Episode 11 – Ischemic Stroke 2013

Ischemic Stroke Guidelines from the ASA

Hot off the presses; the 2013 Ischemic Stroke Guidelines from AHA/ASA (Stroke 2013;44:870)

Want the full recommendations as written by the AHA/ASA?

Stroke Centers

• Comprehensive Stroke Centers are god
• Should have neurocritical care unit
• EMS should bypass hospitals that can’t care for stroke
• Should have tele-rads if no in-house radiologists

Initial Eval

• Door to Drug within 60 minutes (80% compliance)
• Use a Stroke Scale, preferably NIHSS
• Get labs, but glucose is the only one that needs to be done before tPa
• Get EKG and troponin, don’t delay tPA for this

Imaging

• Get either a NCCT or MRI to exclude hemorrhage prior to tPA
• tPA indicated even if ischemic signs, unless a frank hypodensity is noted
• A non-invasive intracranial vascular study is strongly recommended during initial imaging if IA tPA or mechanical thrombectomy is contemplated. This should not delay tPA administration
• In tPA candidates, the CT or MRI should be read within 45 minutes of arrival by a physician with expertise in reading CTs or MRIs of the brain
• Consider CT Perfusion or MRI perfusion in patients outside of the window for IV tPA
• If frank hypodensity involves more than 1/3 of the MCA territory, IV tPA should be withheld

TIAs

• They should get imaging of their cervical vasculature
• Noninvasive imaging by CTA or MRA of the intracranial vasculature is rec. to exclude proximal intracranial stenosis or occlusion. Intracranial lesions may need confirmatory angio if occlusion seen on CTA
• Pts with transient sx should receive imaging within 24 hours, preferably by MRI

Acute Treatment

• Cardiac Monitoring
• New BP meds allowed to get the pt <180/110. Shoot for 180/105 for first 24 hours
• Intubate airway compromise or bulbar dysfunction
• Shoot for pulse ox > 94%. Don’t give supplemental O2 in patients with normal RA pulse ox
• Lower temps >38 C
• Until further evidence, use the same BP goals for IA/mech treatments
• In Non-tPA, only treat if SBP>220 or DBP>120
• Treat hypovolemia with NS and treat CO-reducing dysrhythmias
• Treat hypoglycemia
• May restart home anti-hypertensives after 24 hours
• Treat hyperglycemia to achieve a Blood Sugar of 140–180 mg/dl

IV Fibrinolysis

• Give IV tPA in patients who meet 3 hour criteria (IA)
• Getting it within window is not enough, shoot for the <60 minutes timeframe
• Give IV tPA to pts who meet criteria within 4.5 hours (IB)
• Be prepared to treat complications including bleeding and angioedema
• tPA is reasonable if pt had a seziure if treating team feels deficit is from stroke and not post-ictal state (IIaC)
• Benefits of sono-thrombolysis are unknown at this time
• Other agents besides tPA should only be used in clinical trials
• Benefit of tPA unknown in patients in the 3–4.5 hr range with one of the additional contra-indications
• Use of tPA in pts with mild deficits, rapidly improving deficits, major surgery in prior 3 months, and recent MI may be considered and should be based on risk benefit assessment
• Don’t use streptokinase
• The use of intravenous rtPA in patients taking direct thrombin inhibitors or direct factor Xa inhibitors may be harmful and is not recommended unless sensitive laboratory tests such as aPTT, INR, platelet count, and ECT, TT, or appropriate direct factor Xa activity assays are normal, or the patient has not received a dose of these agents for >2 days (assuming normal renal metabolizing function). Similar consideration should be given to patients being considered for intra-arterial rtPA (Class III; Level of Evidence C)

IA Fibrinolysis

• Pts eligible for IV should receive it even if IA is being contemplated
• Use if < 6hrs duration caused by MCA lesion not eligible for IV tPA
• Minimize delays
• Credential practitioners and track outcomes
• They prefer solitaire FR and Trevo (stent retrievers) over coil retriever (MERCI). Penumbra benefit still being studied
• All mech devices still need additional study to demonstrate benefit
• IA or retrieval are reasonable in pts with contra-indications to IV
• Rescue IA or mech is reasonable in pts who have not fully responded to IV
• Other devices need additional trials
• Intracranial angio and/or stenting requires additional study
• Extracranial angio and/or stenting in unselected patients is not well established

Other Meds

• Thrombin inhibitor benefit unknown
• Anti-coag for severe carotid stenosis is unknown
• Don’t give urgent anti-coag to prevent recurrence, or halt neuro symptoms
• Don’t start within 24 hours of tPA
• Dose of 325 mg of ASA recommended with 24–48 hours of stroke
• Clopidogrel benefit is unknown
• Tirofiban and eptifibatide have unknown benefit
• Don’t use IV IIb/IIIa agents
• Don’t give ASA until after 24 hours from tPA

Blood Pressure Manipulations

• In extreme cases of hypotension that do not respond to fluids, use vasopressors
• Need more evidence for high dose albumin
• Devices to augment CPP are not established yet
• Drug induced hypertension not established
• Don’t hemodilute
• Vasodilatory agents are not recommended

Other Stuff

• If pt was taking statins, you may continue
• Induced hypothermia needs further study
• Laser therapy not recommended yet
• No neuroprotectants have worked out yet

CEA

• Indications for emergent Cardia EA are unknown

Stroke Units

• See full guideline

Neurocritical Care Interventions, etc.

• Patients with major infarctions can crap out, watch them
• Cerebellar infarction will probably need surgery
• Decomp Crani for malignant edema is good
• Treat recurrent seizures like you would in other patients
• Place EVD in pts with hydrocephalus
• Though medical interventions for malignant edema are used, there is not evidence for their efficacy
• No Steroids
• No proph anti-convulsants

ACEP 2013 Ischemic Stroke Guidelines

Available on the ACEP Site

Questions

1. Is IV tPA safe and effective for acute ischemic stroke patients if given within 3 hours of symptom onset?
2. Is IV tPA safe and effective for acute ischemic stroke patients treated between 3 to 4.5 hours after symptom onset?

Patient Management Recommendations

• Level A recommendations: In order to improve functional outcomes, IV tPA should be offered to acute ischemic stroke patients who meet National Institute of Neurological Disorders and Stroke (NINDS) inclusion/exclusion criteria and can be treated within 3 hours after symptom onset.
• Level B recommendations: In order to improve functional outcomes, IV tPA should be considered in acute ischemic stroke patients who meet European Cooperative Acute Stroke Study (ECASS) III inclusion/exclusion criteria and can be treated between 3 to 4.5 hours after symptom onset.

The effectiveness of tPA has been less well established in institutions without the systems in place to safely administer the medication.Within any time window, once the decision is made to administer IV tPA, the patient should be treated as rapidly as possible. As of this writing, tPA for acute ischemic stroke in the 3- to 4.5-hour window is not FDA approved.

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Scott Weingart

Editor-in-Chief, EMCrit.org at EDECMO LLC

An ED Intensivist from NY. No conflicts of interest (coi).

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