Strokes are common; they affect almost 800,000 individuals every year and cause about 1 in 20 deaths in the US. Of the number of strokes every year, about 75% are new, and 25% are recurrent. More women (about 55,000) than men have strokes, and African and Hispanic Americans are at double the risk as Caucasians. A stroke occurs every 40 seconds. Importantly, there has been much research and improvement in the prevention and care of stroke. 

When a stroke is suspected, EMS should be activated with rapid assessment, followed by transport to a stroke center. As early care is vital for improving mortality and morbidity, an integrated system of care is vital. Eight areas identify opportunities for improving care and minimizing delay. Importantly, the public must be aware of the signs of stroke so that they can activate EMS early. Here, we will discuss stroke treatment, including the recommendations from AHA and the American Stroke Association (ASA).

There are eight areas for improving stroke care that can be targeted to minimize delay and improve outcomes: 

• Detect: identify signs/symptoms of stroke
• Dispatch: activate EMS
• Deliver: rapid EMS transport
• Door: admission to an appropriate stroke center
• Data: triage and diagnosis of stroke in the ED
• Decide: use data to determine the best plan for treatment
• Drug: fibrinolytic care or interventional vascular management
• Disposition: immediate post-management care in the stroke or intensive care unit

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Related Video: How Do You Treat a Stroke?

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The survival chain for Stroke

Time is essential in decreasing long-term neurologic disability and improving survival. Both the ASA and AHA have recommended a survival chain to improve care and integrate management inside and outside of the hospital: 

• Early identification of signs of stroke
• Early EMS activation
• Early transport with pre-hospital communication to the stroke center/ED
• Rapid assessment and management at the hospital

Stroke Survival Chain

Notice that this integrates care outside of the hospital with advanced care in the hospital. The final link in the chain occurs at the stroke center and includes:

• Rapid determination of appropriate candidates for fibrinolytics;
• Rapid fibrinolytic treatment in set time frames;
• Follow-up care and admission to stroke or intensive care unit.

Guidelines from the AHA provide guidance for outside of a hospital and ED care. There are specific time frames in which specific assessments and treatments should be completed. The National Institute of Neurologic Disorders Stroke (NINDS) set a goal of meeting these time frames for 80% or more of patients.

The Adult Suspected Stroke Algorithm

Short Description

This algorithm outlines the steps to efficiently assess and manage a suspected stroke patient.

Algorithm at a Glance

• The lay rescuer recognizes the signs and symptoms of a stroke and calls EMS quickly.
• EMS begins the assessment and treatment process and transports the patient as quickly as possible.
• In the emergency department, personnel stabilize the patient and obtain an emergent head CT scan.
• The stroke team does a more in-depth neurological assessment to determine appropriate definitive treatment.
• In the case of hemorrhagic stroke, the provider immediately calls for expert consultation.
• In the case of nonhemorrhagic stroke and in the absence of contraindications, the provider considers the administration of rtPA.
• Following definitive treatment, the patient continues on the stroke pathway as defined by the facility.

Goals for the Management of Adult Suspected Stroke

The provider must succeed in the following to successfully manage patients with a suspected stroke:

• Recognize stroke.
• Differentiate between hemorrhagic and ischemic stroke.
• Understand the appropriate treatment based on the type of stroke.

The Adult Suspected Stroke Algorithm

This algorithm was created to present the steps for assessing and managing patients presenting with stroke symptoms. All ACLS providers must be familiar with the AHA Stroke Algorithm:

ACLS Guidelines for Adult Suspected Acute Stroke Algorithm

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Related Video: Understanding the Adult Suspected Stroke Algorithm

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Box 1: Identifying Signs of Possible Stroke

Acute ischemic stroke is a clinical condition in which there has been no blood circulation to a part of the brain, causing a sudden loss of brain function in the dependent area(s). The signs and symptoms of stroke can be temporary or permanent, depending on how long the area has not received adequate blood flow. 

Box 2: Critical EMS Assessments and Actions

A trained EMS provider uses a validated out-of-hospital stroke assessment tool such as the CPSS and makes a presumptive diagnosis in < 1 minute. 

The sooner EMS personnel bring the stroke patient to a suitable institution, the better the chances of treating the patient because only a hospital that specializes in stroke care can provide the definitive therapy for stroke efficiently and effectively. 

EMS personnel can provide supportive treatments to lessen the effects of a stroke during transport to the ED. Interventions by EMS en route to the stroke center include:

• Ensuring proper management of the patient’s ABCs 
• Providing oxygen for patients with oxygen saturation < 94%, or if oxygen saturation cannot be determined

• Checking the patient’s blood glucose levels with appropriate treatment of hypoglycemia 
• Performing a rapid neurological assessment within 1 minute using an appropriate tool 
• Attempting to establish the time when symptoms started
• Alerting the receiving facility 
• Transporting the patient to the stroke center

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Related Video: Stroke Assessment and Important Time Frames Outside the Hospital

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Box 3: In-Hospital, General Assessment, and Patient Stabilization

When the patient arrives in the emergency department, the in-hospital team is ready to assess and stabilize the patient within 10 minutes. 

The general assessment and stabilization process should include:

• Assessing and managing ABCs and vital signs
• Delivering oxygen to keep the oxygen saturation > 94%
• If not completed by EMS, establishing IV access and obtaining blood samples
• Assessing and treating hypoglycemia
• Performing a basic neurologic assessment using the hospital-prescribed tool. An excellent tool is the National Institutes of Health Stroke Scale (NIHSS).
• Ordering an emergent CT scan of the brain and transporting the patient for the exam when radiology is ready
• Activating the stroke team if one is available or calling an emergent neurological consult
• Obtaining an ECG, but the CT scan should not be delayed for this intervention

Box 4: The Neurological Assessment

The stroke team, consisting of qualified nurses, a neurovascular consultant, and an emergency physician, performs the patient’s neurologic assessment. These providers take a focused patient history, perform a physical examination, and determine the time of the onset of stroke symptoms. 

The neurologic assessment also makes use of an evaluation tool such as the NIHSS or the Canadian Neurological Scale exam. Neurologic assessment by the stroke team does not exceed 25 minutes.

Critical to the treatment of acute ischemic stroke is determining the time of symptom onset confirmed by multiple informants who may include the patient, family members, and other potential witnesses. The healthcare provider asks when the patient was last known to be healthy.

Box 5: CT Scan Interpretation to Determine Cause of Stroke 

The most crucial factor in treating acute stroke is to ascertain whether the patient’s symptoms are due to ischemia or hemorrhage. Hence, an important imaging modality is a noncontrast CT scan of the head. The scan not only detects ischemia or hemorrhage but may also identify if other anatomic anomalies within the brain may have precipitated the stroke.

Box 6: Fibrinolytic Therapy for Acute Ischemic Stroke

If the team administers rtPA within 3 hours of symptom onset, the patient is likely to have a better outcome. Some patients may be given rtPA up to 4.5 hours after the onset of symptoms. The best results are obtained when the intervention is done in an institution with a specialized stroke unit following the NINDS protocol. 

The earlier the treatment is given, the better the outcomes will be. In this step, the patient is reassessed to determine whether the symptoms are quickly resolving. If so, fibrinolytic therapy may not be necessary.

The following table lists the inclusion and exclusion criteria for patients with ischemic stroke who may be eligible for rtPA treatment.

Inclusion and Exclusion Characteristics of Patients with Ischemic Stroke for Treatment with rtPA within 3 Hrs of Symptom Onset

Extending the time-dependent criteria for rtPA therapy after the onset of acute stroke symptoms may be possible in certain circumstances. 

The next table provides additional inclusion and exclusion criteria for patients who may be eligible to receive rtPA between 3 hours to 4.5 hours from the onset of symptoms:

The most significant adverse effect of fibrinolytic therapy is intracranial hemorrhage. Minor and major bleeding complications may also occur elsewhere in the body. Other adverse reactions to rtPA are angioedema and transient hypotension.

Box 7: Neurosurgeon or Neurologist Consult for Hemorrhagic Stroke

If the CT scan detects hemorrhage, a specialist such as a neurologist or neurosurgeon will be consulted to assess the patient for possible surgical intervention and other appropriate treatments.

Box 8: Reassessing Patient’s Need for Fibrinolytic Therapy 

In this step, the patient is reassessed to determine whether symptoms are quickly resolving. If so, fibrinolytic therapy may not be necessary.

Box 9: Patient Not a Candidate for Fibrinolytics

The provider administers aspirin and admits the patient to the appropriate level of care.

Box 10: Informed Consent for rtPA 

After it is determined that the patient is a candidate for fibrinolytic therapy, the attending physician must discuss the risks and benefits of rtPA with the patient or a family member. After all questions are answered and the consent has been signed, the attending physician proceeds with the treatment. 

The team should not give anticoagulants or antiplatelet therapy for 24 hours after administering rtPA or until a follow-up CT scan at 24 hours reveals that there is no intracranial hemorrhage present.

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Related Video: How Do You Treat a Stroke?

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Endovascular Therapy

Selected patients with ischemic stroke can also receive endovascular therapy. This treatment is directed toward resolving a clot that may have formed in the intracerebral blood vessels by disrupting its integrity or removing it and restoring blood flow to the associated brain tissue. 

Patients appropriate for endovascular therapy are among the following:

• Pre-stroke Modified Rankin Scale (mRS) score of 0 to 1
• Acute ischemic stroke receiving intravenous rtPA within 4.5 hours of onset
• Causative occlusion of the internal carotid artery or proximal middle cerebral artery (MCA) (M1)
• Age 18 years and older
• NIHSS score of 6 or more
• Alberta Stroke Program Early CT score (ASPECTS) of 6 or greater
• Treatment can be initiated (via groin puncture) within 6 hours of the onset of symptoms

The clinician should treat any patients meeting the criteria with endovascular therapy in addition to IV rtPA.

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Related Video: What are the Immediate Therapies for Stroke?

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Box 11: Admission to the Appropriate Level of Care 

The provider ensures that the patient is on a hemorrhagic stroke pathway.

Box 12: General Stroke Care

After successful fibrinolytic or endovascular therapy, and within 60 minutes of arrival to the hospital, the patient undergoes general stroke care, which includes the following interventions:

• Implementation of the stroke pathway. The patient is placed on the stroke pathway, which involves a transfer to the stroke unit to closely monitor the patient’s neurologic status and vital signs (blood pressure monitoring is critical). Also, the stroke unit can provide support for the ABCs.
• If a patient worsens in the stroke unit, a CT scan of the brain is requested. There may be cerebral edema or an intracerebral hemorrhage present. 
• Patients with acute ischemic stroke should also be monitored closely for blood glucose levels < 60 mg/dL. Insulin should be given through the subcutaneous route to patients with blood glucose levels of ≥ 185 mg/dL.

The patient should be monitored for complications of fibrinolytic therapy and stroke, including seizures and increased intracerebral pressure. It is critical for the team to monitor for and treat hypertension, as described in the following table:

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Hypertension After Stroke