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Stroke, Ischemic, Diagnosis and Initial Treatment of

This Guideline is Currently under Revision

Guideline Summary

Revision Date: July 2012
Tenth Edition

Scope and Target Population

The scope of the following guideline is the 48 hours beginning when a patient age 18 years or older presents to the health care system with symptoms of ischemic stroke or transient ischemic attack. For most stroke patients who are hospitalized, the guideline's temporal scope will expire before discharge. The guideline work group on Diagnosis and Initial Treatment of Ischemic Stroke recognizes that two time frames are critically important in the overall outcome, and fall outside the defined scope. They are the pre-hospital era, i.e., recognition and pre-hospital care, and continuing care of stroke patients after 48 hours, which includes the development of a long-term secondary prevention strategy.

Aims

  1. Increase the percentage of patients age 18 years and over presenting in time for IV tPA to be initiated within 3 hours, or up to 4.5 hours for patients meeting selected criteria of stroke onset who are evaluated within 10 minutes of arriving in the emergency department. Under usual circumstances these time-related goals should be achievable for patients presenting to an appropriate treatment setting within 2 hours and 30 minutes and 4 hours of symptom onset, respectively.
  2. Increase the percentage of patients age 18 years and over at high risk for stroke presenting with TIA symptoms within 24 hours who are admitted to the hospital inpatient or observational unit or undergo identical assessment in an expedited outpatient program.
  3. Increase the percentage of patients age 18 years and over receiving appropriate thrombolytic and appropriate antithrombotic therapy for ischemic stroke (use of tPA and aspirin, other antiplatelet agents or an anticoagulant).
  4. Increase the percentage of tPA non-recipients who have hypertension appropriately managed in the first 24-48 hours of hospitalization or until neurologically stable.
  5. Increase the percentage of stroke patients age 18 years and over who receive stroke unit care during the initial 24-48 hours including prevention and management of complications such as:
    • dehydration/hypertension/hypotension
    • aspiration
    • hypoglycemia and hyperglycemia
    • deep vein thrombosis
    • immobility
    • falling
    • nutritional status decline
    • hyperthermia
  6. Improve patient and family education of patients with ischemic stroke in both the emergency department and the admitting hospital unit.

Clinical Highlights

  • Intravenous tPA continues to be a proven treatment for ischemic stroke when administered within recommended time parameters.
  • Intravenous tPA, if given, should be administered within three hours (4.5 hours in selected patients; see Annotation #18, "Consider IV Tissue Plasminogen Activator [tPA]/See Stroke Code Algorithm") of stroke onset and less than 60 minutes of arrival at the emergency department.
  • Patients presenting with signs and symptoms of transient ischemic attack should be evaluated for risk of immediate future events using the ABCD2 score.
  • Patients presenting with stroke onset who are not candidates for intravenous tPA should promptly be given aspirin, after exclusion of hemorrhage on CT scan.
  • Education regarding early stroke symptoms, risk factors, diagnostic procedures and treatment options should be offered to the patient and family. Informed consent discussions should be documented in the patient chart.
  • Stroke unit care should be provided for prevention and management of complications within the initial 24-48 hours:
    - manage volume and blood pressure appropriately
    - perform swallow evaluation before oral intake, including medications
    - treat hypoglycemia and hyperglycemia
    - initiate deep vein thrombosis prevention
    - initiate early mobilization
    - establish fall prevention
    - perform nutritional status assessment
    - treat hyperthermia