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ACUTE ISCHEMIC STROKE

Initial Assessment (AHA/ASA 2013)

  1. Establish “last normal” by determining time of symptom onset

  2. Use a standardized stroke scale like the AHA/ASA 20181 to assess severity and help identify region of involvement

  3. Get non-contrast CT head (if CT not available, get brain MRI) and blood glucose, within 20 minutes of presentation and prior to giving tPA. Get O2 saturation, chemistry panel, CBC, markers for cardiac ischemia, PT/PTT, and an ECG, but do not delay tPA to obtain results.

  4. Additional imaging

    1. Consider MRI with diffusion-weighted imaging in consultation with neurology, but do not obtain routinely.

    2. If symptoms persist, get intracranial vascular imaging such as CTA or MRA if candidate for rTPA or mechanical thrombectomy. Do not delay administration of rTPA to await vascular imaging. Do not delay CTA to await creatinine level.

    3. If symptoms have resolved, get intracranial vascular imaging such as CTA or MRA to exclude proximal vessel disease if results would alter management.

    4. In all patients suspected of TIA, get noninvasive imaging of cervical vessels.

Acute Medical Management (AHA/ASA 2013)

  1. Antiplatelet agents

    1. Give oral aspirin 325 mg loading dose within the first 48 hours

    2. Do not routinely give early clopidogrel, tirofiban, and eptifibatide

    3. Aspirin is not a substitute for other acute interventions, including rTPA

    4. Do not give aspirin as an adjunctive treatment to rTPA

  2. Blood pressure

    1. If receiving rTPA

    2. Lower blood pressure to <185 mmHg systolic and <110 mmHg diastolic prior to giving rTPA

    3. Maintain <180/105 mmHg for at least 24 hours after rTPA

    4. If not receiving rTPA

    5. Do not lower blood pressure unless markedly elevated (i.e., >220/120)

    6. If markedly elevated, lower blood pressure by 15% during the first 24 hours

    7. Hold outpatient antihypertensive medications at admission for the first 24 hours

  3. Anticoagulation: Do not routinely start anticoagulation urgently in the following clinical settings:

    1. Severe stenosis of an internal carotid artery ipsilateral to ischemic stroke

    2. Acute stroke, where the aim is to decrease neurologic worsening or improve outcomes

    3. Non-cerebrovascular conditions with indication for anticoagulation, as they increase the risk of serious intracranial hemorrhage

    4. Received rTPA in the previous 24 hours

  4. Blood glucose2

    1. Correct hypoglycemia to blood glucose 60–180 mg/dL; frequent monitoring may be necessary, and intensive care may be appropriate

  5. Volume/Cardiac status

    1. Correct hypovolemia with IV normal saline

    2. Correct cardiac arrhythmias that cause a decrease in output

  6. Neuroprotective modalities

    1. Continue statins in patients who are already taking them at the time of stroke onset

    2. Hypothermia: Utility not well established

    3. Transcranial near-infrared laser therapy: Utility not well established

    4. Hyperbaric oxygen: Utility not well established, except for stroke secondary to air embolism

  7. Positioning/Monitoring

    1. Head of bed 15–30 degrees for patients at risk for obstruction, aspiration, or those with suspected elevated ICP

    2. Supine if non-hypoxemic

    3. Cardiac monitoring for at least 24 hours

    4. Oxygen: Supplemental O2 to maintain O2>94%

Interventions

  1. rTPA (AHA/ASA 2013)

    1. See Table 4-1 for indications and contraindications

    2. <3 hours from symptom onset: Give rTPA 0.9 mg/kg IV for patients who have met selection criteria (see below for criteria); administer TPA as soon as possible, with the goal of door-to-needle time of 60 minutes

    3. 3–4.5 hours from symptom onset: Selection criteria are narrowed to exclude from rTPA therapy patients who are >80 years old, ...

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