Episode 11 – Ischemic Stroke 2013 - a podcast by Scott D. Weingart, MD FCCM

Ischemic Stroke Guidelines from the ASA

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



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

Stroke Centers



* Comprehensive Stroke Centers are god

* Should have neurocritical care unit

* EMS should bypass hospitals that can’t care for stroke

* Should have tele-rads if no in-house radiologists



Initial Eval



* Door to Drug within 60 minutes (80% compliance)

* Use a Stroke Scale, preferably NIHSS

* Get labs, but glucose is the only one that needs to be done before tPa

* Get EKG and troponin, don’t delay tPA for this



 



ED-Based Care

Imaging



* Get either a NCCT or MRI to exclude hemorrhage prior to tPA

* tPA indicated even if ischemic signs, unless a frank hypodensity is noted

* A non-invasive intracranial vascular study is strongly recommended during initial imaging if IA tPA or mechanical thrombectomy is contemplated. This should not delay tPA administration

* In tPA candidates, the CT or MRI should be read within 45 minutes of arrival by a physician with expertise in reading CTs or MRIs of the brain

* Consider CT Perfusion or MRI perfusion in patients outside of the window for IV tPA

* If frank hypodensity involves more than 1/3 of the MCA territory, IV tPA should be withheld



TIAs



* They should get imaging of their cervical vasculature

* Noninvasive imaging by CTA or MRA of the intracranial vasculature is rec. to exclude proximal intracranial stenosis or occlusion. Intracranial lesions may need confirmatory angio if occlusion seen on CTA

* Pts with transient sx should receive imaging within 24 hours, preferably by MRI



Acute Treatment



* Cardiac Monitoring

* New BP meds allowed to get the pt <180/110. Shoot for 180/105 for first 24 hours

* Intubate airway compromise or bulbar dysfunction

* Shoot for pulse ox > 94%. Don’t give supplemental O2 in patients with normal RA pulse ox

* Lower temps >38 C

* Until further evidence, use the same BP goals for IA/mech treatments

* In Non-tPA, only treat if SBP>220 or DBP>120

* Treat hypovolemia with NS and treat CO-reducing dysrhythmias

* Treat hypoglycemia

* May restart home anti-hypertensives after 24 hours

* Treat hyperglycemia to achieve a Blood Sugar of 140–180 mg/dl



IV Fibrinolysis



* Give IV tPA in patients who meet 3 hour criteria (IA)

* Getting it within window is not enough, shoot for the <60 minutes timeframe

* Give IV tPA to pts who meet criteria within 4.5 hours (IB)

* Be prepared to treat complications including bleeding and angioedema

* tPA is reasonable if pt had a seziure if treating team feels deficit is from stroke and not post-ictal state (IIaC)

* Benefits of sono-thrombolysis are unknown at this time

* Other agents besides tPA should only be used in clinical trials

* Benefit of tPA unknown in patients in the 3–4.5 hr range with one of the additional contra-indications

* Use of tPA in pts with mild deficits, rapidly improving deficits, major surgery in prior 3 months, and recent MI may be considered and should be based on risk benefit assessment

* Don’t use streptokinase

* The use of intravenous rtPA in patients taking direct thrombin inhibitors or direct factor Xa inhibitors may be harmful and is not recommended unless sensitive laboratory tests such as aPTT, INR, platelet count, and ECT, TT, or appropriate direct factor Xa activity assays are normal, or the patient has not received a dose of these agents for >2 days (assuming normal renal metabolizing function). Similar consideration should be given to patients being considered ...

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