 75% or more of acute ischemic stroke patients treated with IV-tPA

DTN times within 60 minutes for at least 85% of applicable patients are

required

Honor Roll Elite Plus

Time to thrombolytic therapy within 60 minutes in 75% or more of acute ischemic stroke patients treated with IV-tPA AND time to thrombolytic therapy within 45

minutes in 50% of acute ischemic stroke patients treated with IV tPA

DTN times within 45 minutes for at least 75% of applicable patients and DTN times within 30 minutes for at

least 50% of applicable patients

Honor Roll Advanced Therapy

DTN times in at least 50% of applicable patients within 90 minutes

for direct arriving and within 60 minutes for transfers

Hawai‘i Pacific Health Hospitals are multi-year awardees of the highest level AHA recognition for Stroke care

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Definitions

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A cerebrovascular accident or stroke refers to the acute neurologic impairment that follows an interruption in blood supply or a rupture of a blood vessel to a specific region of the brain. Classified as either ischemic or hemorrhagic.

Initial therapy is based on the presence or absence of bleeding and a presumed ischemic stroke regardless of cause.

Importance of knowing the distinction between ischemic and hemorrhagic stroke:

• Reperfusion therapy with recombinant tissue plasminogen activator (rtPA) is appropriate for ischemic stroke only.

• Hemorrhagic stroke is an absolute contraindication to rtPA therapy.

• rtPA can be fatal if given mistakenly to a patient having a hemorrhagic stroke.


Statistics

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• 87% of strokes are ischemic & eligible for fibrinolytic therapy if patients otherwise qualify.

• 13% of strokes are hemorrhagic (10% intracerebral and 3% subarachnoid).

• The male/female incidence ratio was 1.25 in those 55 to 64 years of age, 1.50 in those 65 to 74, 1.07 in those 75 to 84, and 0.76 in those 85 years of age and older, and blacks and Hispanics had a much higher risk of first-ever stroke than whites.1


Ischemic Stroke 10

Ischemic stroke: Interruption in blood supply is caused by occlusion of an artery to a region of the brain.

• Ischemic stroke rarely leads to death within the first hour.• Ischemic strokes can be defined on the basis of cause and duration of symptoms.

Categories of Ischemic strokes:• Thrombotic stroke: An acute clot that occludes an artery is superimposed on chronic arterial narrowing,

acutely altered endothelial lining, or both. This pathophysiology parallels that for acute coronary syndromes (ACS), in which a ruptured or eroded plaque is the proximate cause of most episodes of ACS.

• Embolic stroke: Intravascular material, most often a blood clot, separates from a proximal source and flows through an artery until it occludes an artery in the brain. Many of these are cardioembolic—originating from the heart—in patients with atrial fibrillation, valvular heart disease, acute myocardial infarction (AMI), or rarely, endocarditis.

• Transient ischemic attack (TIA) (sometimes called “mini-stroke”): A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. Clinically, most TIAs resolve completely and spontaneously within 1 hour.

• Reversible ischemic neurologic deficit (RIND): Any focal neurologic deficit that resolves completely and spontaneously within 24 hours. (RINDs were previously called TIAs.) Any patient with a persistent neurologic deficit beyond 24 hours is said to have had a stroke. New diagnostic techniques have shown that 60% of patients with a TIA or RINDs have definite evidence of brain infarction.

• Hypoperfusion stroke: A more global pattern of brain infarction that results from low blood flow or intermittent periods of no flow. Hypoperfusion stroke often occurs in patients who recover cardiac function after sudden cardiac arrest.


Classification by Vascular Supply

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Classification by vascular supply and anatomic location:• Anterior circulation (carotid artery territory) stroke: Stroke that follows occlusion of

branches of the carotid artery. Such strokes usually involve the cerebral hemispheres. This is the most common type of stroke, occurring in 80% of all ischemic stroke patients.11-13

• Posterior circulation (vertebrobasilar artery territory) stroke: Stroke that follows occlusion of branches of the vertebrobasilar artery. These strokes usually involve the brainstem or cerebellum.


Hemorrhagic Stroke

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Hemorrhagic strokes occur when a blood vessel in the brain suddenly ruptures with hemorrhage into the surrounding tissue. Damage results from direct trauma to brain cells; expanding mass effects, which lead to elevated intracranial pressure; release of damaging mediators; local vascular spasm; and loss of blood supply to brain tissue downstream from the ruptured vessel.

There are 2 types of hemorrhagic stroke, based on the location of the arterial rupture:• Intracerebral hemorrhagic stroke (10%): Occurs when blood leaks directly into the brain

parenchyma, usually from small intracerebral arterioles damaged by chronic hypertension. o Hypertension is the most common cause of intracerebral hemorrhage.o Among the elderly, amyloid angiopathy appears to play a major role in intracerebral hemorrhage.

• Subarachnoid hemorrhagic stroke (3%): Occurs when blood leaks from a cerebral vessel into the subarachnoid space. If the rupture occurs in a cerebral artery, the blood is released at systemic arterial pressure, which causes sudden, painful, and dramatic symptoms.

o Aneurysms cause most subarachnoid hemorrhages.o Arteriovenous malformations cause approximately 5% of subarachnoid hemorrhages.


Pathophysiology

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The “ruptured plaque” concept, the pathophysiologic foundation of ACS, explains many features of ischemic stroke.14-16

• Thrombotic stroke, complete occlusion develops at an atherosclerotic plaque. • Embolic stroke the developing thrombus breaks off and heads downstream. • Ruptured plaques occur in the intracranial branches of the carotid, vertebrobasilar

arteries, extracranial portions of the carotid arteries, and ascending and transverse aorta.

The effects of stroke result from interaction between blood vessels, the coagulation components of blood, inflammatory cells, and chemical mediators of inflammation.

• The most common cause of acute ischemic stroke is atherosclerosis of the carotid or vertebrobasilarartery. Varying degrees of inflammation in vulnerable atherosclerotic plaques predispose these arteries to endothelial erosion, plaque rupture, and platelet activation and aggregation.

• The ensuing development of a thrombus (composed of platelets, fibrin, and other elements) can completely occlude an artery already narrowed by atherosclerosis. This occlusion of blood flow leads to rapid infarction of downstream brain tissue cells, producing a thrombotic stroke.

• The thrombus, either before or immediately after it becomes completely occlusive, may dislodge and travel to more distal cerebral arteries, producing an embolic stroke.


Post-occlusion Dynamics

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Downstream from the thrombotic or embolic obstruction, brain cells begin to die and necrosis occurs. With persistent occlusion, a central area of irreversible brain damage (infarction or necrosis) develops.

• Surrounding the central area of necrosis or infarction is an area of ischemia called the ischemic penumbra or shadow.

• This area of “threatened” brain tissue is an area of potentially reversible brain damage.

• Until the arrival of rtPA therapy, practitioners had few effective methods to reduce the area of threatened brain tissue and to abort the progression from reversible brain damage to irreversible, permanent brain necrosis.


Other Pathophysiologic Processes

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Atrial FibrillationAtrial fibrillation is the most frequent cause of cardioembolic stroke.

• The noncontracting walls of the fibrillating left atrium and left atrial appendage serve as both a stimulus and a reservoir for small emboli.

• The risk of stroke in patients with nonvalvular atrial fibrillation averages 5% per year, 2 to 7 times that of people without atrial fibrillation.1

HypertensionHypertension causes a thickening of the walls of small cerebral arteries, leading to reduced flow and a predisposition to thrombosis.

• Lacunar infarcts are one example of the type of thrombotic stroke caused by chronic hypertension. They are thought to result from occlusion of a small perforating artery to the subcortical areas of the brain.

• A major cerebrovascular burden imposed by chronic hypertension is hemorrhagic stroke.


Stroke Risk Factors

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Stroke prevention requires identification of a patient’s risk factors, followed by elimination, control, or treatment of as many factors as possible.

Physical activities may protect against stroke as demonstrated by a meta-analysis of 31 observational studies conducted mainly in the United States and Europe. • The meta-analysis found that moderate and high levels of leisure-time and occupational

physical activity protected against total stroke, hemorrhagic stroke, and ischemic stroke.21

• Results from the Physicians’ Health Study showed a lower stroke risk associated with vigorous exercise among men.22 The Harvard Alumni Study also showed a decrease in total stroke risk in men who were highly physically active.23


Major stroke risk factors amenable to modification

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Risk Factor Comments

Hypertension• One of the most important modifiable risk factors for stroke• Risk of hemorrhagic stroke increases with elevations in systolic pressure• Control of hypertension decreases risk of stroke

Cigarette smoking• Smoking effects linked to stroke include: accelerated atherosclerosis, transient elevations in blood pressure,

release of toxin enzymes, altered platelet function & reduced platelet survival• Quitting smoking reduces the risk of stroke

Transient ischemicattack

• Significant indicator of person at risk of stroke• 25% of stroke patients had previous TIA• 10% of patients with TIA will have a stroke within 90 days; half of these within the first 2 days• Antiplatelet agents (eg. Aspirin, clopidogrel) can reduce risk of stroke in patients with TIA

Heart disease• Coronary artery disease & heart failure double risk of stroke• Atrial fibrillation increase risk of embolic stroke• Oral anticoagulants reduce the risk of embolic stroke

Diabetes mellitus• Associated with accelerated atherosclerosis• Careful monitoring & control of hyperglycemia reduce the risk of microvascular complications due to diabetes, &

reduction of microvascular complications reduces stroke risk

Hypercoagulopathy • Any hypercoagulative state (eg. Protein S or C deficiency, cancer, pregnancy) increases stroke risk

High RBC count & sickle cell anemia

• An increase in RBC increases stroke risk• Increases in RBC can be treated by removing blood & replacing it with IV fluid or by administering an anticoagulant• Sickle cell anemia increases stroke risk because “sickled” RBC clump, causing arterial occlusion. Stroke risk can

be reduced by maintaining adequate oxygenation & hydration and by providing exchange transfusions

Carotid bruit• Carotid bruits indicate partial obstruction (atherosclerosis) of arteries• Associated with increase of stroke risk• Reduced by surgical endarterectomy only in symptomatic patients with >70% stenosis• Carotid endarterectomy is beneficial in selected asymptomatic patients with high-grade stenosis

Stroke Management 18

Stroke intervention begins with the recognition of the symptoms of stroke.

An important component in this initial step is education - of the patient, family, community, and healthcare provider (out-of-hospital care) to ensure timely access to care for stroke patients and reducing the time to arrival in the ED. In the T.L.L.Temple Foundation Stroke Project, rtPAuse increased from 15% to 52% after patient and physician educational initiatives, and this increase was sustained at 6 months.29,30

Once recognition of potential stroke symptoms occurs, management involves expeditious transfer of the patient to an appropriate facility (out-of-hospital care) and rapid assessment of the patient for reperfusion therapy (in-hospital care).


Stroke Management 19

Patients with acute ischemic stroke have a time-dependent benefit for fibrinolytic therapy similar to that of patients with STEMI, but this time-dependent benefit is much shorter. The NINDS has established critical in-hospital time periods for assessment and management of patients with suspected stroke:

1. Immediate general assessment by the stroke team, emergency physician, or another expert within 10 minutes of arrival; urgent noncontrast computed tomographic (CT) scan ordered

2. Neurologic assessment by the stroke team or their designee and CT scan performed within 25 minutes of hospital arrival

3. Interpretation of the CT scan within 45 minutes of ED arrival

4. Initiation of fibrinolytic therapy in appropriate patients (those without contraindications) within 1 hour of hospital arrival and within 3 hours from symptom onset

5. Door-to-admission time of 3 hours


Identification of Signs of Possible Stroke (Step 1)

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The warning signs of an ischemic stroke or TIA may be varied, subtle, and transient, but they foretell a potentially life-threatening neurologic illness. Similar to symptoms of ACS, symptoms of ischemic stroke can be misinterpreted and denied. Emergency healthcare providers should recognize the importance of these symptoms and respond quickly with medical or surgical measures that have proven efficacy in stroke management.

The signs and symptoms of a stroke may be subtle:• Sudden weakness or numbness of the face, arm, or leg,

especially on one side of the body• Sudden confusion• Trouble speaking or understanding• Sudden trouble seeing in one or both eyes• Sudden trouble walking• Dizziness or loss of balance or coordination• Sudden severe headache with no known cause


Detection: Rapid Recognition of Stroke Symptoms

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Early treatment of stroke depends on the patient, family members, or other bystanders recognizing the event. Patients often ignore the initial signs and symptoms of a stroke, and most delay access to care for several hours after the onset of symptoms. Because of these time delays, many patients with ischemic stroke cannot benefit from fibrinolytic treatment,

which must be started within 3 hours of symptom onset.

In one study of 100 stroke patients, only 8% had received information about the signs of stroke, yet nearly half had previously had a TIA or stroke. A stroke may have a subtle

presentation with only mild facial paralysis or speech difficulty and may go unnoticed or be denied by the patient or bystander. Strokes that occur while the patient is asleep or when the

patient is alone further hamper prompt recognition and action.28


3HOURS

Critical EMS Assessments and Actions (Step 2)22

The Important Role of the Community EMS System in Stroke CareThree of the 4 links in the Stroke Chain of Survival and the first 3 D’s of the 8 D’s of Stroke Care (Detection, Dispatch, and Delivery) require effective operation of the EMS system. For this reason, the AHA/ASA 2013 Guidelines for the Early Management of Adults With Ischemic Stroke strongly emphasizes the important role of these personnel and services. Recent data show that 29% to 65% of patients with signs and symptoms of stroke contact local EMS, but only 14% to 32% of them arrive within 2 hours of symptom onset.33,34 Use of EMS is strongly associated with decreased time to initial physician assessment, CT imaging for stroke, and neurologic evaluation.35,36

EMS Assessments and ActionsEMS assessments and actions for patients with suspected stroke include the following steps:

• Rapid identification of patients with signs and symptoms of acute stroke (Detection)

• Support of vital functions

• Prearrival notification of the receiving facility

• Rapid transport of the patient to the receiving facility


Dispatch: Early Activation & Dispatch of EMS by Calling 9-1-1

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Stroke patients and their families must understand the need to activate the EMS system as soon as they suspect stroke signs or symptoms. The EMS system provides the safest and most efficient method for transporting the patient to the hospital.37

Emergency medical dispatchers play a critical role in the timely treatment of potential stroke patients. Data show that dispatchers correctly identify stroke symptoms on the basis of just the initial phone description in more than half the cases of stroke.33,38 Current literature suggests that 9-1-1 telecommunicators may benefit from the use of scripted stroke-specific screens during a 9-1-1 call.39 Studies are ongoing to investigate the effectiveness of such a stroke assessment tool for 9-1-1 telecommunicators. Dispatchers can triage emergencies over the telephone and prioritize calls to ensure a rapid response by the EMS system. Specific educational efforts about stroke are encouraged, and stroke dispatch should be given a priority similar to that for AMI and trauma.


Delivery: Rapid EMS Identification, Management, & Transport

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Focused history and patient assessment

• A key component of the patient’s history is the time of symptom onset. The history must include this information. The provider may need to obtain this and other details of the patient’s history from family or the appropriate bystander.

• Prehospital providers can help establish the precise time of stroke onset or the last time the patient was noted to be neurologically normal.

• This time point is viewed as “time zero,” a starting point that is critical for time-dependent treatment with fibrinolytic agents.


Key Components of a Focused Stroke Patient History

• Time of symptom onset• Recent past medical history• Stroke• TIA• Atrial fibrillation• Acute coronary syndromes (myocardial infarction)• Trauma or surgery• Bleeding disorder• Complicating disease• Hypertension• Diabetes mellitus• Medication use• Anticoagulants (warfin) or newer anticoagulant

agents (direct thrombin inhibitors or factor Xainhibitors)

• Antiplatelet agents (aspirin, clopidogrel, ticagrelor)• Antihypertensives

Out-of-Hospital Stroke Scales for Early Detection and Delivery

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• Providers can conduct a rapid neurologic assessment by using validated tools such as the Los Angeles Prehospital Stroke Screen (LAPSS) which has a reported sensitivity of 91%, a specificity of 97%, a positive predictive value of up to 97%, and a negative predictive value of 98%41,42


Destination Hospital Protocols

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Prearrival notification to the facility is key to speeding patient evaluation, CT imaging, and reperfusion therapy. An ambulance may bypass a hospital that does not have the resources or the institutional commitment to treat patients with a stroke if a more appropriate hospital is available within a reasonable transport interval.

An ambulance may bypass a hospital if:

• The facility does not have the resources for acute stroke care

• The facility lacks an institutional commitment to treat patients with a stroke

• A more appropriate hospital is available within a reasonable transport interval

Air medical transport appears to be beneficial, but studies are limited. Helicopters may extend the range of reperfusion therapy to rural areas, delivering teams to administer rtPA or rapidly transferring patients to appropriate facilities.43-46 Helicopter transfer of patients has been shown to be cost-effective.46


Destination Hospital Protocols – LVO specific 27

Beginning October 1st, 2019 all LAPSS + patients on O‘ahu will undergo a secondary screening – the Cincinatti Stroke Triage Assessment Tool (CSTAT) in order to evaluate for the likelihood of Large Vessel Occlusion (LVO).

If CSTAT +, EMS will transport the patient directly to Queen’s Medical Center – Punchbowl (QMC-P) for potential thrombectomy (unless the patient is unstable in which case they are to proceed to the closest 911 receiving facility for stabilization prior to transfer to QMC-P)


Prehospital Initial Studies 28

Prehospital care and assessment beyond initial management should be completed during patient transport and should not delay departure for the hospital.

• Establish intravenous (IV) access and administer normal saline. • Avoid glucose-containing fluids unless hypoglycemia is strongly suspected or present

(excess glucose may be harmful to stroke patients). Checking blood glucose in suspected stroke patients is best practice.

• Initiate cardiac monitoring. Obtain a 12-lead electrocardiogram (ECG) if the patient has ongoing ischemic-type chest discomfort.

Patients with acute stroke are at risk for respiratory compromise from aspiration, upper airway obstruction, hypoventilation, and (rarely) neurogenic pulmonary edema.

• The combination of poor perfusion and hypoxemia will exacerbate and extend ischemic brain injury and has been associated with worse outcome from stroke.

• Therefore, both out-of-hospital and in-hospital medical personnel should administer supplemental oxygen to hypoxemic (ie, oxygen saturation is less than 94%) stroke patients or those with unknown oxygen saturation.


In-Hospital Management: Immediate General Assessment and Stabilization (Step 3)

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√ Door: Appropriate Triage to Stroke CenterThe patient with suspected stroke should be assessed within 10 minutes of arrival in the ED. Perform a neurologic screening assessment, order emergent CT scan of the brain, and activate the stroke team or arrange consultation with a stroke expert. Oxygen saturation should be monitored and maintained at 94% or higher. A Cheyne-Stokes pattern of respirations can be reversed with oxygen supplementation. Establish (or confirm) IV access, and obtain blood samples for baseline studies (blood count, coagulation studies, blood glucose, etc). Treat hypoglycemia immediately.

A 12-lead ECG and other ancillary studies do not take priority over the CT scan and are performed as indicated and concomitant with expedited stroke care. There is general agreement that cardiac monitoring should be done during the initial 24 hours of evaluation of patients with acute ischemic stroke to detect atrial fibrillation and potentially life-threatening arrhythmias.48


Critical ConceptsUse protocols in the ED to minimize delay to definitive diagnosis and therapy.49

Diagnostic studies ordered in the ED are aimed at:1. Establishing stroke as the cause of the patient’s symptoms2. Determining the exact time of onset3. Differentiating ischemic from hemorrhagic stroke4. Rapidly administering rTPA to patients with ischemic stroke if no contraindications are present

Data: Rapid Triage, Evaluation, & Management Within the ED

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Immediately initiate diagnostic studies in all patients to assess conditions that may mimic stroke and comorbid problems that can complicate management.


Diagnostic Studies – Do Not Delay CT Imaging or Fibrinolytic TherapyOther routine and selected diagnostic studies are important, but should not delay CT imaging or fibrinolytic therapy unless:

• There is clinical suspicion of a bleeding disorder• The patient has received heparin or oral anticoagulants• Anticoagulant status is uncertain

Diagnostic Studies for Patients With Suspected Stroke

All Patients• Noncontrast brain CT or MRI• Blood glucose• Serum electrolytes• Renal function• CBC and platelet count• Coagulation studies (PTT, PT, INR)• Oxygen saturation• ECG• Serum cardiac markers

Selected Patients• Chest x-ray• Hepatic function• Blood alcohol and toxicology screen• Arterial blood gas• Lumbar puncture• ECG• Pregnancy test

Establish Time of Onset (< 3 Hrs Required for Fibrinolytics, < 4.5 Hrs in Selected Patients)

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Protocols for EMS personnel should direct them to ask the patient and family about when they first noted any stroke symptoms. Neither the patient nor family members may recall the exact hour and minute. But they may be able to relate the onset of symptoms to other events, such

as a television or radio program that was playing, a telephone call, or someone’s arrival or departure. Be aware that time of onset is difficult to establish for patients who are discovered unconscious or unable to communicate or for patients who awaken from sleep with neurologic abnormalities. For these patients, the time of onset of symptoms is defined as the last time the

patient was observed as normal.


Critical Concepts

Time of Symptom Onset is Crucial

• Inability to establish the time of symptom onset with accuracy is a contraindication to rTPA therapy!• If prehospital care personnel cannot reliably determine a specific time, ED personnel should continue the

inquiries. Call or speak directly with a family member, coworker, or bystander.

Immediate Neurologic Assessment by Stroke Team or Designee (Step 4)

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The immediate neurologic stroke assessment should focus on 5 key assessments:

1. Onset of symptoms or when the patient was last seen functioning normally

2. Level of consciousness

3. Level of stroke severity

4. Type of stroke: ischemic versus hemorrhagic

5. Location of stroke: anterior (carotid) versus posterior (vertebrobasilar)

The goal for neurologic assessment is within 25 minutes of the patient’s arrival in the ED. “Time is brain.”

Neurologic assessment is performed incorporating either the National Institutes of Health (NIH) Stroke Scale or Canadian Neurological Scale.


Determine Level of Consciousness (Glasgow Coma Scale)

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The Glasgow Coma Scale (GCS) provides a way to establish the severity of neurologic compromise in patients with altered consciousness and is a reliable tool to assess serial changes in function over time.

The total score ranges from 3 to 15. It is the sum of the best response the patient displays for 3 functions: eye opening (1 through 4), verbal responses (1 through 5), and motor function (1 through 6).50

The patient who has no verbal response, has no eye opening, and is flaccid has a GCS score of 3.

In general, a GCS score of 8 or less is associated with an ominous prognosis.


Glascow Coma Scale50

(Score Maximum = 15)

Eye opening• Spontaneous• In response to speech• In response to pain• None

4321

Best verbal response• Oriented conversation• Confused conversation• Inappropriate words• Incomprehensible sounds• None

54321

Best motor response• Obeys• Localizes• Withdraws• Abnormal flexion• Abnormal extension• None

654321

Interpretation: Score 14 to 15: Mild dysfunctionScore 11 to 13: Moderate to severe dysfunctionScore ≤10: Severe dysfunction

Determine Severity of Stroke (NIH Stroke Scale)34

The NIH Stroke Scale (NIHSS) involves 15 items used to assess the responsive stroke patient. This is a validated measure of stroke severity based on a detailed neurologic examination (cranial nerve and gait testing are omitted). Provides a standardized neurologic evaluation of the patient. The score correlates with long-term outcome in patients with ischemic stroke. The NIH Stroke Scale can be performed in less than 7 minutes. The NIH Stroke Scale received further validation during the landmark NINDS trial of rtPA for acute ischemic stroke.

The total score ranges from 0 (normal) to 42 points.

The scale covers the following major areas:• Level of consciousness: Alert, drowsy; knows month, age; performs tasks correctly• Visual assessment: Follows finger with or without gaze palsy, forced deviation; hemianopsia (none,

partial, complete, bilateral)• Motor function: Face, arm, leg strength and movement• Sensation: Pin prick to face, arm, trunk, leg; compare side to side• Cerebellar function: Finger-nose; heel down shin• Language: Aphasia (name items, describe a picture, read sentences); dysarthria (evaluate speech

clarity by having patient repeat listed words)


Determine Severity of Stroke (NIH Stroke Scale)

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A low NIHSS score (combined, less than 4 or 5) usually indicates minor neurologic deficits, such as sensory losses, dysarthria, or some manual clumsiness. Some disabling neurologic deficits, such as isolated severe aphasia (score of 3) or the visual field losses of hemianopsia(score of 2 or 3), can be associated with a low score on the NIH Stroke Scale.

Current recommendations suggest that patients with mild but disabling stroke symptoms should be considered for IV fibrinolysis if they are 3 hours from symptom onset of ischemic stroke. Recent data and consensus opinion suggest that there should be no exclusion for patients with mild stroke symptoms who, in the opinion of the examiner, have disabling stroke symptoms.9,51,52 In addition, IV fibrinolysis is reasonable for patients who present with moderate to severe ischemic stroke and who demonstrate early improvement but remain moderately impaired and potentially disabled.

Severe deficits (score greater than 22) indicate large areas of ischemic damage. Patients with such deficits face an increased risk of brain hemorrhage. In general, the use of fibrinolytic treatment in these patients should follow careful discussion with the patient, the patient’s spouse and family, and the admitting physicians to ensure that everyone understands the risks and benefits.


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Instructions Scale definition

1a. Level of Consciousness: The investigator must choose a response if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation.

0 = Alert; keenly responsive1 = Not alert; but arousable by minor stimulation to obey, answer, or respond.2 = Not alert; requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped).3 = Responds only with reflex motor or automatic effects or totally unresponsive, flaccid, and areflexive.

1b. LOC Question: The patient is asked the month and his/her age. The answer must be correct – there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not “help” the patient with verbal or nonverbal cues.

0 = Answers both questions correctly.1 = Answers one question correctly.2 = Answers neither question correctly.

1c. LOC Commands: The patient is asked to open and close the eyes and then to grip and release the non-paretic hand. Substitute another one step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to him or her (pantomime), and the result scored (i.e., follows none, one or other physical impediments should be given suitable one-step commands. Only the first attempt is scored.

0 = Performs both tasks correctly.1 = Performs one task correctly.2 = Performs neither task correctly.

2. Best Gaze: Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve paresis (CN III, IV, or VI), score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre-existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy.

0 = Normal.1 = Partial gaze palsy; gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is not present. 2 = Forced deviation, or total gaze paresis not overcome by the oculocephalic maneuver.

NIH Stroke Scale

NIH Stroke Scale (continued)37


Instructions Scale definition3. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or

visual threat, as appropriate. Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-out asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11.

0 = No visual loss. 1 = Partial hemianopenia.2 = Complete hemianopenia.3 = Bilateral hemianopenia (blind including cortical blindness).

4. Facial Palsy: Ask – or use pantomime to encourage the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barriers obscure the face, these should be removed to the extend possible.

0 = Normal symmetrical movements1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling).2 = Partial paralysis (total or near-total paralysis of lower face).3 = Complete paralysis of one or both sides (absence of facial movement in the upper and lower faces).

5. Motor Arm: The limb is placed in the appropriate position; extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice.

0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds. 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support. 2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity.3 = No effort against gravity; limb falls.4 = No movement.UN = Amputation or joint fusion, explain: __________5a = Left Arm5b = Right Arm

7. Limb Ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness test by having the patient touch nose from extended arm position.

0 = Absent.1 = Present in one limb.2 = Present in two limbs.UN = Amputation or joint fusion, explain: __________


8. Sensory: Sensation or grimace to pinprick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately check for hemisensory loss. A score of 2, “severe or total sensory loss, “ should only be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a = 3) are automatically given a 2 on this item.

0 = Normal; no sensory loss. 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial pain with pinprick, but patient is aware of being touched.2 = Severe to total sensory loss; patient is not aware of being touched in the face, arm, and leg.

9. Best Language: A great deal of information about comprehension will be obtained during the preceding sections of the examination. For this scale item, the patient is asked to describe what is happening in the attached picture, to name the items on the attached naming sheet and to read from the attached list of sentences. Comprehension is judged from responses here, as well as to all of the commands in the preceding general neurological exam. If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in a coma (item 1a = 3) will automatically score 3 on this item. The examiner must choose a score for the patient with stupor or limited cooperation, but a score of 3 should be used only if the patient is mute and follows no one-step commands.

0 = No aphasia; normal.1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. Reduction of speech and/or comprehension, however, makes conversation about provided materials difficult or impossible. For example, in conversation about provided materials, examiner can identify picture or naming card content from patient’s response.2 = Severe aphasia; all communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener. Range of information that can be exchanged is limited; listener carries burden of communication. Examiner cannot identify materials provided from patient response. 3 = Mute, global aphasia; no usable speech or auditory comprehension.




10. Dysarthria: If patient is thought to be normal, an adequate sample of speech must be obtained by asking patient to read or repeat words from the attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barriers to producing speech, the examiner should record the score as untestable (UN), and clearly write an explanation for this choice. Do not tell the patient why he or she is being tested.

0 = Normal.1 = Mild-to moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty.2 = Severe dysarthria; patient’s speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysarthria, or is mute/anarthric.UN = Intubated or other physical barrier, explain: __________

11. Extinction and Inattention (formerly Neglect): Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but appear to attend to both sides, the score is normal. The presence of visual spatial neglect or anosagnosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable.

0 = No abnormality.1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities.2 = Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space.



Management of Hypertension 40

Management of hypertension in the stroke patient is controversial.

For patients eligible for fibrinolytic therapy, however, control of blood pressure is required to reduce the risk of bleeding. If a patient who is otherwise eligible for treatment with rtPA has elevated blood pressure, providers can try to lower it to a systolic pressure of 185 mm Hg or less and a diastolic blood pressure of 110 mm Hg or less (Table 8A). Because the maximum interval from onset of stroke until effective treatment with rtPA is limited, most patients with sustained hypertension above these levels (ie, systolic blood pressure higher than 185 mm Hg or diastolic blood pressure higher than 110 mm Hg) cannot be treated with IV rtPA (Table 8B).54-56

Consider lowering blood pressure in acute ischemic stroke patients who are not candidates for acute perfusion therapy when systolic blood pressure is higher than 220 mm Hg or diastolic blood pressure is higher than 120 mm Hg. A reasonable target is to lower blood pressure by only 15% to 25% within the first day.


Management of Hypertension 41


Patient otherwise eligible for acute reperfusion therapy except that BP is >185/110 mm HG:• Labetalol 10-20 mg IV over 1-2 minutes, may repeat x 1 time, or• Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5-15 minutes, maximum 15 mg/hr; when

desired blood pressure is reached, adjust to maintain proper blood pressure limits, or• Other agents (hydralazine, enalaprilat, etc.) may be considered when appropriate

If blood pressure is not maintained at or below 185/110 mm HG, do not administer rTPA.

Potential Approaches to Arterial Hypertension in Acute Ischemic Stroke Patients Who AREPotential Candidates for Acute Reperfusion Therapy 57-60

Management of blood pressure during and after rTPA or other acute reperfusion therapy:• Monitor BP every 15 minutes for 2 hours from the start of rTPA therapy, then every 30 minutes for 6

hours, and then every hour for 16 hours

If systolic blood pressure 180-230 mm Hg or diastolic blood pressure 105-120 mm Hg:• Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg/min, or• Nicardipine IV 5 mg/hr, titrate up to desired effect by 2.5 mg/hr every 5-15 minutes,

maximum 15 mg/hr

If BP not controlled or diastolic blood pressure >140 mm Hg, consider sodium nitroprusside.

Imaging (Step 5)

42

The most commonly obtained brain imaging test is a non–contrast-enhanced CT scan. The noncontrast CT scan accurately identifies most cases of intracranial hemorrhage and discriminates nonvascular causes of neurologic symptoms mimicking stroke (eg, brain tumor).

Ideally the CT scan should be completed within 25 minutes of the patient’s arrival in the ED and should be read within 45 minutes of ED arrival (Step 5). Emergent CT or MRI scans of patients with suspected stroke should be promptly evaluated by a physician with expertise in interpretation of these studies.63,64 During the first few hours of an ischemic stroke, the noncontrast CT scan may not show signs of brain ischemia.

Ongoing research is evaluating MRI, magnetic resonance angiography, and multimodal CT, which includes noncontrast CT, perfusion CT, and CT angiographic studies. Centers may perform more advanced neurologic imaging (multimodal MRI, CT perfusion, and CT angiography), but obtaining these studies should not delay initiation of IV rtPA in eligible patients.

The CT scan is central to the triage and therapy of the stroke patient (hemorrhage or no hemorrhage).• If the CT scan shows no evidence of hemorrhage, the patient may be a candidate for fibrinolytic

therapy (steps 6 & 8).• If hemorrhage (intracerebral or subarachnoid hemorrhage) is noted on the CT scan, the patient is not a

candidate for fibrinolytic therapy. Consult a neurologist or neurosurgeon and consider transfer as needed for appropriate care (step 7).

• If hemorrhage is not present on the initial CT scan and the patient is not a candidate for fibrinolytic therapy for other reasons, consider administration of aspirin (step 9) either rectally or orally after the patient is screened for dysphagia. Admit the patient to a stroke unit (if available) for careful monitoring (step 11).


The Initial Noncontrast CT Scan

43

On CT images, blood from a hemorrhagic stroke has a density that is only about 3% greater than the density of brain tissue. The initial CT scan is made without contrast enhancement.

During the first few hours of a thrombotic or embolic stroke, the noncontrast CT scan will generally appear normal (brain structures without normal blood flow appear initially the same as structures with good blood flow). A well-defined area of hypodensity, purported to be caused by lack of blood flow past an occlusion, will rarely develop within the first 3 hours of a stroke.

A hypodense area on the CT scan generally excludes a patient from fibrinolytic therapy as it typically takes 6 to 12 hours for the edema and swelling to produce the hypodensity.


Critical Concepts

Normal CT = Candidate for Fibrinolytic TherapyAn important, if somewhat counterintuitive, point to remember is that a completely normal CT scan – no sign of

hemorrhage, no large areas of no flow, and no hypodense areas – is supportive of rTPA administration in a stroke patient who otherwise meets the criteria for fibrinolytic therapy.

Decision: Stroke Expertise & Therapy Selection

44

Risk Assessment and Administration of IV rtPA (Step 10)When the CT scan shows no hemorrhage, the probability of acute ischemic stroke is high. The physician or stroke team should review the inclusion and exclusion criteria for IV fibrinolytic therapy and perform a repeat neurologic examination (incorporating the NIH Stroke Scale or Canadian Neurological Scale).

If the patient’s neurologic signs are spontaneously clearing (ie, function is rapidly improving toward normal) and are near baseline, fibrinolytic administration is not recommended.


Decision: Stroke Expertise & Therapy Selection 45

Inclusion and Exclusion Characteristics of Patients With Ischemic Stroke Who Could Be Treated With rtPA Within 3 Hours From Symptom Onset

Inclusion Criteria

• Diagnosis of ischemic stroke causing measurable neurologic deficit• Onset of symptoms <3 hours before beginning treatment• Age ≥18 years

Exclusion Criteria

• Significant head trauma or prior stroke in previous 3 months• Symptoms suggest subarachnoid hemorrhage• Arterial puncture at noncompressible site in previous 7 days• History of previous intracranial hemorrhage

• Intracranial neoplasm, arteriovenous malformation, or aneurysm• Recent intracranial or intraspinal surgery

• Elevated blood pressure (systolic > 185 mm Hg or diastolic > 110 mm Hg)• Active internal bleeding• Acute bleeding diathesis, including but not limited to

• Platelet count <100,000/mm3

• Heparin received within 48 hours, resulting in aPTT greater than the upper limit of normal• Current use of anticoagulant with INR >1.7 or PT >15 seconds• Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or

appropriate factor Xa activity assays)• Blood glucose concentration <50mg/dL (2.7 mmol/L)• CT demonstrated multilobar infarction (hypodensity >Va cerebral hemisphere)

Relative Exclusion Criteria

Recent evidence suggests that under some circumstances – with careful consideration and weighing of risk to benefit – patients may receive fibrinolytic therapy despite 1 or more relative contraindications. Consider risk to benefit of rtPA administration carefully if any one of these relative contraindications is present:• Only minor or rapidly improving stroke symptoms (clearing spontaneously)• Pregnancy• Seizure at onset with postictal residual neurologic impairments• Major surgery or serious trauma within previous 14 days• Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)• Recent acute myocardial infarction (within previous 3 months)

Notes• The checklist includes some US FDA-approved indications and contraindications for administration of rtPA for acute ischemic stroke. Recent AHA/ASA guideline revisions may

differ slightly from FDA criteria. A physician with expertise in acute stroke care may modify this list.• Onset time is either witnessed or last known normal.• In patients without recent use of oral anticoagulants or heparin, treatment with rtPA can be initiated before availability of coagulation study results but should be discontinued if

INR is >1.7 or PT is elevated by local laboratory standards.• In patients without history of thrombocytopenia, treatment with rtPA can be initiated before availability of platelet count but should be discontinued if platelet count is

<100,000/mm3.

Major Benefit: Improved Neurologic Outcome Without Mortality

46

• Several studies have documented a higher likelihood of good to excellent functional outcome when rtPA is administered to adults with acute ischemic stroke within 3 hours of symptom onset.66

• These results have been supported by a subsequent 1-year follow-up study, reanalysis of the NINDS data, and a meta-analysis. Evidence from prospective, randomized studies in adults also documented a greater likelihood of benefit the earlier treatment was begun.

• Many physicians have emphasized the flaws in the NINDS trials, but additional analyses of the original NINDS data by an independent group of investigators confirmed the validity of the results, verifying that improved outcomes in the rtPAtreatment arm persist even when imbalances in baseline stroke severity among treatment groups are corrected.


Risks and Benefits of rtPA for Acute Stroke

47

The physician must verify that there are no exclusion criteria, consider the risks and benefits to the patient, and be prepared to monitor and treat any potential complications.

• The major complication of IV rtPA for stroke is symptomatic intracranial hemorrhage. This complication occurred in 6.4% of the 312 patients treated in the NINDS trial 5 and 4.6% of the 1135 patients treated in 60 Canadian centers.65

• A meta-analysis of 15 published case series on the open-label use of rtPA for acute ischemic stroke in general clinical practice shows a symptomatic hemorrhage rate of 5.2% of 2639 patients treated.66

• Other complications include orolingual angioedema (occurs in about 1.5% of patients), acute hypotension, and systemic bleeding. In one large prospective registry, major systemic bleeding was uncommon (0.4%) and usually occurred at the site of femoral groin puncture for acute angiography.65,67

• In the NINDS trial, fatal intracranial hemorrhage occurred in approximately 3 of every 100 patients treated with rtPA (3%) but only 3 of every 1000 (0.3%) receiving placebo. This means that the risk of fatal bleeding into the brain was 10 times greater in the rtPA-treated patients. But it is important to note that overall mortality was not increased in the rtPA-treated group.

• The risk of harm from rtPA may not be justified for patients with a TIA (eg, no residual symptoms) or rapidly improving deficits with nondisabling symptoms. These patients usually have lesions or partial occlusions that are not resolved by rtPA. However, recent stroke expert opinion suggests considering administration of rtPA if there is a low NIH Stroke Scale score and the patient has mild but disabling stroke symptoms


Drug: Fibrinolytic Therapy

48

Additional Actions Before Fibrinolytic Therapy

Review for CT Exclusions: Are Any Observed?

• Hemorrhage, either intracerebral or subarachnoid, must be excluded. Failure to identify a small area of hemorrhage could be a fatal error.

• Areas of well-defined hypodensity are generally CT exclusions because they indicate either that more than 3 hours has passed since the infarction or that a large area of the brain is threatened.

• CT indications of a large infarction (early hypodensity, obscured junction between gray and white matter, or sulcal effacement) are relative contraindications to rtPA.

– Larger brain infarctions are prone to undergo hemorrhagic transformation, exposing a patient receiving a fibrinolytic agent to the risk of fatal intracerebral hemorrhage. These patients, however, have a poor outcome without intervention, so some authors have concluded that patients with severe deficit or CT findings of hypodensity or mass effect can be candidates for rtPA therapy, with both greater possibility of benefit and greater risk of harm.


Review Patient Data: Is Time Since Symptom Onset Now More Than 3 Hours?

49

• This step reminds the clinician to make one last review of all the information gathered during the patient assessments. In particular, document the estimated length of time that has passed since the onset of the stroke.

• IV infusion of the rtPA must begin within 180 minutes of the beginning of stroke symptoms.


Critical Concepts

Anticoagulants & Antiplatelet Therapy

Neither anticoagulants nor antiplatelet treatment is administered for 24 hours after administration of rtPA, typically until a follow-up CT scan at 24 hours shows no hemorrhage (Step 10).• If the patient has a brain hemorrhage, do not give aspirin (Step 7)• If the patient has ischemic stroke but is not a candidate for rtPA, consider aspirin or another antiplatelet

agent.• Do not administer heparin (unfractionated or low molecular weight). Heparin is associated with an increased

risk of bleeding within the first 24 hours.

Drug: Administration & Monitoring of rtPA Infusion

50

Treatment with IV rtPA within 3 hours of the onset of ischemic stroke improved clinical outcome at 3 months. ED-based or hospital-based stroke specialists should aim to start the initial bolus within 45 minutes of arrival in the ED. Ten percent of a total dose of 0.9 mg/kg (maximum 90 mg) is given by bolus administration and the remainder is given over 60 minutes.

During rtPA infusion:• Monitor neurologic status; if any signs of deterioration develop, obtain an emergent CT scan.• Monitor blood pressure, which may increase during fibrinolytic treatment. Initiate antihypertensive treatment for blood

pressure of 180 to 230 mm Hg systolic or 105 to 120 mm Hg diastolic.• Admit patients to the critical care unit, stroke unit, or other skilled facility capable of careful observation, frequent

neurologic assessments, and cardiovascular monitoring.

Avoid anticoagulant or antiplatelet treatment for the next 24 hours. Treatment of carefully selected acute ischemic stroke patients with IV rtPA between 3 and 4.5 hours after onset of symptoms has also been shown to improve clinical outcome, although the degree of clinical benefit is smaller than that achieved with treatment within 3 hours. Data supporting treatment in this time window come from a large, randomized trial - the third European Cooperative Acute Stroke Study (ECASS-3).

At present, use of IV rtPA within the 3- to 4.5-hour window has not yet been approved by the US Food and Drug Administration (FDA), although it is recommended by a current AHA/ASA science advisory.68

Additional Inclusion & Exclusion Characteristics of Patients With Acute Ischemic Stroke Who Could Be Treated With IV

rtPA Within 3 to 4.5 Hours From Symptom Onset

Inclusion Criteria

• Diagnosis of ischemic stroke causing measurableneurologic deficit

• Onset of symptoms 3 to 4.5 hours before beginning treatment

Exclusion Criteria

• Age >80 years• Severe stroke (NIHSS score >25)• Taking an oral anticoagulant regardless of INR• History of both diabetes and prior ischemic stroke


Endovascular Therapy

51

Substantial new high-quality evidence regarding the clinical efficacy of endovascular treatments of acute ischemic stroke has recently become available8 and while IV rtPA remains as the first-line treatment, the AHA now recommends endovascular therapy for select patients with acute ischemic stroke.Mechanical clot disruption or retrieval with a stent has been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke.Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria:

• Prestroke modified Rankin Scale (mRS) score of 0 to 1

• Acute ischemic stroke receiving IV rtPA within 4.5 hours of onset according to guidelines from professional medical societies

• Causative occlusion of the internal carotid artery or proximal middle cerebral artery (M1)

• Age 18 years or older

• NIH Stroke Scale score of 6 or greater

• Alberta Stroke Program Early CT Score (ASPECTS) of 6 or greater

• Treatment can be initiated (groin puncture) within 6 hours of symptom onset


Transition to Critical Care and Rehabilitation (Steps 11 and 12)

52

Disposition: Rapid Admission to Stroke Unit or Critical Care Unit

Given the requirements for frequent neurologic assessment and vital sign measurements, especially after administration of IV rtPA, patients should be admitted as quickly as possible, ideally within 3 hours from arrival.

• If the patient’s neurologic status deteriorates, an emergent CT scan is required to determine if cerebral edema or hemorrhage is responsible for the deterioration.

• Treatment of hemorrhage or edema should be started immediately as indicated.

Additional stroke care includes support of the airway, oxygenation and ventilation, and nutritional support.

• Normal saline is administered at approximately 75 to 100 mL/h to maintain euvolemia if needed.

• The reported frequency of seizures during the first days of stroke ranges from 2% to 23%. Most seizures occur during the first day and can recur. Seizure prophylaxis is not recommended. Treatment of acute seizures followed by administration of anticonvulsants to prevent further seizures is recommended.

• Monitor the patient for signs of increased intracranial pressure. Continued control of blood pressure is required to reduce the risk of bleeding.


Hyperglycemia

53

Hyperglycemia is present in about one third of patients admitted with stroke.

• Hyperglycemia is associated with worse clinical outcome in patients with acute ischemic stroke than is normoglycemia, but there is no direct evidence that active glucose control improves clinical outcome.

• There is evidence that insulin treatment of hyperglycemia in other critically ill patients improves survival rates.

– For this reason the AHA and the ASA recommend the use of insulin when the serum glucose level is greater than 185 mg/dL in patients with acute stroke; however, the utility of administration of IV or subcutaneous insulin to lower blood glucose in patients with acute ischemic stroke when serum glucose is 185 mg/dL or lower remains uncertain.69,70


Temperature Control 54

Increased temperature in stroke is associated with poor neurologic outcome. • No data have demonstrated that lowering temperature improves outcome, but an elevated

temperature of 37.5°C (99.5°F) or higher should be treated and the source of fever identified and treated if possible.

Induced hypothermia can exert neuroprotective effects after a stroke.

• Hypothermia has been shown to improve survival and functional outcome in patients after resuscitation from sudden cardiac arrest caused by ventricular fibrillation, but it has not been shown in controlled human trials to be effective for acute ischemic stroke.

• In some small human pilot studies and in animal models, hypothermia (33°C to 36°C [91.4°F to 96.8°F]) for acute ischemic stroke has been shown to be relatively safe and feasible (level of evidence 3 to 5).

• Although the effects of hypothermia on both global and focal cerebral ischemia has been promising, cooling to 33°C (91.4°F) and lower appears to be associated with increased complications, including hypotension, cardiac arrhythmias, cardiac failure, pneumonia, thrombocytopenia, and a rebound increase in intracranial pressure during rewarming.

• At present, there is insufficient scientific evidence to recommend for or against the use of hypothermia in the treatment of acute ischemic stroke.


Dysphagia Screening

55

All patients with stroke should be screened for dysphagia before anything is given by mouth.

A simple bedside screening evaluation involves asking the patient to sip water from a cup. If the patient can sip and swallow without difficulty, the patient is asked to take a large gulp of water and swallow. If there are no signs of coughing or aspiration after 30 seconds, then it is safe for the patient to have a thickened diet until formally assessed by a speech pathologist.

Medications may be given in applesauce or jam. Any patient who fails a swallow test may be given medications such as aspirin rectally or, if appropriate, via the IV, intramuscular, or subcutaneous route.


Key Points

56

• Emergency medical services (EMS) activation and transport results in faster hospital arrival and decreased emergency department (ED) evaluation time.

• EMS dispatchers can identify 50% of patients with stroke.

• With standard training in stroke recognition, paramedics demonstrated a sensitivity of 61% to 66% for identifying patients with stroke, and the sensitivity increased to 86% to 97% after receipt of training in use of a stroke assessment tool.

• Public education programs result in sustained identification and treatment of stroke patients.

• Designation of well-organized stroke care, such as acute stroke‒ready hospitals, primary stroke centers (PSCs), and comprehensive stroke centers (CSCs), is strongly recommended.


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aha stroke module (final) · statistics 9 • 87% of strokes are ischemic & eligible for...

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