IV-lIe Circulation December 13. 2005 followed by administration of anticonvulsants to prevent 5. Tissue gen activator for acute ischemic stroke. The National further seizures. 98 Monitor the patient for signs of increased Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group intracranial pressure. Continued control of blood pressure is N Engl Med.1995:33:158l-1587 6. Albers Gw. Bat VE Clark required to reduce the potential risk of bleeding(see Table 4) venous tissue-type plasminogen activator for treatment of acute stroke: the All patients with stroke should be screened for dysphagia dard Treatment with Alteplase to Reverse Stroke (STARS)stu before anything is given by mouth. A simple bedside screening JAMA.2000283:1145-1150. 7. Hazinski M. D-mystifying recognition and management of stroke. Curr evaluation involves asking the patient to sip water from a cup. If Emerg Cardiac Care. 1996: 7: 8. the patient can sip and swallow without difficulty, the patient 8. Acute stroke: current treatment and paradigms. In: Cummins RO, Field JM, asked to take a large gulp of water and swallow. If there are no azinski MF, eds. ACLS: Principles and Practice. Dallas, Tex: American leart Association: 2003: 437-482 signs of coughing or aspiration after 30 seconds, then it is safe 9. Adams H, Adams R, Del Zoppo G, Goldstein LB Guidelines for the early r the patient to have a thickened diet until formally assessed by a speech pathologist. Medications may be given in applesauce or scientific statement from the stroke Council of the American Heart asso- jam. Any patient who fails a swallow test may be given ciation/American Stroke Association. Stroke. 2005: 36: 916-923 10. Adams HP Jr, Adams R, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, medications such as aspirin rectally or if appropriate via the IV, Grubb RL, Higashida R. Kidwell C. Kwiatkowski TG, Marler JR. intramuscular. or subcutaneous route. Hademenos G. Guidelines for the early management of patients with chemic stroke: a scientific statement from the Stroke Council of the Temperature Control American Stroke Association. Stroke. 2003: 34: 1056-1083 Treat fever >37.5.C (99.5.F). Hyperthermia in the setting of I. Marler JR, Jones Pw, Emr M, eds Setting New Directions for Stroke Ca acute cerebral ischemia is associated with increased morbid- Proceedings of a National Symposium on Rapid Identification an Treatment of Acute Stroke. Bethesda, Md: National Institute of Neurological ity and mortality. 99-102 Disorders and Stroke: 1997 Induced hypothermia can exert neuroprotective effects fol- 12. Hacke W, Donnan G. Fieschi C, Kas on Kummer R. Broderick JP lowing stroke. 10-lII Hypothermia has been shown to improve Brott T, Frankel M, Grotta JC, Haley EC Jr, Kwiatkowski T, Levine SR, ewandowski C, Lu M, Lyden P, Marler JR, Patel S, Tilley BC. Albers G. survival and functional outcome in patients following resuscita- luhmki E, wilhelm M, Hamilton S. Association of outcome with early tion from ventricular fibrillation (VF) sudden cardiac arrest stroke treatment: pooled analysis of ATLANTIS. ECASS, and NINDS (LOE 112: LOE 2113), but it has not been shown to be effective rt-PA stroke trials. Lancet. 2004:363: 768-774 13. Barsan wG, Brott TG, Olinger CP, Adams HP Jr, Haley EC Jr, Levy DE for acute ischemic stroke in controlled human trials. In some Identification and entry of the patient with acute cerebral infarction. Ann small human pilot studies and in animal models, hypothermia Emerg Med.1988:17:l192-119 (3%C to 36C)for acute ischemic stroke has been shown to be 4. Barsan WG, Brott TG, Broderick JP, Haley EC, Levy DE, Marler JR Time of hospital presentation in patients with acute stroke. Arch Intern Med relatively safe and feasible (Loe 3 to 5). 993:153:2 effects of hypothermia on both global and focal cerebral ische- 15. Pepe PE, Zachariah BS, Sayre MR, Floccare D. Ensuring the chain of mia in animals have been promising, cooling to <33C covery for stroke in your community. Chain of Recovery Writing Group. appears to be associated with increased complications, including Prehasp Emerg Care. 1998: 2: 89-9 6. Feldmann E, Gordon N. Brooks JM, Brass LM, Fayad PB. Sawaya KL, hypotension, cardiac arrhythmias, cardiac failure, pneumonia, Nazareno F, Levine SR. Factors associated with early presentation of acut thrombocytopenia, and a rebound increase in intracranial pres stroke. Stroke. 1993- 24: 1805-1810 sure during rewarming. 04, 105, 07, 08, 11 17. Lyden P, Rapp k, Babcock T, et al. Ultra-rapid identification, triage, and enrollment of stroke patients into clinical trials. J Stroke Cerebrovasc D Ongoing larger clinical trials of induced hypothermia wi 9942:106-13 likely increase our understanding of the role of hypothermia 8. Morgenstern LB. Staub L Chan W. Wein TH. Bartholomew LK. acute cerebral ischemia. There is insufficient scientific evidence RA, Burgin wS, Groff J, Hickenbottom SL, Saldin K. AM, Kalra A, Dhingra A, Grotta JC. Improving delivery of ac to recommend for or against the use of hypothermia in the herapy: the TLL Temple Foundation Stroke Project. Stroke treatment of acute ischemic stroke( Class Indeterminate) 19. Morgenstern LB, Bartholomew LK, Grotta JC, Staub L, King M, Chan W Summary Sustained benefit of a community and professional intervention to increase acute stroke therapy. Arch Intern Med. 2003: 163: 2198-2202 ances in oke care will have the greatest effect on stroke 20. Cocho D, Belvis R, Marti-Fabregas j. Molina-Porcel L Diaz-Manera J outcome if care is delivered within a system designed to Aleu A, Pagonabarraga J, Garcia-Bargo D, Mauri A, Marti-Vilalta JL improve both efficiency and effectiveness. The ultimate goal Reasons for exclusion from thrombolytic therapy following acute ischemic roke. Neurology. 2005: 64: 719-720 of stroke therapy is to maximize functional recovery 21. Prioritizing interventions to improve rates of thrombolysis for ischemic stroke. Neurology. 2005: 64: 654-659 References ED. Furlan AJ. Abou-Chebl A Nadam DM. Utilization of tissue plasminogen activator for ac 1. Know the Facts. Get the Stats. Our Guide to Heart Disease. Stroke and chemic stroke. Arch Neuro/. 2004: 61: 346-350 Risks. Dallas. Tex: American Heart Association: 2002 Publication No 23. Kleindorfer D, Kissela B, Schneider A, Woo D, Khoury J, Miller R, Alwell 55-05762002-04. K, Gebel J, Szaflarski J. Pancioli A, Jauch E, Moomaw C, Shukla R 2. Armerican Heart Association. Heart Disease and Stroke Statistics-2006 roderick JP. Eligibility for recombinant tissue plasminogen Ite. Dallas, Tex: American Heart Association. In press. cute ischemic stroke: a population-based study. Stroke. 2004; 35: e27-e29 3. Schwamm LH, Pancioli A. Acker JE Ill Goldstein LB, Zorowitz RD 24. OConnor R, McGraw P, Edelsohn L. Thrombolytic therapy for acut nephard TJ, Moyer P, Gorman M, Johnston SC, Duncan PW, Gorelick P, chemic stroke ty of patients remain ineligible for rank J, Stranne SK, Smith R, Federspiel w.Horton KB, Magnis E, Adams ment. Ann Emerg Med. 1999: 33 9-I J. Recommendations for the establishment of stroke systems of can entification and recommendations from the American Stroke Association's Task Force treatment. In: Marler JR, Jones PW, Emr M, eds Setting New Directions fo he Development of Stroke Systems. Circulation. 2005: 111: 1078-1091 Stroke Care Proceedings of a National Symposium on Rapid Identification 4. Dobkin BH. Clinical practice: rehabilitation after stroke. N Engl J Med. and Treatment of Acute Stroke. Bethesda, Md: National Institute of Neuro- 2005:352:1677-1684 logical Disorders and Stroke: 1997: 35-44followed by administration of anticonvulsants to prevent further seizures.98 Monitor the patient for signs of increased intracranial pressure. Continued control of blood pressure is required to reduce the potential risk of bleeding (see Table 4). 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. Temperature Control Treat fever 37.5°C (99.5°F). Hyperthermia in the setting of acute cerebral ischemia is associated with increased morbid￾ity and mortality.99 –102 Induced hypothermia can exert neuroprotective effects fol￾lowing stroke.103–111 Hypothermia has been shown to improve survival and functional outcome in patients following resuscita￾tion from ventricular fibrillation (VF) sudden cardiac arrest (LOE 1112; LOE 2113), but it has not been shown to be effective for acute ischemic stroke in controlled human trials. In some small human pilot studies and in animal models, hypothermia (33°C to 36°C) for acute ischemic stroke has been shown to be relatively safe and feasible (LOE 3 to 5).106,109,110 Although effects of hypothermia on both global and focal cerebral ische￾mia in animals have been promising,111 cooling to
33°C appears to be associated with increased complications, including hypotension, cardiac arrhythmias, cardiac failure, pneumonia, thrombocytopenia, and a rebound increase in intracranial pres￾sure during rewarming.104,105,107,108,111 Ongoing larger clinical trials of induced hypothermia will likely increase our understanding of the role of hypothermia in acute cerebral ischemia. There is insufficient scientific evidence to recommend for or against the use of hypothermia in the treatment of acute ischemic stroke (Class Indeterminate). Summary Advances in stroke care will have the greatest effect on stroke outcome if care is delivered within a system designed to improve both efficiency and effectiveness. The ultimate goal of stroke therapy is to maximize functional recovery. References 1. Know the Facts, Get the Stats: Our Guide to Heart Disease, Stroke and Risks. Dallas, Tex: American Heart Association; 2002. Publication No. 55-0576 2002-04. 2. American Heart Association. Heart Disease and Stroke Statistics—2006 Update. Dallas, Tex: American Heart Association. In press. 3. Schwamm LH, Pancioli A, Acker JE III, Goldstein LB, Zorowitz RD, Shephard TJ, Moyer P, Gorman M, Johnston SC, Duncan PW, Gorelick P, Frank J, Stranne SK, Smith R, Federspiel W, Horton KB, Magnis E, Adams RJ. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association’s Task Force on the Development of Stroke Systems. Circulation. 2005;111:1078 –1091. 4. Dobkin BH. Clinical practice: rehabilitation after stroke. N Engl J Med. 2005;352:1677–1684. 5. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333:1581–1587. 6. Albers GW, Bates VE, Clark WM, Bell R, Verro P, Hamilton SA. Intra￾venous tissue-type plasminogen activator for treatment of acute stroke: the Standard Treatment with Alteplase to Reverse Stroke (STARS) study. JAMA. 2000;283:1145–1150. 7. Hazinski M. D-mystifying recognition and management of stroke. Curr Emerg Cardiac Care. 1996;7:8. 8. Acute stroke: current treatment and paradigms. In: Cummins RO, Field JM, Hazinski MF, eds. ACLS: Principles and Practice. Dallas, Tex: American Heart Association; 2003:437– 482. 9. Adams H, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update: a scientific statement from the Stroke Council of the American Heart Asso￾ciation/American Stroke Association. Stroke. 2005;36:916 –923. 10. Adams HP Jr, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatkowski TG, Marler JR, Hademenos GJ. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke. 2003;34:1056 –1083. 11. Marler JR, Jones PW, Emr M, eds. Setting New Directions for Stroke Care: Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke. Bethesda, Md: National Institute of Neurological Disorders and Stroke; 1997. 12. Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, Broderick JP, Brott T, Frankel M, Grotta JC, Haley EC Jr, Kwiatkowski T, Levine SR, Lewandowski C, Lu M, Lyden P, Marler JR, Patel S, Tilley BC, Albers G, Bluhmki E, Wilhelm M, Hamilton S. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363:768 –774. 13. Barsan WG, Brott TG, Olinger CP, Adams HP Jr, Haley EC Jr, Levy DE. Identification and entry of the patient with acute cerebral infarction. Ann Emerg Med. 1988;17:1192–1195. 14. Barsan WG, Brott TG, Broderick JP, Haley EC, Levy DE, Marler JR. Time of hospital presentation in patients with acute stroke. Arch Intern Med. 1993;153:2558 –2561. 15. Pepe PE, Zachariah BS, Sayre MR, Floccare D. Ensuring the chain of recovery for stroke in your community. Chain of Recovery Writing Group. Prehosp Emerg Care. 1998;2:89 –95. 16. Feldmann E, Gordon N, Brooks JM, Brass LM, Fayad PB, Sawaya KL, Nazareno F, Levine SR. Factors associated with early presentation of acute stroke. Stroke. 1993;24:1805–1810. 17. Lyden P, Rapp K, Babcock T, et al. Ultra-rapid identification, triage, and enrollment of stroke patients into clinical trials. J Stroke Cerebrovasc Dis. 1994;2:106 –113. 18. Morgenstern LB, Staub L, Chan W, Wein TH, Bartholomew LK, King M, Felberg RA, Burgin WS, Groff J, Hickenbottom SL, Saldin K, Demchuk AM, Kalra A, Dhingra A, Grotta JC. Improving delivery of acute stroke therapy: the TLL Temple Foundation Stroke Project. Stroke. 2002;33: 160 –166. 19. Morgenstern LB, Bartholomew LK, Grotta JC, Staub L, King M, Chan W. Sustained benefit of a community and professional intervention to increase acute stroke therapy. Arch Intern Med. 2003;163:2198 –2202. 20. Cocho D, Belvis R, Marti-Fabregas J, Molina-Porcel L, Diaz-Manera J, Aleu A, Pagonabarraga J, Garcia-Bargo D, Mauri A, Marti-Vilalta JL. Reasons for exclusion from thrombolytic therapy following acute ischemic stroke. Neurology. 2005;64:719 –720. 21. Prioritizing interventions to improve rates of thrombolysis for ischemic stroke. Neurology. 2005;64:654 – 659. 22. Katzan IL, Hammer MD, Hixson ED, Furlan AJ, Abou-Chebl A, Nadzam DM. Utilization of intravenous tissue plasminogen activator for acute is￾chemic stroke. Arch Neurol. 2004;61:346 –350. 23. Kleindorfer D, Kissela B, Schneider A, Woo D, Khoury J, Miller R, Alwell K, Gebel J, Szaflarski J, Pancioli A, Jauch E, Moomaw C, Shukla R, Broderick JP. Eligibility for recombinant tissue plasminogen activator in acute ischemic stroke: a population-based study. Stroke. 2004;35:e27–e29. 24. O’Connor R, McGraw P, Edelsohn L. Thrombolytic therapy for acute ischemic stroke: why the majority of patients remain ineligible for treatment. Ann Emerg Med. 1999;33:9 –14. 25. Sayre MR, Swor RA, Honeykutt LK. Prehospital identification and treatment. In: Marler JR, Jones PW, Emr M, eds. Setting New Directions for Stroke Care: Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke. Bethesda, Md: National Institute of Neuro￾logical Disorders and Stroke; 1997:35– 44. IV-118 Circulation December 13, 2005