• any patient with rapidly evolving neurological deficits should be evaluated as a potential candidate for recanalization therapy and transported ASAP to the nearest Stroke Center (SC) or Comprehensive Stroke Center (CSC) for urgent diagnostic evaluation and treatment

Definition and clinical presentation of acute stroke

  • sudden onset of neurological deficit
    • not all stroke subtypes meet this criterion (mild SAH, the early phase of cerebral sinus thrombosis, etc.)
    • conversely, not all acute-onset focal symptoms are stroke-related → stroke mimics (tumor, trauma, epileptic seizures, hypoglycemia, etc.)
      • other cause at age < 50 years ~ 21%
      • other cause at age > 50 years ~ 3%
  • several prehospital tests have been developed to facilitate stroke detection (FAST, 3-ISS, C-STAT, LAMS, PASS, RACE, FAST+)
Typical clinical course
  • sudden onset
  • usually, the deficit is maximal initially; the undulating and progressive course is possible (thrombus dynamics, quality of collateral circulation….)
  • focal, negative symptoms (hemiparesis, hemihypesthesia, dysarthria, aphasia, hemianopsia, etc.-)
    • common in ischemic stroke or ICH
    • usually absent in SAH and the early phase of sinus thrombosis
  • associated symptoms – headache, vertigo, and nausea
Common signs and symptoms
  • hemiparesis
  • hemihypesthesia
  • hemianopsia, monocular visual disturbances
  • hemiparesthesias
  • aphasia
  • dysarthria, dysphonia, dysphagia
  • vestibular and cerebellar syndrome
  • oculomotor disorders

→ see topical stroke diagnosis

Less likely stroke symptoms
  • isolated diplopia
  • isolated dysphagia
  • isolated tinnitus/hearing loss
  • vertigo
  • isolated imbalance and falls
  • isolated confusion (don’t miss aphasia!)
  • the original concept of TIA and RIND is obsolete
  • according to the old definition, a TIA was defined as a sudden focal neurological deficit of presumed vascular origin lasting < 24 hours; however, ~30-50% of such TIAs had an infarction on MR-DWI
  • a new definition of TIA: short-term impairment of neurological function caused by the cerebral, spinal cord, or retinal ischemia (with clinical symptoms usually lasting < 1h) unless there is evidence of cerebral infarction [Albers, 2002] [Furie, 2011]
  • cerebral infarction – persistent clinical symptoms or positive imaging studies (i.e., even if neurological findings are normal)

From a practical point of view, both stroke and TIA are prognostically serious conditions that require urgent diagnosis and treatment → TIA see here

  • triage positive patient = at least 1 major or 2 minor symptoms (see table)
Major stroke symptoms
Minor stroke symptoms
  • hemiparesis or monoparesis
  • central paresis of the facial nerve
  • speech disorder (aphasia, dysarthria)
  • altered level of consciousness (LOC)
    • quantitative (somnolence, sopor, coma)
    • qualitative (delirium)
  • visual disturbance (visual field defects, sudden loss of vision in one eye, diplopia)
  • balance and gait disturbance
  • unilateral sensory impairment (hypesthesia, anesthesia, paresthesias)
  • symptoms of potential SAH
    • sudden onset of a severe, atypical headache (“worst headache ever”)
    • the gradual development of neck stiffness (meningeal syndrome)
  • the scale reflects acute stroke severity and predicts proximal MCA occlusion with reasonable accuracy (Singer, 2005)
  • it evaluates 3 parameters:
    • level of consciousness (LOC)
    • gaze
    • motor function
  • each item is graded from 0 to 2, with 0 representing normal findings and 2 severe abnormalities (i.e., profound drowsiness or worse, forced gaze deviation, and severe hemiparesis, respectively)
  • the worst score is 6; a score of ≥4 predicts proximal vessel occlusion (T-segment of ICA or M1-segment) almost as accurately as an NIHSS score of ≥14

Pre-hospital management and triage

Monitoring vital signs, symptomatic therapy

  • perform rapid assessment of vital signs (ABC) – A – airway, B – breathing, C – circulation
    • maintain arterial blood oxygen saturation >94%, and do not administer oxygen to non-hypoxic patients  (AHA/ASA 2018 I/C-LD)
    • secure airway if needed
    • monitor blood pressure – correct hypotension, do not treat hypertension with few exceptions (→ hypertension in the acute stage of stroke see here)
  • obtain venous access
    • a green cannula (18G, inner diameter 1.3 mm) – if CTP is a standard part of the imaging protocol
    • a pink cannula  (20G, inner diameter 1.1 mm) – if CTA alone is planned
  • check glycemia, do not administer glucose (except for hypoglycemia), and do not administer anything orally
  • ECG
  • initiate symptomatic therapy (antiemetics, anticonvulsants, etc.)

Triage of patients with suspected stroke

  • the emergency service should recognize the clinical signs of stroke (FAST, FAST PLUS, 3I-SS, etc.),  obtain the relevant medical history and the exact time of onset, and look for contraindications to thrombolysis (see below)
  • the candidate for recanalization treatment should be urgently transported to the Stroke Center or the Comprehensive Stroke Center) (AHA/ASA 2019 I/B-NR)
    • for patients with suspected LVO, direct transport to the nearest CSC may be preferred (AHA/ASA 2019 IIb/B-NR)
    • data analysis from the DAWN trial showed no difference in outcome between transfer to an SC with secondary transport to a CSC versus direct transport to a CSC [Aghaebrahim,2019]
    • patients with suspected LVO for whom IVT is contraindicated should be transferred directly to a CSC after prior consultation (AHA/ASA 2019 IIb/C-EO)
    • if a symptomatic LVO is detected in the SC, the nearest CSC should be consulted immediately
When the patient should be transferred primarily to a center providing endovascular treatment
presumed LVO < 4.5h from the onset of symptoms, if the time of IVT initiation would not differ significantly between SC and CSC
an acute stroke patient with a known absolute contraindication to  IVT (anticoagulant therapy, endocarditis, aortic dissection, recent delivery, etc.)
signs and symptoms of SAH
When to transfer the patient from the SC to the CSC
selected patients with LVO < 24h after symptoms onset mechanical recanalization
patients at risk of malignant ischemia for whom decompressive craniectomy is considered
patients with arterial dissection indicated for interventional procedure
patients with ICH, SAH, or IVH who are candidates for surgical intervention
patients with cerebral sinus thrombosis who are likely candidates for endovascular or surgical intervention

Relevant information to obtain

  • try to find out:
    • the exact time of stroke onset, or
    • the time when the patient was last seen well, or
    • at least the time when a witness found the patient
  • in wake-up stroke (WUS), try to narrow down the time of onset (find out when the patient went to sleep, if he/she went to the bathroom during the night, etc. )
  • obtain phone contact with a person who can specify the circumstances of stroke onset and provide the patient’s personal and medical history
  • obtain a personal and medical history, focusing on known contraindications to thrombolysis
    • anticoagulants use (warfarin, DOACs) and the time of the last dose
    • recent surgery or bleeding
    • predisposition to bleeding
    • allergies and adverse reactions (to iodinated contrast media, drugs, food allergies, etc.)
    • history of renal insufficiency
  • paramedics should obtain a list of the patient’s diagnoses and  medications from family members and bring available medical records
  • assess the patient’s pre-stroke biological status and life expectancy

Initial hospital management

An overview of basic procedures is presented – perform them as quickly as possible; many of them can be done simultaneously, before or during thrombolysis

  • recanalization therapy should begin ASAP after arrival at the hospital
  • it is recommended to follow the approved in-house stroke protocol
    • the patient is taken to the emergency department, stroke unit, or directly to the CT department
    • brain and vascular imaging (± perfusion) are performed
  • none of the following procedures (except for stabilization of vital signs, BP correction, and non-contrast CT scan) should delay recanalization therapy
  • monitor baseline vital signs during transport and diagnostic evaluation (at least secure oximetry and pulse rate during the CT scan)

Initial assessment and stabilization of vital functions

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Intravenous access and laboratory testing

  • collect blood samples
    • blood glucose – the only test required before starting the IVT (AHA/ASA 2019 I/B-NR)
    • bilirubin, osmolality, liver panel (AST, ALT, GMT)
    • urea, creatinine, eGFR
    • ionogram (Na, K, Cl)
    • inflammatory markers
    • cardiac enzymes (CK, CKMB, LD) + hs-troponin T  (AHA/ASA 2019 I/C-LD)
      • elevation in 5-34% of patients
      • IM can cause stroke, and conversely, stroke can provoke IM
      • approximately 10% of mild troponin T elevations are not due to MI (hypertensive crisis, tachycardia, cardiac failure, pulmonary embolism, renal failure, aortic dissection)
      • even borderline elevations of hs-troponin T may be associated with MI (in cryptogenic stroke with suspected cardioembolism, TTE or cardiac MRI should be performed)
        complete blood count
    • complete blood count (CBC)
    • coagulation test
      • APTT, prothrombin time, AT III, fibrinogen
      • specific tests to detect DOAC activity
      • INR (if the patient is using warfarin) can be quickly determined with a bedside coagulometer (CoaguChek)
    • other tests
      • ASTRUP
      • toxicology screen, including alcohol
      • pregnancy test
      • D-dimer
  • insert IV cannula (2 cannulas are needed if thrombolysis is planned)
    • if the peripheral vein cannot be secured, cannulate the femoral or jugular vein
  • consider placing a urinary catheter
    • palpate the bladder for fullness; urinary retention may provoke agitation
  • patients who are not receiving anticoagulant therapy or who do not have known thrombocytopenia or a known bleeding abnormality, IVT can be initiated without knowing the actual  INR, aPTT, and platelet count if their evaluation and determination would postpone the initiation of thrombolysis
  • if tests show INR > 1.7 or aPTT above the upper laboratory limit or a platelet count < 100 000/μl, IVT must be stopped immediately
  • the risk of unexpected thrombocytopenia or coagulopathy is very low – 0.3-0.4% [Rost, 2009], [Cucchiara, 2007]

AHA/ASA guidelines 2019

Medical history, clinical examination, symptomatic therapy

  • medical history (from the patient or witnesses)
    • when stroke symptoms started or when the patient was last seen well
    • with transient symptoms estimate their duration (longer duration increases the likelihood of detecting a DWI lesion)
    • stroke onset circumstances – look for signs of potential epileptic seizure
    • history of previous stroke, MI, HT, DLP, diabetes
    • history of coagulation disorders, recent bleeding, or surgery
    • medications (especially anticoagulation), comorbidities, allergies, previous reaction to an iodinated contrast agent
    • history of smoking, drug or alcohol abuse
  • clinical examination
    • general + neurological examination + NIHSS   → topical clinical diagnostics see here
  • start symptomatic therapy (analgesics, antiemetics, etc.)

Brain and vascular imaging

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Clinical-radiologic correlation

  • a vascular neurologist (strokologist, stroke specialist) should be able to correctly indicate and analyze various imaging modalities (including neurosonology) and ultimately make a clinical-imaging correlation
  • taking all this knowledge into account, together with a careful risk-benefit assessment, he/she can decide on the appropriate therapy
  • the decision tree is most complex in acute ischemic stroke, where the diagnostic evaluation should help to answer the following questions:
  • is it a stroke/TIA?
  • what type of stroke is it (ischemic, hemorrhagic)?
  • what part of the brain/arterial territory is affected?
  • is a relevant artery occluded?
  • can the affected part of the brain be saved (e.g., with IVT or thrombectomy)?
  • what is the most likely cause of the stroke and what should be done to prevent recurrence?
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Early management of patients with suspected stroke
link: https://www.stroke-manual.com/early-management-of-patients-with-suspected-stroke/