Published online before print November 28, 2005, doi: 10.1161/CIRCULATIONAHA.105.166562
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(Circulation. 2005;112:IV-111 – IV-120.)
© 2005 American Heart Association, Inc.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care |
Part 9: Adult Stroke
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Introduction |
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 Top Introduction Management GoalsStroke Recognition and EMS...In-Hospital CareSummaryReferences |
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Each year in the United States about 700 000 people of all ages suffer a new or repeat stroke. Approximately 158 000 of these people will die, making stroke the third leading cause of death in the United States.1,2 Many advances have been made in stroke prevention, treatment, and rehabilitation.3,4 For example, fibrinolytic therapy can limit the extent of neurologic damage from stroke and improve outcome, but the time available for treatment is limited.5,6 Healthcare providers, hospitals, and communities must develop systems to increase the efficiency and effectiveness of stroke care.3 The "7 D’s of Stroke Care"—detection, dispatch, delivery, door (arrival and urgent triage in the emergency department [ED]), data, decision, and drug administration—highlight the major steps in diagnosis and treatment and the key points at which delays can occur.7,8
This chapter summarizes the management of acute stroke in the adult patient. It summarizes out-of-hospital care through the first hours of therapy. For additional information about the management of acute ischemic stroke, see the AHA/American Stroke Association (ASA) guidelines for the management of acute ischemic stroke.9,10
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Management Goals |
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TopIntroductionManagement GoalsStroke Recognition and EMS...In-Hospital CareSummaryReferences |
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The goal of stroke care is to minimize brain injury and maximize patient recovery. The AHA and ASA developed a community-oriented "Stroke Chain of Survival" that links actions to be taken by patients, family members, and healthcare providers to maximize stroke recovery. These links are
- Rapid recognition and reaction to stroke warning signs
- Rapid emergency medical services (EMS) dispatch
- Rapid EMS system transport and hospital prenotification
- Rapid diagnosis and treatment in the hospital
The AHA ECC stroke guidelines focus on the initial out-of-hospital and ED assessment and management of the patient with acute stroke as depicted in the algorithm Goals for Management of Patients With Suspected Stroke (Figure). The time goals of the National Institute of Neurological Disorders and Stroke (NINDS)11 are illustrated along the left side of the algorithm as clocks with a sweep hand depicting the goal in minutes from ED arrival to task completion to remind the clinician of the time-sensitive nature of management of acute ischemic stroke.
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The sections below summarize the principles and goals of stroke assessment and management, highlighting key controversies, new recommendations, and training issues. The text refers to the numbered boxes in the algorithm.
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Stroke Recognition and EMS Care |
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TopIntroductionManagement GoalsStroke Recognition and EMS...In-Hospital CareSummaryReferences |
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Stroke Warning Signs
Identifying clinical signs of possible stroke (Box 1) is important because fibrinolytic treatment must be provided within a few hours of onset of symptoms.5,12 Most strokes occur at home, and only half of all victims of acute stroke use EMS for transport to the hospital.13–15 In addition, stroke victims often deny or rationalize16 their symptoms. This can delay EMS access and treatment and result in increased morbidity and mortality. Even high-risk patients fail to recognize the signs of a stroke.16 Community and professional education is essential,17 and it has successfully increased the proportion of stroke victims treated with fibrinolytic therapy.18,19
The signs and symptoms of a stroke may be subtle. They include sudden weakness or numbness of the face, arm, or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance or coordination; or sudden severe headache with no known cause.
EMS Dispatch
Currently <10% of patients with acute ischemic stroke are ultimately eligible for fibrinolytic therapy because they fail to arrive at the receiving hospital within 3 hours of onset of symptoms.20–24
EMS systems must provide education and training to minimize delays in prehospital dispatch, assessment, and transport. Emergency medical dispatchers must identify potential stroke victims and provide high-priority dispatch to patients with possible stroke. EMS providers must be able to support cardiopulmonary function, perform rapid stroke assessment, establish time of onset of symptoms (or last time the patient was known to be normal), triage and transport the patient, and provide prearrival notification to the receiving hospital (Box 2).25–28
Stroke Assessment Tools
EMS providers can identify stroke patients with reasonable sensitivity and specificity, using abbreviated out-of-hospital tools such as the Cincinnati Prehospital Stroke Scale (CPSS)27,29–31 (Table 1) or the Los Angeles Prehospital Stroke Screen (LAPSS) (Table 2).32,33 The CPSS is based on physical examination only. The EMS provider checks for 3 physical findings: facial droop, arm weakness, and speech abnormalities. The presence of a single abnormality on the CPSS has a sensitivity of 59% and a specificity of 89% when scored by prehospital providers.30 The LAPSS requires the examiner to rule out other causes of altered level of consciousness (eg, history of seizures, hypoglycemia) and then identify asymmetry in any of 3 examination categories: facial smile or grimace, grip, and arm strength. The LAPSS has a specificity of 97% and a sensitivity of 93%.32,33
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With standard training in stroke recognition, paramedics have demonstrated a sensitivity of 61% to 66% for identifying patients with stroke.31,34,35 After training in using a stroke assessment tool, paramedic sensitivity for identifying patients with stroke increased to 86% to 97% (LOE 3 to 5).33,36,37 Therefore, all paramedics and emergency medical technicians-basic (EMT-basic) should be trained in the recognition of stroke using a validated, abbreviated out-of-hospital screening tool, such as the CPSS or the LAPSS (Class IIa).
Transport and Care
Once EMS providers suspect the diagnosis of stroke, they should establish the time of onset of symptoms. This time represents time zero for the patient. If the patient wakes from sleep or is found with symptoms of a stroke, time zero is the last time the patient was observed to be normal. EMS providers must rapidly deliver the patient to a medical facility capable of providing acute stroke care and provide prearrival notification to the receiving facility.25
EMS providers should consider transporting a witness, family member, or caregiver with the patient to verify the time of onset of stroke symptoms. En route to the facility providers should support cardiopulmonary function, monitor neurologic status, and if authorized by medical control, check blood glucose.
Patients with acute stroke are at risk for respiratory compromise from aspiration, upper airway obstruction, hypoventilation, and (rarely) neurogenic pulmonary edema. The combination of poor perfusion and hypoxemia will exacerbate and extend ischemic brain injury, and it has been associated with worse outcome from stroke.38 Although one small randomized clinical trial (LOE 2)39 of selected stroke patients suggested a transient improvement in clinical deficit and MRI abnormalities following 8 hours of high-flow supplementary oxygen (by face mask), a larger quasi-randomized trial (LOE 3)40 did not show any clinical benefit from routine administration of low-flow (3 L/min) oxygen for 24 hours to all patients with ischemic stroke. In contrast, the administration of supplementary oxygen to the subset of stroke patients who are hypoxemic is indirectly supported by several studies showing improved functional outcomes and survival of stroke patients treated in dedicated stroke units in which higher supplementary oxygen concentrations were used (LOE 7).38,39,41,42
Both out-of-hospital and in-hospital medical personnel should administer supplementary oxygen to hypoxemic (ie, oxygen saturation <92%) stroke patients (Class I) or those with unknown oxygen saturation. Clinicians may consider giving oxygen to patients who are not hypoxemic (Class IIb).
The role of stroke centers and stroke units continues to be debated.43 Initial evidence44–50 indicated a favorable benefit from triage of stroke patients directly to designated stroke centers (Class IIb), but the concept of routine out-of-hospital triage of stroke patients requires more rigorous evaluation.
Each receiving hospital should define its capability for treating patients with acute stroke and should communicate this information to the EMS system and the community. Although not every hospital is capable of organizing the necessary resources to safely administer fibrinolytic therapy, every hospital with an ED should have a written plan describing how patients with acute stroke are to be managed in that institution. The plan should detail the roles of healthcare professionals in the care of patients with acute stroke and define which patients will be treated with fibrinolytic therapy at that facility and when transfer to another hospital with a dedicated stroke unit is appropriate (Class IIa).
Multiple randomized clinical trials and meta-analyses in adults (LOE 1)51–54 document consistent improvement in 1-year survival rate, functional outcomes, and quality of life when patients hospitalized with acute stroke are cared for in a dedicated stroke unit by a multidisciplinary team experienced in managing stroke. Although the studies reported were conducted outside the United States in in-hospital units that provided both acute care and rehabilitation, the improved outcomes were apparent very early in the stroke care. These results should be relevant to the outcome of dedicated stroke units staffed with experienced multidisciplinary teams in the United States. When such a facility is available within a reasonable transport interval, stroke patients who require hospitalization should be admitted there (Class I).
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In-Hospital Care |
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Initial ED Assessment and Stabilization
Protocols should be used in the ED to minimize delay to definitive diagnosis and therapy.28 As a goal, ED personnel should assess the patient with suspected stroke within 10 minutes of arrival in the ED (Box 3). General care includes assessment and support of airway, breathing, and circulation and evaluation of baseline vital signs. We recommend that providers administer oxygen to hypoxemic patients in the ED (Class I) and consider oxygen administration for patients without hypoxemia (Class IIb).
Establish or confirm intravenous (IV) access and obtain blood samples for baseline studies (blood count, coagulation studies, blood glucose, etc). Promptly treat hypoglycemia. The ED physician should perform a neurologic screening assessment, order an emergent computerized tomography (CT) scan of the brain, and activate the stroke team or arrange consultation with a stroke expert.
A 12-lead ECG does not take priority over the CT scan, but it may identify a recent acute myocardial infarction or arrhythmias (eg, atrial fibrillation) as the cause of an embolic stroke. If the patient is hemodynamically stable, treatment of other arrhythmias, including bradycardia, premature atrial or ventricular contractions, or defects or blocks in atrioventricular conduction, may not be necessary.55 There is general agreement to recommend cardiac monitoring during the initial evaluation of patients with acute ischemic stroke to detect atrial fibrillation and potentially life-threatening arrhythmias.10
Assessment
The stroke team, another expert, or an emergency physician with access to remote stroke expert support will review the patient history and verify time of onset of symptoms (Box 4).56–58 This may require interviewing out-of-hospital providers, witnesses, and family members to establish the time that the patient was last known to be normal. Neurologic assessment is performed incorporating either the National Institutes of Health (NIH) Stroke Scale or Canadian Neurologic Scale (see the ASA website: www.strokeassociation.org).
Management of hypertension in the stroke patient is controversial. For patients eligible for fibrinolytic therapy, however, control of blood pressure is required to reduce the potential risk of bleeding. If a patient who is otherwise eligible for treatment with tissue plasminogen activator (tPA) has elevated blood pressure, providers can try to lower it to a systolic pressure of <185 mm Hg and a diastolic blood pressure of <110 mm Hg. Because the maximum interval from onset of stroke until effective treatment of stroke with tPA is limited, most patients with sustained hypertension above these levels (ie, systolic blood pressure >185 mm Hg or diastolic blood pressure >110 mm Hg) cannot be treated with IV tPA (Table 4).9,10
Ideally the CT scan should be completed within 25 minutes of the patient’s arrival in the ED and should be read within 45 minutes of ED arrival (Box 5). Emergent CT or magnetic resonance imaging (MRI) scans of patients with suspected stroke should be promptly evaluated by a physician with expertise in interpretation of these studies.59,60 During the first few hours of an ischemic stroke, the noncontrast CT scan may not indicate signs of brain ischemia. If the CT scan shows no evidence of hemorrhage, the patient may be a candidate for fibrinolytic therapy (Boxes 6 and 8).
If hemorrhage is noted on the CT scan, the patient is not a candidate for fibrinolytic therapy. Consult a neurologist or neurosurgeon and consider transfer as needed for appropriate care (Box 7).
If hemorrhage is not present on the initial CT scan and the patient is not a candidate for fibrinolytic therapy for other reasons, consider administration of aspirin (Box 9) either rectally or orally after the patient is screened for dysphagia (see below). Admit the patient to a stroke unit (if available) for careful monitoring (Box 11). Although the aspirin is not a time-critical intervention, it is appropriate to administer aspirin in the ED if the patient is not a candidate for fibrinolysis.
Fibrinolytic Therapy (Boxes 6, 8, and 10)
If the CT scan shows no hemorrhage, the probability of acute ischemic stroke remains. The physician should review the inclusion and exclusion criteria for IV fibrinolytic therapy (Table 3) and perform a repeat neurologic examination (incorporating the NIH Stroke Scale or Canadian Neurologic Scale). If the patient’s neurologic signs are spontaneously clearing (ie, function is rapidly improving toward normal) and is near baseline, fibrinolytic administration is not recommended (Box 6).10
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As with all medications, fibrinolytics have potential adverse effects. The physician must verify that there are no exclusion criteria, consider the risks and benefits to the patient, and be prepared to monitor and treat any potential complications. The major complication of IV tPA for stroke is symptomatic intracranial hemorrhage. This complication occurred in 6.4% of the 312 patients treated in the NINDS trials5 and 4.6% of the 1135 patients treated in 60 Canadian centers.61 A meta-analysis of 15 published case series on the open-label use of tPA for acute ischemic stroke in general clinical practice shows a symptomatic hemorrhage rate of 5.2% of 2639 patients treated.62 Other complications include orolingual angioedema (occurs in about 1.5% of patients), acute hypotension, and systemic bleeding. In one large prospective registry, major systemic bleeding was uncommon (0.4%) and usually occurred at the site of femoral groin puncture for acute angiography.61,63
If the patient remains a candidate for fibrinolytic therapy (Box 8), the physician should discuss the risks and potential benefits of the therapy with the patient or family if available (Box 10). After this discussion, if the patient/family elects to proceed with fibrinolytic therapy, give the patient tPA and begin the stroke pathway of care (see below). Neither anticoagulants nor antiplatelet treatment is administered for 24 hours after administration of tPA, typically until a follow-up CT scan at 24 hours shows no hemorrhage.
Several studies (LOE 1)5,12,61 have documented a higher likelihood of good to excellent functional outcome when tPA is administered to adult patients with acute ischemic stroke within 3 hours of onset of symptoms. These results are obtained when tPA is administered by physicians in hospitals with a stroke protocol that rigorously adheres to the eligibility criteria and therapeutic regimen of the NINDS protocol. These results have been supported by subsequent 1-year follow-up,64 reanalysis of the NINDS data,65 and a meta-analysis (LOE 1).66 Evidence from prospective, randomized (LOE 1)5,12,65,67 studies in adults also documents a greater likelihood of benefit the earlier treatment is begun. Many physicians have emphasized the flaws in the NINDS trials.68,69 But additional analyses of the original NINDS data by an independent group of investigators confirmed the validity of the results,65 verifying that improved outcomes in the tPA treatment arm persist even when imbalances in the baseline stroke severity among treatment groups is corrected.70
Administration of IV tPA to patients with acute ischemic stroke who meet the NINDS eligibility criteria is recommended if tPA is administered by physicians in the setting of a clearly defined protocol, a knowledgeable team, and institutional commitment (Class I). It is important to note that the superior outcomes reported in both community and tertiary care hospitals in the NINDS trials have been difficult to replicate in hospitals with less experience in, and institutional commitment to, acute stroke care.71,72 There is strong evidence to avoid all delays and treat patients as soon as possible. Failure to adhere to protocol is associated with an increased rate of complications, particularly the risk of symptomatic intracranial hemorrhage.71,73
Community hospitals have reported outcomes comparable to the results of the NINDS trials after implementing a stroke program with a focus on quality improvement.61,74,75 The experience of the Cleveland Clinic system is instructive.71,75 A quality improvement program increased compliance with the tPA treatment protocol in 9 community hospitals, and the rate of symptomatic intracerebral hemorrhage fell from 13.4% to 6.4%.75
There is a relationship between violations of the NINDS treatment protocol and increased risk of symptomatic intracerebral hemorrhage and death.62 In Germany there was an increased risk of death after administration of tPA for acute ischemic stroke in hospitals that treated 
5 patients per year, which suggests that clinical experience is an important factor in ensuring adherence to protocol.63 Adding a dedicated stroke team to a community hospital can increase the number of patients with acute stroke treated with fibrinolytic therapy and produce excellent clinical outcomes.76 These findings show that it is important to have an institutional commitment to ensure optimal patient outcomes.
Evidence from 2 prospective randomized studies in adults and a meta-analysis77,78 and additional case series79–86 documented improved outcome from therapies such as intra-arterial tPA. Thus, for patients with acute ischemic stroke who are not candidates for standard IV fibrinolysis, administration of intra-arterial fibrinolysis in centers that have the resources and expertise available may be considered within the first few hours after the onset of symptoms (Class IIb). Intra-arterial administration of tPA has not yet been approved by the US Food and Drug Administration (FDA).
General Stroke Care
Admit the patient to a stroke unit (if available) for careful observation (Box 11), including monitoring of blood pressure and neurologic status and treatment of hypertension if indicated (Table 4). If the patient’s neurologic status deteriorates, order an emergent CT scan to determine if cerebral edema or hemorrhage is responsible for the deterioration and treat if possible.
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Hyperglycemia is associated with worse clinical outcome in patients with acute ischemic stroke than is normoglycemia,87–94 but there is no direct evidence that active glucose control improves clinical outcome.95,96 There is evidence that insulin treatment of hyperglycemia in other critically ill patients improves survival rates (LOE 7 for stroke).97 For this reason administration of IV or subcutaneous insulin may be considered (Class IIb) to lower blood glucose in patients with acute ischemic stroke when the serum glucose level is >10 mmol/L (>about 200 mg/dL).
Additional stroke care includes support of the airway, oxygenation and ventilation, and nutritional support. Administer approximately 75 to 100 mL/h of normal saline to maintain euvolemia if needed. Seizure prophylaxis is not recommended, but we recommend treatment of acute seizures followed by administration of anticonvulsants to prevent further seizures.98 Monitor the patient for signs of increased intracranial pressure. Continued control of blood pressure is required to reduce the potential risk of bleeding (see Table 4).
All patients with stroke should be screened for dysphagia before anything is given by mouth. A simple bedside screening evaluation involves asking the patient to sip water from a cup. If the patient can sip and swallow without difficulty, the patient is asked to take a large gulp of water and swallow. If there are no signs of coughing or aspiration after 30 seconds, then it is safe for the patient to have a thickened diet until formally assessed by a speech pathologist. Medications may be given in applesauce or jam. Any patient who fails a swallow test may be given medications such as aspirin rectally or if appropriate via the IV, intramuscular, or subcutaneous route.
Temperature Control
Treat fever >37.5°C (99.5°F). Hyperthermia in the setting of acute cerebral ischemia is associated with increased morbidity and mortality.99–102
Induced hypothermia can exert neuroprotective effects following stroke.103–111 Hypothermia has been shown to improve survival and functional outcome in patients following resuscitation from ventricular fibrillation (VF) sudden cardiac arrest (LOE 1112; LOE 2113), but it has not been shown to be effective for acute ischemic stroke in controlled human trials. In some small human pilot studies and in animal models, hypothermia (33°C to 36°C) for acute ischemic stroke has been shown to be relatively safe and feasible (LOE 3 to 5).106,109,110 Although effects of hypothermia on both global and focal cerebral ischemia in animals have been promising,111 cooling to 33°C appears to be associated with increased complications, including hypotension, cardiac arrhythmias, cardiac failure, pneumonia, thrombocytopenia, and a rebound increase in intracranial pressure during rewarming.104,105,107,108,111
Ongoing larger clinical trials of induced hypothermia will likely increase our understanding of the role of hypothermia in acute cerebral ischemia. There is insufficient scientific evidence to recommend for or against the use of hypothermia in the treatment of acute ischemic stroke (Class Indeterminate).
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Summary |
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TopIntroductionManagement GoalsStroke Recognition and EMS...In-Hospital CareSummaryReferences |
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Advances in stroke care will have the greatest effect on stroke outcome if care is delivered within a system designed to improve both efficiency and effectiveness. The ultimate goal of stroke therapy is to maximize functional recovery.
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Footnotes |
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This special supplement to Circulation is freely available at http://www.circulationaha.org
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References |
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