II. Protocol: Step 1 Prehospital Assessment

  1. Activate EMS system in all potential CVA patients
  2. Fingerstick Glucose
  3. Prehospital evaluation of patient
    1. Cincinnati Prehospital Stroke Scale
    2. Los Angeles Prehospital Stroke Screen (LAPSS)
    3. VAN Score
  4. Transport to hospital with Stroke Team if possible (otherwise nearest facility)
    1. Assessment tools (e.g. VAN Score) help triage patients with large vessel Occlusion (LVO)
    2. Consider direct transport to tertiary center for mechanical thrombectomy if suspected LVO

III. Protocol: Step 2 Immediate General Assessment (<10 minutes)

  1. ABC Management
  2. Obtain full Vital Signs including Oxygen Saturation
  3. Deliver Oxygen by Nasal Cannula (if Oxygen Saturation <90%)
  4. Do not delay CT Head (see Step 4 below)
    1. Consider having Paramedics wheel patient directly from Ambulance to CT (if stability allows)
    2. Defer non-critical testing (e.g. EKG) until after CT Head
  5. Cardiovascular measures
    1. Obtain Intravenous Access
    2. Electrocardiogram
    3. Telemetry
  6. Airway management
    1. Maintain adequate airway and oxygenation throughout process (critical)
    2. Intubation is indicated in unreliable airway or Hypoxia refractory to oxygenation
    3. RSI medication selection should avoid Intracranial Pressure increase and avoid Hypotension
      1. Avoid pretreatment Lidocaine and Fentanyl (no proven efficacy)
        1. Fentanyl (50-100 mcg) has been used to block sympathetic surge when vallecula is entered
      2. Maintain Blood Pressure within target range throughout intubation
        1. Prevent Hypotension
      3. Induction
        1. Etomidate
        2. Ketamine (if not severely hypertensive)
      4. Paralysis (either agent)
        1. Succinylcholine (may transiently increase ICP)
        2. Rocuronium (delays repeat neuromuscular exam for >40 minutes)
  7. Obtain bedside Serum Glucose (fingerstick Blood Sugar)
    1. Hypoglycemia (<63 mg/dl): Administer D50W (do not over-correct)
    2. Hyperglycemia (>300 mg/dl): Administer Insulin
  8. Labs to obtain in all patients
    1. Complete Blood Count (CBC) with Platelet Count
    2. Basic metabolic profile (e.g. Chem8)
    3. ProTime (PT)
    4. Partial Thromboplastin Time (PTT)
    5. Troponin I (or other Serum Cardiac Marker)
  9. Labs and other diagnostics to obtain in selected patients
    1. Liver Function Tests
    2. Urine toxicology screen
    3. Blood Alcohol Level
    4. Pregnancy Test
    5. Arterial Blood Gas
    6. Chest XRay

IV. Protocol: Step 3 Immediate Neurologic Assessment (<25 minutes)

  1. Alert Stroke Team of possible Thrombolytic candidate
  2. History: Mnemonic ("LoST MIND")
    1. Last well or Onset
    2. Seizure
    3. Trauma (esp. Closed Head Injury)
    4. Migraine
    5. Illness (recent)
    6. Neck injury
    7. Diabetes Mellitus (Hypoglycemia)
  3. Determine eligibility for Fibrinolytics
    1. Consider Thrombolytics (must be started within 3 hours of onset)
    2. Complete CVA Fibrinolytic Checklist
    3. CVA Blood Pressure Control
  4. Neurologic Examination
    1. Assess Level of Consciousness (Glasgow Coma Scale)
    2. Assess Stroke Severity
      1. NIH Stroke Scale (preferred in U.S.)
      2. Hunat and Hess Scale
  5. Physical Examination
    1. Identify acute comorbidities
  6. Consider most common differential diagnosis (stroke mimics)
    1. Complicated Migraine (especially younger women)
    2. Hemorrhagic Stroke (Intracerebral Hemorrhage)
    3. Hypoglycemia
    4. Hypertensive Encephalopathy
    5. Seizure (post-ictal paralysis or Todd's Paralysis)

V. Protocol: Step 4 Rule-out Hemorrhagic CVA

  1. Imaging
    1. Obtain urgent noncontrast Head CT (<25 minutes)
      1. MRI Brain is as sensitive for Hemorrhage and may be substituted if no delay
      2. However CT Head is typically the preferred study over MRI
      3. Fiebach (2004) Stroke 35(2): 502-6 [PubMed]
    2. Head CT read by radiologist (<45 minutes)
    3. CT C-Spine Indications
      1. Altered Level of Consciousness
      2. Trauma
  2. Head CT suggests Intracranial Bleeding
    1. See Hemorrhagic CVA
    2. Immediate angiography (e.g. CT Angiogram, MR Angiogram) to evaluate for aneurysm
    3. Neurosurgery Consultation
    4. Reverse Anticoagulants or Bleeding Disorder
    5. Manage Hypertension appropriately
  3. Head CT negative despite high suspicion for Subarachnoid Hemorrhage
    1. Lumbar Puncture contraindicates Thrombolytics
    2. Consider Head CT Angiogram (CTA) instead
    3. Obtain Lumbar Puncture to assess for subarachnoid blood
      1. Recommended at 12 hours after onset of symptoms
      2. Send cell count (although blood cells can be seen also with Traumatic LP)
      3. Send specimen for spectrophotometry for Bilirubin (only produced in vivo)
  4. Head CT negative suggesting Ischemic CVA
    1. Consider Thrombolytic Therapy below for moderate to severe CVA (NIH Stroke Scale of 5 or more)
    2. Consider mechanical thrombectomy for large vessel Occlusion (as early as possible, within 24 hours)
    3. Additional imaging to consider (if no delay to Thrombolytics)
      1. Head and Neck CT Angiogram (CTA) with and without contrast
        1. May help direct specific interventions
        2. Examples: Directed Thrombolysis or clot extraction in large proximal thrombosis
      2. Perfusion-weight CT or MRI
        1. Identifies the penumbra (ischemic brain surrounding the infarct)
        2. May be salvageable outside the 3-4.5 hour window (with endovascular therapy)
      3. Transcranial Doppler Ultrasound
        1. Identifies arterial vasospasm

VI. Protocol: Step 5 Interventions Based on Time From Onset

  1. Imaging prerequisites
    1. CT Head (all patients, exclude Hemorrhage)
    2. CTA or MRA (evaluate for large vessel Occlusion)
  2. From 0 hours to 4.5 hours after onset
    1. CVA Thrombolysis if indicated (see below)
    2. Consider endovascular intervention (mechanical thrombectomy) in large vessel Occlusion (see below)
  3. From 4.5 to 9 hours after onset
    1. Consider endovascular intervention (mechanical thrombectomy) in large vessel Occlusion (see below)
    2. May consider IV Alteplase (CVA Thrombolysis) in large vessel Occlusion where transfer for thrombectomy is not possible
  4. From 9 to 24 hours after onset
    1. Consider endovascular intervention (mechanical thrombectomy) in large vessel Occlusion (see below)
  5. From 24 hours after onset
    1. Initiate Dual Antiplatelet Therapy for 21 days if no contraindication
  6. References
    1. Aron and Eyre (2023) Crit Dec Emerg Med 37(3): 13
    2. Powers (2020) N Engl J Med 383(3): 252-60 [PubMed]

VII. Protocol: Step 6 Thrombolytic Therapy (if indicated, typically <4.5 hours from onset)

  1. Immediate Consultation with stroke team (where available)
  2. Evaluate for Thrombolytic Contraindications
    1. See CVA Fibrinolytic Checklist
  3. Blood Pressure (if SBP >185 mmHg or DBP >110 mmHg)
    1. See CVA Blood Pressure Control
    2. Failure to control Blood Pressure <185/110 mmHg with the following agents contraindicates Thrombolysis
    3. Consider administering Labetalol 10 mg dose while obtaining CT Head if presenting BP >185/110
    4. Preparations
      1. Labetalol 10-20 mg IVP for 1-2 doses or
      2. Nicardipine or
      3. Nitropaste 1-2 inches or
      4. Enalapril 1.25 mg IVP
  4. Review risks and benefits of CVA Thrombolysis with patient and family
    1. Given 18 patients with moderate to severe stroke (NIH Stroke Scale of 5 or more)
    2. No TPA given
      1. Good CVA recovery: 6 patients (33% or one third)
      2. Poor or no CVA recovery: 12 patients (66% or two thirds)
    3. TPA given within 3 hours
      1. Major CNS bleeding: 1 patient (6%)
        1. With 45% of those patients dying and the others with typically severe Disability
      2. Good CVA recovery: 8 patients (44%) or an additional 2 patients more than if no TPA had been given
        1. Best outcomes are with the least delay in Thrombolytic delivery
      3. Poor or no CVA recovery: 9 patients (50%)
    4. References
      1. (1995) N Engl J Med 333:1581-1587 [PubMed]
      2. Man (2020) JAMA 323(21):2170-84 [PubMed]
  5. Review indications for CVA Thrombolysis
    1. Age over 18 years old
    2. Persistent neurologic deficits with NIH Stroke Scale of 5 or more
      1. Large vessel Occlusion (e.g. Middle Cerebral Artery, cerebellar artery) may have low NIH Stroke Scale
        1. See VAN Score
        2. NIH Stroke Score particularly underestimates deficits from Cerebellar Strokes
        3. These patients may significantly benefit from Thrombolysis
        4. CTA Head and Neck identifies large vessel Occlusion and can help inform decision
        5. Orman and Schrock in Herbert (2017) EM:Rap 17(10):16-7
      2. Consider TPA in significant focal deficits despite NIH Stroke Scale <5
        1. Even low NIH Stroke Scores can have significant Disability
        2. Demaerschalk (2016) Stroke 47:581-641 [PubMed]
      3. Mild strokes may also dramatically worsen in first 24 hours
        1. Consider CT perfusion study if no delay (identifies at risk prenumbra)
        2. Ng (2016) Stroke 47(7): 1914-6 +PMID:27197850 [PubMed]
    3. CVA Symptom onset within 3 to 4.5 hours
      1. May consider for <4.5 hours from onset in some patients based on ECASS3 trial
        1. See CVA Fibrinolytic Checklist
          1. Cases in which extended time limit to 4.5 hours may be appropriate
        2. Consider CT Head with perfusion-weighted imaging to define penumbra
          1. Late presentations may be considered if no delay
        3. Consider in wake-up stroke (limited evidence, discuss with stroke consultant)
          1. Barreto (2016) Ann Neurol 80(2): 211-8 +PMID:27273860 [PubMed]
      2. However no benefit and increased risk Intracranial Hemorrhage when extended to 6 hours
        1. Arora and Menchine in Herbert (2014) EM: Rap 14(1): 8
  6. Precaution
    1. Do not delay CVA Thrombolysis for lab results unless high suspicion of abnormality
  7. Management
    1. See CVA Thrombolysis
    2. Hypertension control is critical not only before Thrombolysis, but especially after Thrombolysis

VIII. Protocol: Step 7 General Measures

  1. Consider endovascular intervention (mechanical thrombectomy) in large vessel Occlusion (see below)
  2. Admit all stroke patients for 24-48 hours
    1. Admit to ICU all patients following CVA Thrombolysis or endovascular intervention
      1. Close monitoring of Blood Pressure, Temperature, Blood Glucose
      2. Monitor for neurologic changes, Cerebral edema, Cerebral Herniation
    2. Cardiac monitoring (telemetry)
      1. Evaluate for paroxysmal Atrial Fibrillation
      2. Cardiac monitoring with 30 day loop recorder is often obtained after discharge
    3. Obtain Transthoracic Echocardiogram
      1. Evaluate for cardiac source of embolism
      2. Indications to consider Transesophageal Echocardiogram instead (better Test Sensitivity)
        1. Age <45 years
        2. Mechanical Heart Valve
        3. Suspected aortic valve source
    4. Frequent neurologic checks (every 2-3 hours is a common interval)
      1. Speech
      2. Extremity Motor Strength
      3. Facial symmetry
    5. Consider transfer to stroke center
      1. All patients receiving CVA Thrombolysis should be transferred to stroke center (neurology ICU)
  3. Keep patient NPO acutely to lower risk of aspiration
    1. Swallowing assessment for aspiration risk
  4. Gentle Intravenous Fluid hydration only (avoid D5W)
    1. Normal Saline or Lactated Ringers at 50 cc/hour
  5. Avoid fever
    1. Acetaminophen (Tylenol)
    2. Cooling blankets
  6. Continue Oxygen by Nasal Cannula to keep O2 Sat >92%
  7. Consider Thiamine in Alcoholics and malnourishment

IX. Protocol: Step 8 Observe for and treat complications

  1. Blood Sugar Monitoring
    1. Hypoglycemia (<63 mg/dl): Administer D50W (do not over-correct)
    2. Hyperglycemia (>300 mg/dl): Administer Insulin
  2. CVA Blood Pressure Control
    1. See CVA Blood Pressure Control
    2. Post-tPA Blood Pressure control is initiated at BP >180/105
    3. Non-tPA Blood Pressure control is initiated if BP >220/120 mmHg
    4. Avoid lowering Blood Pressure too low in first 24 hours
    5. Anticipate spontaneous resolution over days
  3. Seizures
    1. Evaluate with Glucose and Serum Sodium
    2. Treat with Diazepam and Phenytoin
  4. Cerebral edema (peaks on day 3-5, duration 10 days)
    1. Severe, large volume cerebral edema (malignant edema)
    2. Responsible for one third of the 25% of CVA cases that deteriorate
    3. RSI and Intubate
    4. Mannitol
    5. Neurosurgery Consultation for decompression
    6. Corticosteroids are not indicated
  5. Delirium
    1. Avoid medications that cause Altered Level of Consciousness (e.g. Sedatives, Anticholinergics)
    2. Preserve normal sleep-wake cycle by avoiding disturbing night-time sleep
    3. Maintain orientation by maximizing sensory input (adequate lighting, eliminate background noise)
  6. Pressure Sores (Decubitus Ulcer)
    1. Early mobilization and frequent turning
    2. Frequent skin examination
    3. Alternating pressure mattresses
    4. Maintain adequate nutrition (see below)
  7. Malnutrition
    1. Assess albumin, Prealbumin, and Cholesterol as markers of Malnutrition
  8. Fever
    1. Associated with worse outcome in Ischemic Stroke
    2. Thoroughly investigate for fever cause
    3. Lower fever with antipyretics
  9. Pneumonia
    1. Early mobilization
    2. Incentive Spirometry hourly
    3. Decrease Aspiration Pneumonia risk
      1. Avoid medications that cause Altered Level of Consciousness
      2. Assess swollowing study
  10. Urinary Tract Infections
    1. Avoid indwelling catheters as much as possible
  11. Mental Health
    1. Major Depression
      1. Major Depression is present in up to 30% of patients in first year after CVA
      2. Major Depression is associated with increased morbidity and mortality following CVA
    2. Anxiety Disorder
    3. Caregiver Stress
  12. Dysphagia
    1. See Swallowing Evaluation after Stroke
    2. See Dysphagia after Cerebrovascular Accident (Oropharyngeal Dysphagia)
    3. Present in 65% of patients following CVA and persists in 11 to 50% of patients after 6 months
    4. Risk of Aspiration Pneumonia, Choking and Malnutrition
  13. Post-Stroke Pain
    1. Post-stroke pain is present in up to 50% in first 6 months post-CVA
    2. Risk Factors include younger age, Ischemic CVA, Tobacco Abuse, spasticity
    3. Peripheral nociceptive pain may occur
    4. Central neuropathic pain options
      1. Short-term: Pamidronate, Prednisone
      2. Medium-term: Levetiracetam, Lamotrigine, Pregabalin, Etanercept
      3. Bo (2022) Oxid Med Cell Longev 2022: 3511385 [PubMed]
  14. Other common complications
    1. Serum Inappropriate ADH Syndrome
    2. Venous Thromboembolism (e.g. Pulmonary Embolism, Deep Vein Thrombosis)

X. Protocol: Step 9 Adjunctive Therapy

  1. See Dysphagia after Cerebrovascular Accident
  2. See Prevention of Ischemic Stroke
  3. Start Anticoagulation (e.g. Warfarin, DOAC) in EMBOLIC CVA
  4. Start Antiplatelet Therapy (e.g. Aspirin, Clopidogrel, Aggrenox) in NON-embolic CVA
    1. See Antiplatelet Therapy in CVA and TIA
    2. Do not start within the first 24 hours if Thrombolysis (e.g. tPA) is used
    3. Avoid Heparin
  5. Evaluate for significant Carotid Stenosis
    1. See Carotid Stenosis for indications
    2. Typically carotid endarterectomy is recommended for Carotid Stenosis >70%
    3. Indications depend on patient perioperative risk, comorbidity, age and symptoms
    4. NNT 7 to prevent recurrent CVA in 5 years
    5. Optimally performed within 2 weeks of CVA
  6. Evaluate for other secondary causes after Ischemic Stroke or TIA
    1. See CVA Causes
    2. See Transient Ischemic Attack
    3. Evaluate for paroxysmal Atrial Fibrillation (telemetry, Event Monitor, implantable loop recorder)
    4. Evaluate for cardioembolic source (Echocardiogram)
  7. Early rehabilitation
    1. Efficacy
      1. With early rehabilitation, residual deficits may improve rapidly in the first 30 days after CVA
      2. Maximal recovery is typically reached after 6 months
    2. Speech Therapy
      1. Dysphagia (swallow study)
      2. Communication Difficulty (e.g. Aphasia, Dysarthria)
    3. Occupational Therapy and Physical Therapy
      1. Cognitive Impairment (e.g. SLUMS Exam, Mini-Cog)
      2. Mobility Impairment
      3. Fall Risk and Imbalance
      4. Contractures or spasticity

XI. Precautions: Neurointerventional Endovascular Procedures (e.g. Thrombectomy, Directed Thrombolysis)

  1. CT perfusion imaging (or diffusion weighted) may be used to identify patients who will benefit
    1. Best candidates are those with small infarct and large prenumbra (viable tissue at risk)
    2. Collateral circulation may sustain prenumbra area to allow for intervention well past 3 to 4.5 hours
    3. Orman and Radecki in Herbert (2017) EM:Rap 17(5):10-11
  2. Neurointerventional Endovascular Procedure Indications
    1. Not recommended for most acute Ischemic CVA based on current data (except for indications below)
    2. Indications for directed Thrombolysis in moderate to severe CVA patients (NIHSS>8-15)
      1. May be considered in large vessel, proximal Occlusion unchanged at 1 hour following tPA
      2. Consider within 6 hours if standard tPA protocol contraindicated (per AHA/ASA and ACCP)
      3. Consider within 24 hours of onset in large vessel Occlusion and large prenumbra on perfusion imaging
        1. Previously limited to small infarcted cores, but as of 2023 evidence grows for large infarcted cores
        2. Increased CNS Hemorrhage risk with endovascular therapy and larger infarctions in some studies
        3. Huo (2023) N Engl J Med 388(14):1272-83 +PMID: 36762852 [PubMed]
        4. Sarraj (2023) N Engl J Med 388(14):1259-71 +PMID: 36762865 [PubMed]
  3. Studied for severe ischemic Cerebrovascular Accident with high NIH Score (>15-16)
    1. Studies that showed benefit with severe CVA with proximal lesions by CTA or MRA, and intervention <6 hours
      1. MR CLEAN Study showed benefit but 5% risk of new CVA and no mortality benefit
        1. Most patients also received TPA (90%)
        2. Berkhemer (2015) N Engl J Med 273(1):11-20 [PubMed]
      2. Studies ESCAPE, SWIFT-PRIME and EXTEND-IA show significant functional improvements
        1. Radecki and Orman in Herbert (2015) EM:Rap 15(5): 14-16
      3. DAWN Study found benefit from 6 to 24 hours after onset
        1. Nogueira (2018) N Engl J Med 378(1):11-21 [PubMed]
    2. Studies that showed no benefit compared with Thrombolysis (less rigid in patient selection, timing)
      1. Broderick (2013) N Engl J Med 368(10):893-903 [PubMed]
      2. Cicone (2013) N Engl J Med 368(10): 904-13 [PubMed]
      3. Kidwell (2013) N Engl J Med 368(1): 914-23 [PubMed]

XII. Prognosis

  1. Indicators of poor outcome
    1. Hyperglycemia
    2. Fever
    3. Hypertension
  2. Factors with positive impact on functional recovery
    1. Family Support has significant positive impact

XIII. Prevention

XIV. Resources

  1. tPA for Stroke Patient Information - Risks and Benefits
    1. http://www.aaem.org/UserFiles/file/tpaedtool-AAEM.pdf

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