Acute Ischemic Stroke
God Knows
Stroke is the 2nd leading cause of death in the U. S. and the leading cause of brain injury in adults.  Each year approximately 750,000 Americans suffer a new or recurrent stroke. 

Main change in treatment is the use of thrombolytic therapy for ischemic stroke.

Need to identify the type of stroke:  ischemic-occlusion of an artery in the brain or hemorrhagic-arterial bleed in the brain.

Education to patients and families as to what to look for will reduce the time to get patient to the Emergency Room.
God Knows
8 Ds:

Carotid (Anterior) Circ
(Signs and Symptoms):

Unilateral paralysis - arms, hands, face, 
                                  one sided numbness
Sensory loss
Language disturbance - trouble selecting
                                    appropriate words, 
                                    slurred speech
Visual disturbance - blurred vision
Monocular blindness - loss of vision in
                                      one eye
Vertebrobasilar (Posterior) Circ. (Signs and Symptoms):
Vertigo - sense of spinning
Visual disturbance - blurred
Diplopia - 2 images seen
Paralysis - weakness
Numbness - sensory loss
Dysarthria - slurred speach
Ataxia - poor balance, stumbling gate
Use the Cincinnati Prehospital Scale to check for possible stroke:

*check for facial droop by having pt show teeth or smile
*check for arm drift by having pt hold their arms out in front of them palms up and close their eyes- normal is both move or none move, abnormal is one stays and the other drifts away
*check speech by having patient repeat, "You can't teach an old dog new tricks." normal is correct words and no slurring, abnormal is slurring of words and/or wrong words
2.  Dispatch - Early activation and dispatch of emergency medical services
(EMS) system by calling 911

3.  Delivery -  Rapid EMS identification, management, and transport
Goal is to identify a stroke quickly and transport quickly to a hospital with 
a CT scanner, rapid transport!  
Notify the stroke team at the hospital ASAP for possible stroke.  Note:  check 
a blood glucose in route if possible.  

4.  Door - Appropriate triage to stroke center
Immediate general assessment < 10 minutes after arrival to hospital
Assess ABCs,
O2, IV, Monitor
VS, lab
Check blood glucose if not done already
Assess neurological function - Review history and neuro exam:  Glasgow Coma 
Scale for level of consciousness (LOC), NIH stroke scale or Hunt and 
Hess scale
Activate stroke team

CT scan < 25 minutes after arrival to hospital
CT read < 45 minutes after arrival to hospital

5.  Data - Rapid triage, evaluation, and management within the emergency 
department (ED)
Question: Does CT scan show intracerebral or subarachnoid hemorrhage?
If yes, then consult neurosurgery.
If no, then review CT exclusions

Repeat neuro exam: check for increasing deficits or improvements

Review thrombolytic exclusions: If hemorrhage still suspected despite negative 
CT scan, then lumbar puncture may be ordered; if no blood on L.P., then
support pt. If yes blood on L.P., then consult neurosurgery.

6.  Decision - Stroke expertise and therapy selection
If pt remains a candidate and < 3 hours from 1st symptoms, consider 
Thrombolytic Therapy 

7.  Drug - Fibrinolytic therapy, intra-arterial strategies
Review risk and benefits with patient and family
Thrombolytic tx goal is to treat < 60 minutes from arrival to the hospital

Exclusion criteria:
Age > 80 
NIHSS > 25 (National Institutes of Health Stroke Scale)
Taken oral anticoagulant regardless of INR
Combination of hx of diabetes and previous stroke

8.  Disposition: Rapid admission to stroke unit, critical-care unit

*Monitor neurological status
*Emergency CT if neurologic deterioration occurs
*Monitor BP
  *Patient otherwise eligible for acute reperfusion therapy except that blood pressure is 
     >185/110 mm Hg
  *Labetalol 10–20 mg IV over 1–2 minutes, may repeat ×1, 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 reached, lower to 3 mg/hr, or
  *Other agents (hydralazine, enalapril, etc.) may be considered when 
  *If blood pressure is not maintained at or below 185/110 mm Hg, do not 
    administer tPA
  *Management of blood pressure during and after tPA or other acute perfusion 
    Monitor blood pressure every 15 minutes for 2 hours from the start of tPA  
     therapy; then every 30 minutes for 6 hours; and then every hour for remainder 
     of therapy.
     *If systolic BP 185–230 mm Hg or diastolic BP 110–120 mm Hg
     *Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min, or
     *Nicardipine IV 5 mg/h, titrate up to desired effect by 2.5 mg/hr every 5–15 
       minutes, maximum 15 mg/h
     *If blood pressure not controlled or diastolic BP >140 mm Hg, consider
       sodium nitroprusside

*No anticoagulants or antiplatelets tx x 24 hours unless not a candidate for 
  fibrinolytic therapy - then consider Aspirin
*Labetalol is favored for controlling BP because it does not cause cerebral
*Nitroprusside causes cerebral vasodilation and can increase ICP (intracranial 
*tPA (Tissue Plasminogen Activator) is currently the only FDA approved 
   drug for ischemic stroke.  

*Suggested dosing only-follow your own policy and procedures:
- 0.9 mg/kg max 90 mg (Give 10% as bolus and rest over 1 hour)
- Give only if < 3 hrs of onset of symptoms
- Make sure you establish 2 large bore IVs #18g or greater before starting, so no 
   sticks are required after giving TPA and so blood can be given if patient bleeds.
- Listed in the AHA's ACLS book the chapter on stroke is a checklist. All yes 
   and all no boxes must be checked to proceed.  Although TPA is short acting, a 
   vessel that goes from being ischemic from a clot to bleeding can happen 
   suddenly and quickly. Monitor very closely.

1.  Prehospital Detection - Rapid recognition of stroke symptoms Note:  time is of the essence, so find out when the symptoms started exactly! Timeline is within 3 - 4.5 hours of onset of symptoms for thrombolytic therapy, IV and intra-arterial for 6 hours longer, although this longer time frame is not currently approved by the FDA.