Part 9: Adult Stroke / V-115 Establish or confirm intravenous (Iv) access and obtain rectally or orally after the patient is screened for dysphagia blood samples for baseline studies(blood count, coagulation (see below). Admit the patient to a stroke unit (if available) studies, blood glucose, etc). Promptly treat hypoglycen for careful monitoring(Box 11). Although the aspirin is not a The ED physician should perform a neurologic screening time-critical intervention, it is appropriate to administer assessment, order an emergent computerized tomography aspirin in the ED if the patient is not a candidate for (CT) scan of the brain, and activate the stroke team or arrange fibrinolysis consultation with a stroke expert. A 12-lead ECG does not take priority over the CT scan, but Fibrinolytic Therapy(Boxes 6,8, and 10) may identify a recent acute myocardial infarction or If the Ct scan shows no hemorrhage, the probability of acute arrhythmias(eg, atrial fibrillation)as the cause of an embolic ischemic stroke remains. The physician should review the stroke. If the patient is hemodynamically stable, treatment of inclusion and exclusion criteria for I fibrinolytic therapy other arrhythmias, including bradycardia, premature atrial or (Table 3)and perform a repeat neurologic examination ventricular contractions, or defects or blocks in atrioventric-(incorporating the NIH Stroke Scale or Canadian Neurologic ular conduction, may not be necessary. ss There is general Scale). If the patient's neurologic signs are spontaneously greement to recommend cardiac monitoring during the clearing(ie, function is rapidly improving toward normal) itial evaluation of patients with acute ischemic stroke to and is near baseline, fibrinolytic administration is not recom- detect atrial fibrillation and potentially life-threatening mended ( Box 6). 0 arrhythmias. 10 As with all medications, fibrinolytics have potential ad- verse effects. The physician must verify that there are no Assessment exclusion criteria. consider the risks and benefits to the The stroke team, another expert, or an emergency physician patient, and be prepared to monitor and treat any potential with access to remote stroke expert support will review the complications. The major complication of Iv tPA for stroke patient history and verify time of onset of symptoms(Box is symptomatic intracranial hemorrhage. This complication 4).56-58 This may require interviewing out-of-hospital provid- occurred in 6.4% of the 312 patients treated in the NINDS ers, witnesses, and family members to establish the time that trials and 4.6% of the 1 135 patients treated in 60 Canadian the patient was last known to be normal. Neurologic assess- centers. 6l A meta-analysis of 15 published case series on the ment is performed incorporating either the National Institutes open-label use of tPA for acute ischemic stroke in general of Health(NIH) Stroke Scale or Canadian Neurologic Scale clinical practice shows a symptomatic hemorrhage rate of (seetheAsawebsitewww.strokeassociation.org) 5.2% of 2639 patients treated. 62 Other complications include Management of hypertension in the stroke patient is orolingual angioedema(occurs in about 1.5% of patients however,control of blood pressure is required to reduce the prospective registry, major systemic bleeding. In one large acute hypotension, and systemic blee ential risk of a patient who is otherwise (0.4%)and usually occurred at the site of femoral groin eligible for treatment with tissue plasminogen activator(tPA) puncture for acute angiography. 61. 63 has elevated blood pressure, providers can try to lower it to a If the patient remains a candidate for fibrinolytic therapy systolic pressure of <185 mm Hg and a diastolic blood (Box 8), the physician should discuss the risks and potential pressure of <110 mm Hg. Because the maximum interval benefits of the therapy with the patient or family if available from onset of stroke until effective treatment of stroke with (Box 10). After this discussion, if the patient/family elects to tPA is limited, most patients with sustained hypertension proceed with fibrinolytic therapy, give the patient tPA and above these levels (ie, systolic blood pressure >185 mm Hg begin the stroke pathway of care (see below). Neither or diastolic blood pressure >110 mm Hg) cannot be treated anticoagulants nor antiplatelet treatment is administered for with Iv tPA ( Table 4). 9.10 24 hours after administration of tPA, typically until a deally the CT scan should be completed within 25 minutes follow-up CT scan at 24 hours shows no hemorrhage of the patient 's arrival in the ED and should be read within 45 Several studies(LOE 1)5, 12.6 have documented a higher tes of ED arrival (Box 5). Emergent CT or magnet likelihood of good to excellent functional outcome when resonance imaging (MRI) scans of patients with suspected tPA is administered to adult patients with acute ischemic stroke should be promptly evaluated by a physician with stroke within 3 hours of onset of symptoms. These results expertise in interpretation of these studies. 9,560 During the are obtained when tPA is administered by physicians in first few hours of an ischemic stroke, the noncontrast CT scan hospitals with a stroke protocol that rigorously adheres to may not indicate signs of brain ischemia. If the CT scan the eligibility criteria and therapeutic regimen of the shows no evidence of hemorrhage, the patient may be NINDS protocol. These results have been supported by candidate for fibrinolytic therapy(Boxes 6 and 8) subsequent 1-year follow-up, 64 reanalysis of the NINDS If hemorrhage is noted on the CT scan, the patient is not a data, 5 and a meta-analysis(LOE 1).66 Evidence from candidate for fibrinolytic therapy. Consult a neurologist or prospective, randomized(LOE 1). 2. 65. 67 studies in adults neurosurgeon and consider transfer as needed for appropriate also documents a greater likelihood of benefit the earlier care(Box 7) treatment is begun. Many physicians have emphasized the If hemorrhage is not present on the initial CT scan an patient is not a candidate for fibrinolytic therapy for reasons, consider administration of aspirin(Box 9) her flaws in the NINDS trials. 68, 69 But additional analyses of the original NINDS data by an independent group of investigators confirmed the validity of the results, 6.5 veriEstablish or confirm intravenous (IV) access and obtain blood samples for baseline studies (blood count, coagulation studies, blood glucose, etc). Promptly treat hypoglycemia. The ED physician should perform a neurologic screening assessment, order an emergent computerized tomography (CT) scan of the brain, and activate the stroke team or arrange consultation with a stroke expert. A 12-lead ECG does not take priority over the CT scan, but it may identify a recent acute myocardial infarction or arrhythmias (eg, atrial fibrillation) as the cause of an embolic stroke. If the patient is hemodynamically stable, treatment of other arrhythmias, including bradycardia, premature atrial or ventricular contractions, or defects or blocks in atrioventric￾ular conduction, may not be necessary.55 There is general agreement to recommend cardiac monitoring during the initial evaluation of patients with acute ischemic stroke to detect atrial fibrillation and potentially life-threatening arrhythmias.10 Assessment The stroke team, another expert, or an emergency physician with access to remote stroke expert support will review the patient history and verify time of onset of symptoms (Box 4).56 –58 This may require interviewing out-of-hospital provid￾ers, witnesses, and family members to establish the time that the patient was last known to be normal. Neurologic assess￾ment is performed incorporating either the National Institutes of Health (NIH) Stroke Scale or Canadian Neurologic Scale (see the ASA website: www.strokeassociation.org). 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 potential risk of bleeding. If a patient who is otherwise eligible for treatment with tissue plasminogen activator (tPA) has elevated blood pressure, providers can try to lower it to a systolic pressure of
185 mm Hg and a diastolic blood pressure of
110 mm Hg. Because the maximum interval from onset of stroke until effective treatment of stroke with tPA is limited, most patients with sustained hypertension above these levels (ie, systolic blood pressure 185 mm Hg or diastolic blood pressure 110 mm Hg) cannot be treated with IV tPA (Table 4).9,10 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 (Box 5). Emergent CT or magnetic resonance imaging (MRI) scans of patients with suspected stroke should be promptly evaluated by a physician with expertise in interpretation of these studies.59,60 During the first few hours of an ischemic stroke, the noncontrast CT scan may not indicate signs of brain ischemia. If the CT scan shows no evidence of hemorrhage, the patient may be a candidate for fibrinolytic therapy (Boxes 6 and 8). If 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 (Box 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 (Box 9) either rectally or orally after the patient is screened for dysphagia (see below). Admit the patient to a stroke unit (if available) for careful monitoring (Box 11). Although the aspirin is not a time-critical intervention, it is appropriate to administer aspirin in the ED if the patient is not a candidate for fibrinolysis. Fibrinolytic Therapy (Boxes 6, 8, and 10) If the CT scan shows no hemorrhage, the probability of acute ischemic stroke remains. The physician should review the inclusion and exclusion criteria for IV fibrinolytic therapy (Table 3) and perform a repeat neurologic examination (incorporating the NIH Stroke Scale or Canadian Neurologic Scale). If the patient’s neurologic signs are spontaneously clearing (ie, function is rapidly improving toward normal) and is near baseline, fibrinolytic administration is not recom￾mended (Box 6).10 As with all medications, fibrinolytics have potential ad￾verse effects. 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 tPA for stroke is symptomatic intracranial hemorrhage. This complication occurred in 6.4% of the 312 patients treated in the NINDS trials5 and 4.6% of the 1135 patients treated in 60 Canadian centers.61 A meta-analysis of 15 published case series on the open-label use of tPA for acute ischemic stroke in general clinical practice shows a symptomatic hemorrhage rate of 5.2% of 2639 patients treated.62 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.61,63 If the patient remains a candidate for fibrinolytic therapy (Box 8), the physician should discuss the risks and potential benefits of the therapy with the patient or family if available (Box 10). After this discussion, if the patient/family elects to proceed with fibrinolytic therapy, give the patient tPA and begin the stroke pathway of care (see below). Neither anticoagulants nor antiplatelet treatment is administered for 24 hours after administration of tPA, typically until a follow-up CT scan at 24 hours shows no hemorrhage. Several studies (LOE 1)5,12,61 have documented a higher likelihood of good to excellent functional outcome when tPA is administered to adult patients with acute ischemic stroke within 3 hours of onset of symptoms. These results are obtained when tPA is administered by physicians in hospitals with a stroke protocol that rigorously adheres to the eligibility criteria and therapeutic regimen of the NINDS protocol. These results have been supported by subsequent 1-year follow-up,64 reanalysis of the NINDS data,65 and a meta-analysis (LOE 1).66 Evidence from prospective, randomized (LOE 1)5,12,65,67 studies in adults also documents a greater likelihood of benefit the earlier treatment is begun. Many physicians have emphasized the flaws in the NINDS trials.68,69 But additional analyses of the original NINDS data by an independent group of investigators confirmed the validity of the results,65 veri￾Part 9: Adult Stroke IV-115