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
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