Circulation 2000

Part 7: The Era of Reperfusion: Section 2: Acute Stroke

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Part 7: The Era of ReperfusionSection 2: Acute Stroke

Major Guidelines Changesc Intravenous administration of tissue-type plasminogen ac-

tivator (tPA) for patients with acute ischemic stroke and nocontraindications is recommended:Within 3 hours of onset of stroke symptoms (Class I)Between 3 and 6 hours of onset of stroke symptoms

(Class Indeterminate)c Intra-arterial fibrinolysis within 3 to 6 hours after the onset

of symptoms may be beneficial in patients with occlusionof the middle cerebral artery (Class IIb).

IntroductionA stroke is a disruption in blood supply to a region of thebrain that causes neurological impairment. Stroke is rankedamong the top 3 leading causes of death in most countries andis the leading cause of brain injury in adults. Internationallymillions of people have a new or recurrent stroke each year,and nearly a quarter of these people die.1 The stroke rate isdeclining in most western and northern European countries,but there is a large and increasing rate in Russia, possiblyattributable to a higher prevalence of hypertension.2 Althoughstroke mortality and attack rates are falling in many countries,the gain achieved by prevention has been counterbalanced bya growth in the aging population (more people at risk).3,4

Strokes can be classified into 2 major categories, ischemicand hemorrhagic. Approximately 85% of all strokes areischemic.5 Ischemic strokes occur primarily because a bloodvessel supplying the brain is occluded, usually by a thrombusor embolism. Hemorrhagic strokes are the result of rupture ofa cerebral artery. Associated spasm of the artery and variousdegrees of bleeding occur. Until recently, care of the strokepatient was largely supportive, focusing on prevention andtreatment of respiratory and cardiovascular complications. Nospecific therapy was available to alter the course and extent ofthe evolving stroke. Therefore, little emphasis or need wasplaced on rapid transport or intervention.

Fibrinolytic therapy now offers healthcare providers anopportunity to possibly limit the extent of neurologicaldamage and to improve outcome in stroke patients. Atime-dependent benefit similar to that observed in patientswith acute myocardial infarction (AMI) is possible. The timeavailable for treatment, however, is limited.6 Early recogni-tion of stroke and rapid triage, evaluation in the EmergencyDepartment (ED), and definitive management are essential.79

Early RecognitionEarly treatment of stroke depends strongly on recognition ofthe event by the patient, family members, or bystanders.10Common symptoms of transient ischemic attack (TIA) andstroke are described in Table 1.

Role of EMS in Stroke CareRapid activation of the EMS system is essential to optimizecare of the patient with stroke. Stroke patients who use theEMS system arrive at the hospital faster than those who donot, a major advantage for time-critical treatment.1118 Fur-thermore, emergency dispatchers can send the appropriateemergency team with a priority dispatch response and pro-vide instructions for care of the patient until arrival of EMSpersonnel.1921 EMS personnel can then quickly transport thepatient to a stroke center and notify the facility before arrivalto ensure rapid hospital-based evaluation and treatment.Initial contact of the family physician and transport of thepatient by car have been shown to delay patient arrival andinitial evaluation at the hospital. Such delays may render thepatient ineligible for fibrinolytic therapy.11,15,19

Only half of stroke patients currently use the EMS systemfor transport to the hospital.11,22 Strokes that occur when thepatient is alone or sleeping may further delay prompt recog-nition and action.23 Eighty-five percent of strokes occur athome.22 As a result, public education programs have appro-priately focused their efforts on persons at risk for stroke andtheir friends and family members. Public education hasreduced the time to arrival at the ED.8,12

The 7 Ds of Stroke ManagementKey points in the management of stroke can be remembered byusing the mnemonic of the 7 Ds: Detection, Dispatch, Delivery,Door, Data, Decision, and Drug (see algorithm for suspectedstroke).24 Delay may occur at any point, so the response at eachpoint must be skilled and efficient. The first 3 Ds (detection,dispatch, and delivery) are the responsibility of BLS providers inthe community, including the lay public and EMS responders.Detection occurs when a patient, family member, or bystanderrecognizes the signs and symptoms of a stroke or TIA andactivates the EMS system (by phoning 911 or other emergencyresponse number). EMS dispatchers must prioritize the call for asuspected stroke patient as they would for a victim of AMI orserious trauma and dispatch the appropriate EMS team with hightransport priority. EMS providers must respond rapidly, confirmthe signs and symptoms of stroke, and transport the patient(delivery) to a stroke center (a hospital that can provide fibrino-

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lytic therapy within 1 hour after arrival at the ED door). Theremaining 3 Ds are performed in the hospital: data includesobtaining a computed tomography (CT) scan, decision is madein identifying candidates eligible for fibrinolytic therapy, anddrug includes treating eligible patients with fibrinolytic therapy.

Airway and VentilationAirway obstruction may be a major problem in acute stroke,particularly if the patient loses consciousness. Hypoxia andhypercarbia can occur as the result of inadequate ventilation,contributing to cardiac and respiratory instability. Aspiration

Figure. Algorithm for suspected stroke.

Part 7: Era of Reperfusion: Acute Stroke I-205

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of secretions or gastric contents is a serious complicationassociated with considerable morbidity and mortality. EMSproviders must ensure that the patient has an adequate airway.Assisted ventilation or tracheal intubation may be required.

Vital SignsCheck vital signs (pulse, respirations, blood pressure, andtemperature) frequently to detect abnormalities and changes.Abnormal respirations are particularly prevalent in comatosestroke patients and usually reflect serious brain dysfunction.Hypertension often occurs after a stroke and may be causedby underlying hypertension, a stress reaction to the neurolog-ical event, or a physiological response to decreased brainperfusion. Blood pressure often returns to normal withoutantihypertensive treatment.25

A variety of cardiovascular problems may be present in thepatient with stroke. Cardiac arrhythmias may contribute to thecerebral thromboembolism, or they may be the consequenceof brain injury. In particular, episodes of paroxysmal atrialfibrillation, severe symptomatic bradycardia, or high-degreeatrioventricular block may point to cardiac rhythm distur-bances as causative or contributory. In the elderly and inpatients with diabetes, AMI with atypical or undetectablesymptoms can occur.26,27 Obtain a 12-lead ECG and attemptto rule out left ventricular mural emboli if an acute or recentMI is suspected. Life-threatening cardiac arrhythmias are apotential early complication of stroke, particularly of intra-cranial hemorrhages.2830 Continuous monitoring of cardiacrhythm and systemic perfusion is part of the early manage-ment of a stroke patient.

General Medical AssessmentExamine the patient for evidence of injury to the head orneck, because trauma is an important consideration in thedifferential diagnosis of stroke. Blood pressure in both upperextremities should be measured. A difference of .10 mm Hgshould raise consideration of aortic dissection and compro-mise of brain blood supply. Perform diagnostic studies suchas CT or angiography if indicated by history or clinicalfindings. Cardiac murmur, arterial bruit, absent pulse, orother abnormalities should be sought during the cardiovascu-

lar examination. The presence of an ocular hemorrhage mayallow early identification of intracranial bleeding.

Brief Emergency Neurological EvaluationThe emergency neurological evaluation for stroke shouldinclude 6 key elements:

c Stroke screen or scalec Time of onset of stroke signsc Level of consciousnessc Type of stroke (hemorrhagic versus nonhemorrhagic)c Location of stroke (carotid versus vertebrobasilar)c Severity of stroke

Stroke Screen or ScalePerforming an extensive neurological examination outsidethe hospital is impractical because it delays transport of thepatient to the ED. To conduct an out-of-hospital neurologicalevaluation, use a validated tool such as the CincinnatiPrehospital Stroke Scale (Table 2) or the Los AngelesPrehospital Stroke Screen (LAPSS)16 (Table 3).31,32 TheCincinnati scale is used to elicit any of the 3 major physicalfindings suggestive of stroke: facial droop, arm drift, andabnormal speech.31 LAPSS requires the examiner to rule outother causes of altered level of consciousness (eg, history ofseizures or severe hyperglycemia or hypoglycemia) and thenidentify asymmetry (right versus left) in facial smile/grimace,grip, or arm strength. Asymmetry in any category indicates apossible stroke18,32 These two scales are sensitive and specificin identifying stroke patients.18,31,32 Either evaluation can beperformed quickly.

Ambulance personnel can identify stroke patients withreasonable sensitivity and specificity. Once a stroke is sus-pected, minimize time in the field and immediately transportthe patient to a stroke center.

Clinical signs and symptoms of acute stroke often fluctu-ate. Deterioration or improvement can be detected by fre-quent and repeated focal neurological examinations. Re-peated examinations need not be exhaustive. The GlasgowComa Scale tests eye opening, verbal response, and motor

TABLE 1. Common Signs and Symptoms of TransientIschemic Attack (TIA) and Stroke

Unilateral paralysisWeakness, clumsiness, or heaviness, usually involving1 side of the body

Unilateral numbnessSensory loss, tingling, or abnormal sensation, usuallyinvolving 1 side of the body

Language disturbanceTrouble understanding or speaking (aphasia) orslurred speech (dysarthria)

Monocular blindnessPainless visual loss in one eye, often described as acurtain dropping

VertigoSense of spinning or whirling that persists at rest. Isolated vertigois also a common symptom of many nonvascular diseases; therefore, atleast one other symptom of TIA or stroke should also be present.

AtaxiaPoor balance, stumbling gait, staggering, incoordination of one sideof the body

TABLE 2. Cincinnati Prehospital Stroke Scale

Try to elicit one of the following signs (abnormality in any one is stronglysuggestive of stroke):

Facial droop (have patient show teeth or smile):

Normal: both sides of face move equally well

Abnormal: one side of face does not move as well as the other side

Arm drift (have patient close eyes and hold both arms straight out for 10seconds):

Normal: both arms move the same or both arms do not move at all(other findings, such as pronator grip, may be helpful)

Abnormal: one arm does not move or one arm drifts down

Abnormal speech (have the patient say you cant teach an old dog newtricks):

Normal: patient uses correct words with no slurring

Abnormal: patient slurs words, uses the wrong words, or is unable tospeak

From Reference 31.

I-206 Circulation August 22, 2000


response.33 It is useful for assessing the initial severity ofneurological injury in patients with altered consciousness,especially in cases of injury caused by intracerebralhemorrhage.

Obtain the following information en route to or at thehospital. (Do not delay transport to complete a more detailedevaluation. Rapid transport is essential.)Time of Onset of SymptomsIf stroke symptoms started within 6 hours of the arrival ofEMS personnel, immediately notify the receiving hospital.Prearrival notification of the receiving hospital shortens thetime to definitive hospital-based evaluation and intervention.Provide results of the stroke scale or screen, the GlasgowComa Scale score, and the estimated time of symptom onsetin addition to standard information. This allows the ED orCasualty Service time to prepare and coordinate the patientstime-sensitive therapy. The receiving hospital should have awritten plan to begin therapy as quickly as possible.

Level of ConsciousnessDetermining the stroke patients level of consciousness iscrucial. Depressed consciousness within hours of the onset ofsymptoms implies severe brain injury with increased intra-cranial pressure (ICP), usually due to an intracerebral orsubarachnoid hemorrhage. Coma, the lack of any purposefulresponse to external stimuli, is the result of damage to bothcerebral hemispheres or the brain stem. Coma usually impliesmassive hemorrhage, occlusion of the basilar artery, orcardiac arrest with global brain ischemia. Massive ischemicstroke with cerebral edema may cause coma but is rare. Donot overlook concurrent metabolic problems. Consider drugoverdose, sepsis, or severe metabolic abnormalities.

Type of Stroke (Ischemic Versus Hemorrhagic)The history and physical findings of hemorrhagic and ische-mic stroke overlap (see Table 4). Do not depend solely on

clinical presentation for diagnosis. In most cases, noncontrastCT is the definitive test for differentiating ischemic andhemorrhagic stroke. (CT is discussed in Emergency Diag-nostic Studies.)Location of StrokeHigher cortical, language, visual, cranial nerve, motor, andsensory functions should be assessed in alert patients withbrain infarction. Neurological signs help distinguish infarc-tion of the carotid territory from infarction with a vertebro-basilar distribution. Crossed (cranial nerve palsy with con-tralateral motor or sensory deficit) or bilateral neurologicalsigns suggest that the infarct is located in the brain stem.Specific patterns of deficit, such as pure sensory stroke ordysarthria with a clumsy hand, may be present. Such deficitssuggest a subcortical or lacunar infarct caused by small-vessel disease. The specificity of clinical signs such as puremotor deficit, however, is low. Distinguishing between lacu-nar and nonlacunar infarcts on the basis of clinical features isoften difficult, especially within hours of the onset of stroke.

Severity of StrokeThe National Institutes of Health Stroke Scale (NIHSS) measuresneurological function, and scores on this scale are correlated withthe severity of stroke and long-term outcome in patients withischemic stroke.25,34,35 The scale provides a reliable, valid, and

TABLE 3. Los Angeles Prehospital Stroke Screen (LAPSS)

For evaluation of acute, noncomatose, nontraumatic neurological complaint: If items 1 through 6 are ALL checked yes (or unknown), notify the receivinghospital before arrival of the potential stroke patient. If any are checked no, follow appropriate treatment protocol.

Interpretation: Ninety-three percent of patients with stroke will have positive findings (all items checked yes or unknown) on the LAPSS (sensitivity593%),and 97% of those with positive findings will have a stroke (specificity597%). The patient may still be having a stroke if LAPSS criteria are not met.

Criteria Yes Unknown No

1. Age .45 years [ ] [ ] [ ]

2. History of seizures or epilepsy absent [ ] [ ] [ ]

3. Symptom duration ,24 hours [ ] [ ] [ ]

4. At baseline, patient is not wheelchair bound or bedridden [ ] [ ] [ ]

5. Blood glucose between 60 and 400 [ ] [ ] [ ]

6. Obvious asymmetry (right vs left) in any of the following 3 categories (must beunilateral)

[ ] [ ] [ ]

Equal R Weak L Weak

Facial smile/grimace [ ] [ ] Droop [ ] Droop

Grip [ ] [ ] Weak grip [ ] Weak grip

[ ] [ ] No grip [ ] No grip

Arm strength [ ] [ ] Drifts down [ ] Drifts down

[ ] [ ] Falls rapidly [ ] Falls rapidly

From References 18 and 32.

TABLE 4. Presenting Clinical Features of Hemorrhagic andNonhemorrhagic Stroke

HeadacheDecreased Level of

ConsciousnessFocalDeficit

Infarction 11 1 111

Intracerebral hemorrhage 111 111 111

Subarachnoid hemorrhage 111 11 1

1 indicates mild; 11, moderate; and 111, severe.



easy-to-perform alternative to the standard neurological evaluationfor patients with ischemic stroke, and it has been used for triage ofpatients to different treatment protocols.36,37 The NIHSS total scoreranges from 0 (normal) to 42 points, evaluating 5 major areas offunctioning:

1. Level of consciousness2. Visual function3. Motor function4. Sensation and neglect5. Cerebellar function

The NIHSS is not a comprehensive neurological examina-tion (eg, it does not record gait or all cranial nerve deficits),and more detailed neurological assessment may be requiredin certain cases.

The Scandinavian Stroke Scale was used in the EuropeanCooperative Acute Stroke Study and has been shown toidentify predictors of early and late progression in strokepatients.38,39

The Hunt and Hess Scale (see Table 5) is often used tograde the severity of stroke in patients with subarachnoidhemorrhage.40 The Hunt and Hess grade is correlated withsurvival after subarachnoid hemorrhage and the risk ofcomplications such as vasospasm. The scale may be used toguide the timing of aneurysm clipping or coiling.

Differential DiagnosisVery few nonvascular neurological diseases will cause sud-den onset of focal brain dysfunction, the hallmark of stroke.The list of potential diagnoses (see Table 6) is longer if thepatient is comatose and the medical history is unavailable. Ifthe patients condition gradually worsens over several days, anonvascular neurological disease may be present.

Prehospital TransportEMS systems should develop protocols that provide forpriority dispatch, treatment, and transport of patients withsigns and symptoms of acute ischemic stroke. These proto-cols should convey the same urgency as those for patientswith signs and symptoms of AMI or major trauma (Class IIb).Give highest priority to patients with a suspected stroke andairway compromise or an altered level of consciousness.

In addition, triage and transport patients with acute onset ofstroke symptoms to a facility that can begin fibrinolytictherapy within 1 hour of arrival, unless that facility is .30minutes away by ground ambulance (Class IIb).

ED Triage and TreatmentThe ED must be prepared for the arrival of the stroke patientso that triage and therapy can begin immediately. Maximum

time intervals for completion of diagnostic studies of candi-dates for fibrinolytic therapy are listed in Table 7.

Emergency Diagnostic StudiesEmergency diagnostic studies are used to establish stroke asthe cause of the patients symptoms, to differentiate betweenbrain infarction and brain hemorrhage, and to determine themost likely cause of the stroke. Protocols may prioritize andstreamline the order of these tests.

CT is the most important diagnostic test for differentiatingbetween infarction and hemorrhage or other intracranialmasses.41 To avoid confusing blood and contrast medium,perform CT without contrast enhancement. Withhold antico-agulants and fibrinolytics until brain hemorrhage is ruled out.

The CT scan of almost all patients with a recent intrace-rebral hemorrhage will show increased density at the site ofbleeding.42 Findings in patients with subarachnoid hemor-rhage, however, may be subtle (eg, the scan may show onlya thin, white layer adjacent to the brain). Approximately 5%of patients with subarachnoid hemorrhage will have normalfindings on the CT scan.43,44 Such patients usually have asmall subarachnoid hemorrhage and are alert with no focalneurological deficits (Hunt and Hess grade 1). If clinicalsuspicion of subarachnoid hemorrhage remains despite neg-ative findings on the CT scan, perform lumbar puncture.

Magnetic resonance imaging (MRI) is not part of theroutine evaluation of acute stroke. MRI is very sensitive andwill detect some lesions missed by CT. Although MRI candetect early hemorrhage,45,46 it is not superior to CT. MRI isalso time consuming and may hamper continuous observationof acutely ill patients. New MRI techniques such as magneticresonance angiography and diffusion- and perfusion-weighted MRI may help delineate the site of occlusion or theregion of the brain at risk for infarction.47,48 These techniques

TABLE 5. Hunt and Hess Scale for Subarachnoid Hemorrhage

Grade Neurological Status

1 Asymptomatic

2 Severe headache or nuchal rigidity; no neurological deficit

3 Drowsy; minimal neurological deficit

4 Stuporous; moderate to severe hemiparesis

5 Deep coma; decerebrate posturing

From Reference 40.

TABLE 6. Differential Diagnosis of Stroke

Hemorrhagic stroke

Ischemic stroke

Craniocerebral/cervical trauma

Meningitis/encephalitis

Hypertensive encephalopathy

Intracranial mass

Tumor

Subdural/epidural hematoma

Seizure with persistent neurological signs (Todds paralysis)

Migraine with persistent neurological signs

Metabolic disturbances

Hyperglycemia (nonketotic hyperosmolar coma)

Hypoglycemia

Postcardiac arrest ischemia

Toxicological cause

Endocrine disorder (myxedema)

Uremia

Psychiatric syndromes

Shock and CNS hypoperfusion

CNS indicates central nervous system.



are being evaluated for use in clinical practice. Diffusion-weighted MRI has been approved for use in stroke patients bythe US Food and Drug Administration (Class Indeterminate).

Emergency cerebral angiography is performed in manypatients with subarachnoid hemorrhage in anticipation ofaneurysm clipping. Neurointerventional procedures such asaneurysm coiling, angioplasty, and intra-arterial thrombolysisalso require emergency angiography in certain patients. Manyother studies, including echocardiography, ultrasonographyof the carotid artery, and transcranial Doppler, can beperformed electively.

Emergency ManagementRapidly identify, evaluate, and treat all patients with signsand symptoms of acute stroke. Stroke protocols and pathwaysmay assist in the rapid assessment of these patients. Clini-cians may find the use of a checklist helpful to identifycontraindications to tPA therapy.49 Target times for in-hospital evaluation and treatment are given in Table 7.50

General Emergency TherapyEstablish intravenous access en route to the hospital or in theED (see Table 8). Administer normal saline or lactatedRingers solution at a rate of 50 mL/h. Unless the patient ishypotensive, avoid rapid infusions, which increase the risk ofcerebral edema. Do not administer dextrose in water unlesshypoglycemia is strongly suspected; this solution is hypo-tonic and may increase cerebral edema.5157 Correct hyper-glycemia and hyperthermia (Class IIa). Do not routinelyadminister supplemental oxygen to nonhypoxic (oxygen sat-uration .90%) stroke victims with minor or moderatestrokes. Oxygen may be beneficial, however, to patients withsevere strokes, but additional research is needed.58

Management of Elevated Blood PressureManagement of blood pressure after acute ischemic or hem-orrhagic stroke is controversial. Many patients have hyper-tension after an ischemic or hemorrhagic stroke, but fewrequire emergency treatment. Elevated blood pressure after astroke is not a hypertensive emergency unless there are othermedical problems (eg, AMI or aortic dissection).59 In mostpatients, blood pressure will spontaneously decline as pain,agitation, vomiting, and increased ICP are controlled.25

Antihypertensive treatment is reserved for patients withmarkedly elevated blood pressures or specific medical indi-cations. Current recommendations are based on the type ofstroke (hemorrhagic or ischemic) and whether the patientwith ischemic stroke is a candidate for fibrinolytic therapy. Inresponse to requests for general guidance regarding themanagement of hypertension in stroke patients, a table ofsuggested antihypertensive therapy approaches is provided(see Table 9). It is important to note, however, that thesesuggestions were based on consensus opinion and are notevidence-based.

Antihypertensive therapy can be harmful. Antihypertensivetherapy can lower the cerebral perfusion pressure and lead toworsening of the stroke.59 In addition, the response of strokepatients to antihypertensive therapy can be exaggerated. Useof short-acting nifedipine is contraindicated.59 For patientswith an arterial occlusion, maintenance of adequate collateralflow is of paramount importance.

In candidates for fibrinolytic therapy, however, strictcontrol of blood pressure is required to reduce the potentialfor bleeding. Fibrinolytic therapy is not recommended forpatients who have a systolic blood pressure .185 mm Hg ora diastolic blood pressure .110 mm Hg at the time oftreatment (see Table 9).60,61 Simple measures often can lowerblood pressure below this level. If more aggressive measuresare required, do not use fibrinolytics.

Management of SeizuresRecurrent seizures are a potentially life-threatening compli-cation of stroke. They can worsen the stroke and should becontrolled. Administration of anticonvulsant medications toprevent recurrent seizures is strongly recommended, butprophylactic administration is not indicated.59 Protection ofthe airway, administration of supplementary oxygen, andmaintenance of normothermia are part of supportive care.

Benzodiazepines are first-line agents for treating seizures.Intravenous diazepam (5 mg over 2 minutes to a maximum of10 mg) or lorazepam (1 to 4 mg over 2 to 10 minutes) usuallywill stop seizures but may produce respiratory depression.Lorazepam, which has a short half-life, may be the superioragent. Administration of these agents can be repeated, butthey should be followed by a longer-acting anticonvulsantsuch as phenytoin, fosphenytoin, or phenobarbital.

Management of Increased ICPDeath during the first week after stroke commonly is caused bybrain edema and increased ICP. Fortunately only 10% to 20% of

TABLE 7. NINDS-Recommended Stroke Evaluation Targets forPotential Fibrinolytic Candidates*

Time Target

Door to doctor 10 Minutes

Door to CT completion 25 Minutes

Door to CT read 45 Minutes

Door to treatment 60 Minutes

Access to neurological expertise 15 Minutes

Access to neurosurgical expertise 2 Hours

Admission to monitored bed 3 Hours

NINDS indicates National Institute of Neurological Disorders and Stroke; CT,computed tomography.

*Target times will not be achieved in all cases, but they represent areasonable goal.

By phone or in person.

TABLE 8. General Management of Acute Stroke

1. Intravenous fluids Avoid D5W and excessive fluid loading

2. Blood sugar Determine immediately. Bolus of 50% dextroseif hypoglycemic; insulin if .300 mg%

3. Thiamine 100 mg if malnourished, alcoholic

4. Oxygen Pulse oximetry. Supplement if SO2 ,90%

5. Acetaminophen If febrile

6. NPO If at risk for aspiration

7. Cardiac monitor

D5W indicates 5% dextrose in water; SO2, oxygen saturation.



stroke patients develop brain edema sufficient to cause clinicaldeterioration. When brain edema is clinically suspect, modestfluid restriction, elevation of the head of the bed (20 to 30),support of oxygenation and ventilation (avoidance of hypoxemiaand hypoventilation), and control of agitation and pain will helplower increased ICP. Goals of therapy are (1) reduction ofincreased ICP, (2) maintenance of cerebral perfusion to preventworsening of ischemia, and (3) prevention of brain herniation.

Reduction of the partial pressure of CO2 in arterial gas(PaCO2) through intubation and hyperventilation is the mostrapid means of lowering ICP in cases of impending brainherniation. Optimal PaCO2 is 30 to 35 mm Hg.62 PaCO2 values#25 mm Hg are occasionally acceptable in rapidly deterio-rating patients, but if such values are sustained, ischemia ofthe brain may occur.62 Aggressive tracheal suctioning in-creases ICP and should be avoided, with suctioning reducedin frequency and duration to that necessary to maintaintracheal tube patency.

Hyperosmolar therapy with mannitol is used to reduce themass effect on diencephalic structures or to maximize cerebralperfusion pressure. Mannitol can be given as a bolus (0.25 to 0.5g/kg per dose given over 20 minutes rapidly) and repeated every6 hours to a maximum dose of 2 g/kg daily.59 High initial dosesare given in emergencies. The effect on ICP usually occurs about20 minutes after administration. Lower doses (25 to 50 g every4 hours) given as intermittent boluses are used to manage ICP

over longer periods. Furosemide, hypertonic saline, and acet-azolamide may also help lower ICP.

High doses of barbiturates (eg, thiopental 1 to 5 mg/kg)rapidly lower ICP and suppress electrical brain activity.Because high doses of barbiturates suppress respiratoryactivity and may produce vasodilation and myocardialdepression, they should be administered in conjunctionwith mechanical ventilatory support and careful bloodpressure monitoring. ICP must be monitored when abarbiturate coma is induced, because the barbituratesobliterate the clinical response. The ICP is used to evaluateresponse to therapy.

Routine measurement of ICP is not indicated, and the valueof ICP measurement has not been shown. ICP measurement,however, may be helpful in deteriorating patients, can guidetherapy, and can serve as an indicator of prognosis andoutcome.59

Neurosurgical decompression can be lifesaving in somepatients with high ICP and intracranial hemorrhage, edemaafter stroke, or other mass effects on brain tissue. Surgery forcerebellar hemorrhage or edema after stroke can produceremarkable improvement. Pharmacological and ventilatorymeasures for controlling ICP are much less effective thansurgery in patients with cerebellar lesions. Corticosteroids arenot effective and should not be used.63 Cerebellar edema orhemorrhage frequently causes obstructive hydrocephalus,

TABLE 9. Suggested Antihypertensive Therapy for Patients With Acute Stroke

Blood Pressure* Treatment

Patients ineligible for fibrinolytic therapy

1. DBP .140 mm Hg Sodium nitroprusside (0.5 mg/kg per minute).

Aim for 10% to 20% reduction in DBP.

2. SBP .220, DBP 121 to 140, or MAP.130 mm Hg

10 to 20 mg labetalol IV push over 1 to 2 minutes. May repeat or double labetalol every 20minutes to a maximum dose of 150 mg.

3. SBP ,220, DBP #120, or MAP,130 mm Hg

Emergency antihypertensive therapy is deferred in the absence of aortic dissection, AMI, severeCHF, or hypertensive encephalopathy.

Candidates for fibrinolytic therapy

Pretreatment

1. SBP .185 or DBP .110 mm Hg 1 to 2 inches of nitropaste or 1 to 2 doses of 10 to 20 mg labetalol IV push. If BP is notreduced to and maintained at ,185/110 mm Hg, do not administer fibrinolytics.

During and after treatment

1. Monitor BP Check BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, and then every 1hour for 16 hours.

2. DBP .140 mm Hg Sodium nitroprusside (0.5 mg/kg per minute)

3. SBP .230 or DBP 121 to 140 mm Hg (1) 10 mg labetalol IV push over 1 to 2 minutes. May repeat or double labetalol every 10minutes to a maximum dose of 150 mg, or give the initial labetalol bolus and then start alabetalol drip at 2 to 8 mg/min.

(2) If BP is not controlled by labetalol, consider sodium nitroprusside.

4. SBP 180 to 230 or DBP 105 to 120 mm Hg 10 mg labetalol IV push. May repeat or double labetalol every 10 to 20 minutes to a maximumdose of 150 mg, or give initial labetalol bolus and then start a labetalol drip at 2 to 8 mg/min.

(Note: These suggestions are consensus rather than evidence-based and should be individualized, with consideration given to clinical status and baseline bloodpressure.)

DBP indicates diastolic blood pressure; SBP, systolic blood pressure; MAP, mean arterial pressure; BP, blood pressure; IV, intravenous; AMI, acute myocardialinfarction; and CHF, congestive heart failure.

*Before treatment, all initial blood pressures should be verified by repeating reading in 5 minutes.As estimated by one third the sum of SBP and double DBP.Avoid labetalol in patients with asthma, cardiac failure, or severe abnormalities in cardiac conduction. For patients with refractory hypertension, consider

alternative therapy with sodium nitroprusside or enalapril.



necessitating ventricular drainage. Closely monitor patientswith cerebellar lesions for neurological deterioration.

Pharmacological and Interventional TherapiesIschemic StrokeFibrinolytic TherapyUse of intra-arterial and intravenous fibrinolytic agents suchas tPA, streptokinase, ancrod, urokinase, and prourokinase instroke patients has been evaluated in several clinicaltrials.39,6472 The Cochrane Stroke Review group73 evaluated17 trials with .5000 patients in which .50% of patientsreceived tPA. Fibrinolytic therapy significantly increased theodds ratio of death within the first 10 days and at follow-up,mainly because of fatal intracerebral hemorrhage. Patientstreated within 3 hours, however, had reduced death anddependency compared with patients treated within 3 to 6hours. Overall, the proportion of patients with death ordisability was reduced. It is difficult to draw conclusions fromthis review because there was significant heterogeneityamong the comparison trials.73 In the clinical trials reviewed,many different agents were administered, with many differenttime intervals between onset of stroke symptoms and drugadministration.

The National Institute of Neurological Disorders and Stroke rtPAStroke Trial64 evaluated a single agent administered within 3 hoursof symptom onset in a prospective, blinded, randomized, controlledclinical trial. Intravenous tPA was administered in a dose of 0.9 mggiven as a 10% bolus over 1 minute, followed by a 1-hour infusionversus a placebo. In this trial, patients treated with tPA within 3hours of onset of symptoms were at least 30% more likely to haveminimal or no disability at 3 months compared with those treatedwith placebo. The risk of fatal intracranial hemorrhage, however,was 10 times greater in the tPA-treated group (3% versus 0.3%). Asimilar increase in the frequency of all symptomatic hemorrhages(6.4% versus 0.6%) was also observed in this group. This increasein symptomatic hemorrhage did not lead to an overall increase inmortality in the treated group.

Based on the results of parts I and II of the NationalInstitute of Neurological Disorders and Stroke study,intravenous administration of tPA is recommended forcarefully selected patients with acute ischemic stroke ifthey have no contraindications to fibrinolytic therapy andif the drug can be administered within 3 hours of the onsetof stroke symptoms (Class I). Contraindications to tPA arelisted in Table 10.

Investigators have tried to extend the time for treatmentbeyond 3 hours by using various fibrinolytic agents andnew approaches to administration (eg, intra-arterial thera-py).39,65 67,69 72 Evidence suggested that use of intravenoustPA 3 to 6 hours after the onset of symptoms may bebeneficial in certain patients,73 but recent studies havebeen discouraging. The ATLANTIS Trial found no signif-icant differences in 90-day efficacy end points in patientstreated between 3 and 5 hours.65 The Thrombolytic Ther-apy in Acute Ischemic Stroke Study enrolled 142 patientsat 42 sites in North America and found a small butsignificant benefit of tPA in patients treated after 3 hourswhen assessed at 1 day; this benefit was not maintained at

30 days.74 In both of these trials, the rate of symptomaticintracerebral hemorrhage was increased. At this timeroutine use of intravenous tPA .3 hours after the onset ofsymptoms is not recommended (Class Indeterminate).

Results of a recent, randomized trial of intra-arterialprourokinase suggest that use of intra-arterial fibrinolyticagents 3 to 6 hours after the onset of symptoms may bebeneficial in patients with occlusion of the middle cerebralartery (Class IIb).71

Three large, randomized trials of streptokinase in patientswith stroke have been reported.69,70,75 All 3 studies weresuspended because of increased hemorrhage and mortality inthe group treated with streptokinase. Do not use streptokinasein patients who have had a stroke except in clinical studiesapproved by the appropriate institutional review board.

Anticoagulant TherapyThe efficacy of anticoagulants in acute stroke has not beenestablished. Heparin is frequently administered to patientswith acute ischemic stroke, but its value is unproved.76,77Heparin may help prevent recurrent embolism or propagationof a thrombus, but it may lead to bleeding complications,including brain hemorrhage. There is no consensus on whenheparin therapy should be started or on the dose and durationof therapy. Emergency physicians should consult the attend-ing neurologist about the use of heparin in specific patients(Class IIb). Low-molecular-weight anticoagulants have sev-eral advantages not provided by unfractionated heparin.71 Useof low-molecular-weight anticoagulants in the managementof stroke is being evaluated.

Aspirin, warfarin, and ticlopidine reduce the risk ofsubsequent stroke in patients with TIA.78 81 These anti-platelet agents should be started within the first few daysafter a TIA. When started within 48 hours of the onset ofischemic stroke, aspirin produces a small but definite netbenefit in patients who are ineligible for fibrinolytic

TABLE 10. Contraindications to tPA Therapy for AcuteIschemic Stroke

Evidence of intracranial hemorrhage on pretreatment evaluation

Suspicion of subarachnoid hemorrhage on pretreatment evaluation

Recent (within 3 months) intracranial or intraspinal surgery, serious headtrauma, or previous stroke

History of intracranial hemorrhage

Uncontrolled hypertension at time of treatment (see Management of HighBlood Pressure)

Seizure at stroke onset

Active internal bleeding

Intracranial neoplasm, arteriovenous malformation, or aneurysm

Known bleeding diathesis, including but not limited to

Current use of oral anticoagulants (eg, warfarin sodium), aninternational normalized ratio .1.7, or a prothrombin time .15seconds

Administration of heparin within 48 hours preceding the onset of strokeand an elevated activated partial thromboplastin time at presentation

Platelet count ,100 000/mm3

tPA indicates tissue plasminogen activator.



therapy.82,83 Antiplatelet therapy with aspirin 160 to 300mg daily within 48 hours of onset of presumed ischemicstroke reduces the risk of early recurrent ischemic strokewithout a major risk of early hemorrhagic complicationsand improves long-term outcome.84

The Cochrane Stroke Group completed a comprehensivereview of anticoagulants in 21 trials involving 23 427 pa-tients. A number of anticoagulants were used in clinical trials:standard unfractionated heparin, low-molecular-weight hepa-rins, heparinoids, oral anticoagulants, and thrombin inhibi-tors. The conclusion of the Cochrane group was that imme-diate anticoagulant therapy in patients with acute ischemicstroke is not associated with net gain for either short- orlong-term benefit. Routine use of any type of anticoagulant inacute ischemic stroke is not recommended.85

Other TreatmentsCalcium channelblocking drugs, volume expansion, hemodi-lution, and low-molecular-weight dextran have not been shownto improve clinical outcome after ischemic stroke. A number ofcytoprotective agents are being investigated for use in patientswith acute ischemic or hemorrhagic stroke. Many of these agentshave been shown to provide no benefit in humans, even thoughbenefit was shown in animal models.86

Hemorrhagic Stroke

Subarachnoid HemorrhagePatients with subarachnoid hemorrhage often require emer-gency arteriography. If a saccular aneurysm is detected, earlyintracranial surgery with clipping (or coiling) of the aneurysmis usually advised.87 The calcium channelblocking drugnimodipine (60 mg orally every 4 hours, 0.35 mg/kg) im-proves outcome after subarachnoid hemorrhage.8892 Correc-tion of hyponatremia and water loss is also important. Avoidstrict fluid restriction, however, which may stimulate inap-propriate secretion of antidiuretic hormone.

Intracerebral HemorrhageHemorrhage into the brain can be devastating. Death may occurbecause of compression or distortion of vital deep-brain structuresor increased ICP. Mortality is a function of the volume and locationof the intracerebral bleeding. Optimal management requires preven-tion of continued bleeding, appropriate management of ICP, andtimely neurosurgical decompression when warranted. Large intra-cerebral or cerebellar hematomas often require surgical intervention.A CT scan is required for differential diagnosis. Placement of aventriculostomy tube through a burr hole can be lifesaving ifhydrocephalus is the cause of coma.

Appendix A: NIH Stroke ScaleQuick and Easy Version

Category Description ScoreBaseline

Date/Time Date/Time

1a. Level of consciousness (LOC) Alert 0

(Alert, drowsy, etc) Drowsy 1

Stuporous 2

Coma 3

1b. LOC questions Answers both correctly 0

(Month, age) Answers 1 correctly 1

Incorrect 2

1c. LOC commands Obeys both correctly 0

(Open, close eyes, make fist, let go) Obeys 1 correctly 1

Incorrect 2

2. Best gaze Normal 0

(Eyes openpatient follows examiners finger or face) Partial gaze palsy 1

Forced deviation 2

3. Visual No visual loss 0

(Introduce visual stimulus/threat to patients visual Partial hemianopia 1

field quadrants) Complete hemianopia 2

Bilateral hemianopia 3

4. Facial palsy Normal 0

(Show teeth, raise eyebrows, and squeeze eyes shut) Minor 1

Partial 2

Complete 3



Appendix A: Continued

Category Description ScoreBaseline

Date/Time Date/Time

5a. Motor armleft No drift 0

(Elevate extremity to 90 and score drift/movement) Drift 1

Cant resist gravity 2

No effort against gravity 3

No movement 4

Amputation, joint fusion (explain) 9

5b. Motor armright No drift 0




No movement 4


6a. Motor legleft No drift 0




No movement 4


6b. Motor legright No drift 0




No movement 4


7. Limb ataxia Absent 0

(Fingernose, heel down shin) Present in 1 limb 1

Present in 2 limbs 2

8. Sensory Normal 0

(Pin prick to face, arm, trunk, and legcompare side Partial loss 1

to side) Severe loss 2

9. Best language No aphasia 0

(Name items, describe a picture, and read sentences) Mild to moderate aphasia 1

Severe aphasia 2

Mute 3

10. Dysarthria Normal articulation 0

(Evaluate speech clarity by patient repeating listed words) Mild to moderate dysarthria 1

Near to unintelligible or worse 2

Intubated or other physicalbarrier

9

11. Extinction and inattention No neglect 0

(Use information from prior testing to identify neglect or Partial neglect 1

double simultaneous stimuli testing) Complete neglect 2

Individual Administering Scale:

Adapted with permission from Spilker J, Kongable G. The NIH Stroke Scale: its importance and practical application in the clinical setting. Stroke Intervent.2000;2:714. For further information, please refer to the website http://www.stroke-site.org.



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Appendix B: Scandinavian Stroke Scale(Scandinavian Stroke Study Group, 1985)

1. Consciousness

Fully conscious6

Somnolent, can be awakened to full consciousness4

Reacts to verbal command but is not fully conscious2

Stupor (reacts to pain only)0

Coma0

2. Orientation

Correct for time, place, and person6

Two of these (time, place, person)4

One of these2

Completely disoriented0

3. Speech

No aphasia10

Impairment of comprehension or expression disability6

More than yes/no but not longer sentences3

Only yes/no or less0

4. Eye movement

No gaze palsy4

Gaze palsy present2

Forced lateral gaze0

5. Facial palsy

None/dubious/slight2

Present0

6. Gait

Walks at least 5 m without aids12

Walks with aids9

Walks with help of another person6

Sits without support3

Bedridden/wheelchair0

7. Arm, motor power (assessed only on affected side)

Raises arm with normal strength6

Raises arm with reduced strength5

Raises arm with flexion in elbow4

Can move but not against gravity2

Paralysis0

8. Hand, motor power (assessed only on affected side)

Normal strength6

Reduced strength in full range4

Some movement, fingertips do not reach palm2

Paralysis0

9. Leg, motor power (assessed only on affected side)

Normal strength6

Raises straight leg against resistance with reducedstrength5

Raises leg with flexion of knee against gravity4

Can move but not against gravity2

Paralysis0

10. Foot paresis

None2

Present0



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Circulation 2000