AHA/ASA GuidelineGuidelines for the Early Management of Adults with Ischemic Stroke

The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists

Broderick, J. et al. Stroke. May 2007;38:1655-1711

Class I Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

Level A: Recommendation based on evidence from multiple randomized trials or meta-analyses Multiple (3-5) population risk strata evaluated; General consistency of direction and magnitude of effect

Level B: Recommendation based on evidence from a single randomized trial or non-randomized studies Limited (2-3) population risk strata evaluated

Level C: Recommendation based on expert opinion, case studies, or standard-of-care Very limited (1-2) population risk strata evaluated

shouldis recommendedis indicatedis useful/effective/

beneficial

is reasonablecan be useful/effective/

beneficialis probably recommended

or indicated

may/might be consideredmay/might be reasonableusefulness/effectiveness is

unknown /unclear/uncertain or not well established

is not recommendedis not indicatedshould notis not

useful/effective/beneficialmay be harmful

Stroke Chain of Survival• Recognition of stroke signs and symptomsDetection

• Call 9-1-1 and priority EMS dispatchDispatch

• Prompt transport and prehospital notification to hospitalDelivery

• Immediate ED triageDoor

• ED evaluation, prompt laboratory studies, and CT imagingData

• Diagnosis and decision about appropriate therapyDecision

• Administration of appropriate drugs or other interventionsDrug

Guidelines for EMS Management of Patients With Suspected StrokeRecommended Not Recommended• Manage ABCs• Cardiac monitoring• Intravenous access• Assess for hypoglycemia• NPO• Alert receiving ED• Rapid transport to closest appropriate

facility capable of treating acute stroke• O2 (as required O2 saturation <92%)

• Dextrose-containing fluids in nonhypoglycemic patients

• Hypotension/excessive blood pressure reduction

• Excessive intravenous fluids

Key Components of History

Onset of symptoms

Recent events • Stroke • Myocardial infarction • Trauma • Surgery • Bleeding

Comorbid diseases • Hypertension • Diabetes mellitus

Use of medications • Anticoagulants • Insulin • Antihypertensives

Standardized Measures for Stroke: JCAHO Primary Stroke Centers• tPA considered• Screen for dysphagia• DVT prophylaxis• Lipid profile during

hospitalization• Smoking cessation• Education about stroke• Plan for rehabilitation

considered

• Antithrombotic medications started within 48 hours

• Antithrombotic medications prescribed at discharge

• Anticoagulants prescribed to patients with atrial fibrillation

Stroke Mimics and Clinical FeaturesConversion disorder Lack of cranial nerve findings,

neurological findings in a nonvascular distribution, inconsistent examination

Hypertensive encephalopathy Headache, delirium, significant hypertension, cerebral edema

Hypoglycemia History of diabetes, serum glucose low, decreased level of consciousness

Complicated migraine History of similar events, preceding aura, headache

Seizures History of seizures, witnessed seizure activity, postictal period

Immediate Diagnostic Studies: Evaluation of aPatient With Suspected Acute Ischemic Stroke

All patients• Noncontrast brain CT or MRI• Blood glucose• Serum electrolytes/renal function

tests• ECG• Markers of cardiac ischemia• CBC, including platelet count*• PT/INR*• aPPT*• Oxygen saturation

Selected patients• Hepatic function tests• Toxicology screen• Blood alcohol level• Pregnancy test• ABG (if hypoxia is suspected)• CXR (if lung disease is suspected)• Lumbar puncture

(if SAH is suspected and CT scan is negative for blood)

• EEG (if seizures are suspected)

Approach to Arterial Hypertension in Acute Ischemic Stroke

Indication that patient is eligible for treatment with intravenous rtPA or other acute reperfusion intervention• BP level

– SBP 185 mmHg or DBP 110 mmHg• Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat 1; or• Nitropaste 1 to 2 inches; or• Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5- to 15-

minute intervals, maximum dose 15 mg/h; when desired blood pressure attained, reduce to 3 mg/h

– If BP does not decline and remains 185/110 mmHg, do not administer rtPA

Management of BP during and after treatment with rtPA or other acute reperfusion interventionMonitor BP every 15 minutes during treatment and then for another 2 hours,

then every 30 minutes for 6 hours, and then every hour for 16 hoursBP level• SBP 180 to 230 mmHg or DBP 105 to 120 mmHg

– Labetalol 10 mg IV over 1 to 2 minutes, may repeat every 10 to 20 minutes, maximum dose of 300 mg; or

– Labetalol 10 mg IV followed by an infusion at 2 to 8 mg/min• SBP 230 mmHg or DBP 121 to 140 mmHg

– Labetalol 10 mg IV over 1 to 2 minutes, may repeat every 10 to 20 minutes, maximum dose of 300 mg; or

– Labetalol 10 mg IV followed by an infusion at 2 to 8 mg/min; or– Nicardipine infusion, 5 mg/h, titrate up to desired effect by increasing 2.5

mg/h every 5 minutes to maximum of 15 mg/h• If BP not controlled, consider sodium nitroprusside

Recommendation has changed from previous statements• Reasonable goal to lower BP by 15% during the

first 24 hours after onset of stroke. The level of BP that would mandate such treatment is not known, but consensus exists that medications should be withheld unless the SBP >220 mmHg or the DBP >120 mmHg (Class I, Level of Evidence C)

Recommendation has changed from previous statements• Hyperglycemia should be treated in patients

with acute ischemic stroke. The minimum threshold described in previous statements likely was too high, and lower

serum glucose concentrations (possibly >140

to 185 mg/dL) probably should trigger administration of insulin (Class IIa, Level of Evidence C).

Characteristics of Patients with Ischemic Stroke Who Could Be Treated with rtPA• Diagnosis of ischemic stroke causing measurable neurological

deficit• The neurological signs should not be clearing spontaneously.• The neurological signs should not be minor and isolated.• Caution should be exercised in treating a patient with major

deficits.• The symptoms of stroke should not be suggestive of SAH.• Onset of symptoms 3 hours before beginning treatment• No head trauma or prior stroke in previous 3 months

• No myocardial infarction in the previous 3 months• No gastrointestinal or urinary tract hemorrhage in previous 21

days• No major surgery in the previous 14 days• No arterial puncture at a noncompressible site in the previous

7 days• No history of previous ICH• BP not elevated (185/110 mm Hg)• No evidence of active bleeding or acute trauma (fracture) on

examination

• Not taking an oral anticoagulant or, if anticoagulant being taken, INR 1.7

• If receiving heparin in previous 48 hours, aPTT must be in normal range.

• Platelet count 100,000 /mm3

• Blood glucose concentration 50 mg/dL• No seizure with postictal residual neurological impairments• CT does not show a multilobar infarction (hypodensity 1/3

cerebral hemisphere)• The patient or family members understand the potential risks

and benefits from treatment

Treatment of Acute Ischemic Stroke: Intravenous Administration of rtPA• Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 minutes with 10% of the dose

given as a bolus over 1 minute.• Admit the patient to ICU or stroke unit for monitoring.• Perform neurological assessments every 15 minutes during the infusion and every

30 minutes for the next 6 hours, then hourly until 24 hours after treatment.• If the patient develops severe headache, acute hypertension, nausea, or vomiting,

discontinue the infusion (if rtPA is being administered) and obtain emergency CT.• Measure BP every 15 minutes for the first 2 hours and subsequently every 30

minutes for the next 6 hours, then hourly until 24 hours after treatment.• Increase the frequency of BP measurements if SBP is 180 mmHg or if DBP 105

mmHg administer antihypertensive medications to maintain BP at or below these level.

• Delay placement of NG tubes, indwelling bladder catheters, or intra-arterial pressure catheters.

• Obtain a follow-up CT at 24 h before starting anticoagulants or antiplatelet agents.

Identify signs of possible stroke

Critical EMS assessment and actions• Support ABCs; give O2 if needed • Perform prehospital stroke assessment • Establish time when patient last known normal• Transport; consider triage to a center with stroke unit if

appropriate• Alert hospital• Check glucose if possible

Immediate general assessment and stabilization• Assess ABCs, vital signs• Provide O2 if hypoxemic• Obtain IV access and blood samples• Check glucose; treat if indicated• Perform neurologic screening assessment• Activate stroke team• Oder emergent CT scan of brain• Obtain 12-lead ECG

Immediate neurologic neurologic assessment by stroke team or designee• Review patient history• Establish symptom onset• Perform neurologic examination (NIHSS)

MINS TIME GOLES

ED Arrival

ED Arrival

10 min

25 min

Does CT scan show any hemorrhage

Probable acute ischemic stroke; consider fibrinolytic therapy• Check for fibrinolytic exclusions• Repeat neurologic exam: are deficits rapidly improving to

normal?

Consult neurologist or neurosurgon; consider transfer if not available

Patient remains candidate for fibrinolytic therapy? Administer aspirin

Review risks/benefits with patient and family: if accptable-• Give tPA• No anticoagulants or antiplatelet treatment for 24 hours

• Begin stroke pathway• Admit to stroke unit if

available• Monitor BP; treat if indicated• Monitor neurologic status;

emergency CT if deterioration• Monitor blood glucose; treat

if needed• Initiate supportive therapy;

treat comorbidities

HemorrhageNo hemorrhage

Candidate

Not a Candidate

ED Arrival

45 min

ED Arrival60 min