Acute Ischemic Stroke Management in the ED – Part 1

Acute Ischemic Stroke Management

Your shift has just started, and you received a 56-year-old female patient, brought by her family due to a sudden loss of movement. The patient seems awake; you approach her, introduce yourself, and ask for her name. She does not understand. You ask her to look at you and to raise her arms, then you see: the left side of her body was paralyzed. In your head, a stroke sign lights up: you need to decide whether to activate the stroke protocol immediately or not, after all:

Time Is Brain

Important Hints

  • Know the protocols and references of your hospital and your region for acute stroke management. Your Emergency Department should be prepared to suspect of stroke in any patient presenting with acute neurological deficits and have a pre-established protocol for prioritizing care.

  • The prehospital service (EMS) should provide notification to the receiving hospital that a suspected stroke patient in the therapeutic window is en route and direct the patient to the closest hospital with thrombolytic support.

  • By AHA/ASA recommendations, door-to-needle time <60 minutes should be sought in more than 50% of patients treated with alteplase (tPA) (1)

Neurons are very sensitive to changes in brain flow and die within minutes in the absence of perfusion: thus the urgency in attempting rapid reperfusion. (2)

Do not delay the patient evaluation because the emergency department is overcrowded! Move the patient to a monitored bed as soon as possible.

While the patient is being monitored, continue your focused neurological examination quickly and accurately. Asking for the patient to lift and hold the arms, then the legs, tests sensitivity and strength. Then you should ask her to try to smile, assess the eye movement, pupils, search for nystagmus, and ask her to try to expose the tongue, assessing movement and understanding. You ask her simple questions: full name, date, where she is, point to a cell phone, a mug and a watch and ask if she recognizes them. At the same time, you evaluate strength, orientation and deficits.

VITAL SIGNS
Blood Pressure: 180/110 mmHg
Pulse: 125 bpm
SatO2%: 98
Respiratory Rate: 18 bpm

Do not forget to measure capillary GLUCOSE (135mg/dl). Important to rule out other causes of neurological symptoms that can mimic a stroke.

Hypoglycemia

Hypoglycemia is the first condition we evaluate for when the patient presents with acute neurological deficit, decreased level of consciousness, weakness, syncope, convulsion, etc. Hypoglycemia is defined by a blood glucose level less than 45 mg/dl. Symptoms improve rapidly as soon as corrected in most cases. However, it may take time for a complete improvement, and does not always rule out a stroke. (3)

Seizure

Seizure and post-ictal condition are also conditions that can mimic a stroke. Todd’s Paralysis is a focal weakness localized to one side of the body, which occurs around 13% of seizures. These deficits usually last up to 20 minutes but may last 48 hours. Unfortunately, seizures may present in the setting of acute stroke or patients with a stroke history due to neuronal damage. (3)

Stroke Mimics

Stroke mimics are common, accounting for 5% to 31% of patients with acute focal neurological deficit. (3) Diagnosis is not always simple, and abnormal eye movements, increased diastolic blood pressure greater than 90mmHg, and history of atrial fibrillation or angina are most commonly found in stroke. In the presence of decreased level of consciousness, cognitive dysfunction and normal eye movements are more common in stroke mimics.

Stroke Mimics

Condition

Misdiagnosed as stroke (%)

Brain tumor
7-15
Labyrinthitis
5-6
Metabolic disorder
3-13
Migraine
11-47
Psychiatric disorder
1-40
Seizures
11-40
Sepsis
14-17
Syncope
5-22
Transient global amnesia
3-10
Other
11-37

From Konrad CN, Crocco T, Biola J, Larrabee H. Is it stroke, or something else? The Journal of Family Practice. 2010 Jan; 59 (1): 26-31.

The time is ticking, and you must make critical decisions.

  • Is it a stroke? Or a disease with an acute neurological symptom that mimics a stroke?

  • I need a brain imaging study in less than 20 minutes. (2) Will I need to protect the patient's airway before, or should I go straight to the imaging exam?

  • What brain imaging study do I have and what should I do first? CT or MRI?

  • Is there an indication for IV alteplase? Should I do it in my unit, or should I referral the patient to another center?

  • Are there indications for mechanical thrombectomy? Should I do CT angiography at the same time?

Management of acute stroke will depend on:

  • The support you have.
  • Time of onset of the stroke, that is, duration of symptoms.
  • The severity of symptoms:
    • Physical examination: NIHSS, etc.
    • Signs of a large vessel stroke
    • Area of irreversible ischemia “core” versus penumbra area, salvageable area
  • The desire of the patient/family after being informed of the risks/benefits.

Clinical History

The clinical history must be acquired quickly and directly. Essential points: time of symptoms, associated symptoms, comorbidities, and medications of continuous use.

It is important to note that the time of the symptom is counted from the last time the patient was seen without symptoms and not when someone noticed the deficit. (1) If the patient woke up with the deficit, time counts from when he/she was seen without symptoms (e.g., the day before bedtime).

Laboratory, Imaging, Management

Unnecessary tests should not delay brain imaging. It should be performed within 20 minutes of the patient’s arrival at the hospital!

If you do not have a CT scanner in your hospital, the patient should be referred for a center that has one, preferably with a stroke unit. In this situation, physical examination and accurate data of the clinical history must be passed to the place of reference. A physician should accompany the patient.

Treatment of blood pressure only if BP> 220 x 110mmHg, preferably with easy-to-control intravenous medication (labetalol, nicardipine, sodium nitroprusside, etc.). Avoid oral medications due to bronchospasm risk and unpredictable effect. Not having intravenous options, I would consider tolerating hypertension until the diagnosis is confirmed.

Venous access with the collection of samples such as complete blood count, electrolytes, renal function, TAP, APTT, troponin, and more as needed, according to patient comorbidities and medications.

Do not delay the brain image waiting for the collection of laboratory tests. Do not delay imaging or therapy with tPA expecting laboratory test results, unless it is essential.

Venous access before the examination is essential if there is a decision to perform CT angiography of cervical and intracranial vessels in the possibility of mechanical thrombectomy. However, performing CTA should not delay the performance of chemical thrombolysis if indicated. That is, the radiology sector should be prepared to perform immediately after CT if indicated.

Which imaging test is the best? and Why?

MRI

Weighted MRI diffusion shows a greater positivity than CT in the first 24 hours for ischemic stroke, especially in the vertebrobasilar territory. However, its role in ED is still limited because of its uncertain accuracy for the diagnosis of acute hemorrhage, low immediate availability, patient contraindications (not cooperating, claustrophobia, metal implants, pacemaker, etc.) and cost-effectiveness.

CT

CT without contrast, is relatively accessible in most reference centers. It discards other causes of neurological deficit such as ICH, abscess, brain tumor, etc. It may not diagnose acute stroke. But together with a compatible clinical story, it is the only necessary brain image for performing IV alteplase. (2)

Every patient with acute neurological deficit, independent of time, must perform a brain imaging, mainly to rule out other causes, such as ICH, which completely changes the treatment.

All patients with acute neurological deficits, mainly without a diagnosis, must be accompanied by a physician assistant during transfer to imaging, due to the risk of abrupt change/worsening of the clinical status.

It is important to have communication between the ED areas, to warn the radiology department in advance that the patient is on the way, and that the exam should be prioritized. (2)

You accompany the patient during the CT scan. And this is her exam:

Do the best you can, ask for help when in doubt, study and care with love.

To Be Continued.

References and Further Reading

  1. Tintinalli, Judith E.,, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. Eighth edition. New York: McGraw-Hill Education, 2016.
  2. William J. Powers et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke. AHA/ASA Guideline. 2018 Mar;49(3):e46-e110. doi: 10.1161/STR.0000000000000158. Epub 2018 Jan 24.
  3. Brit Long, MD, Stroke Mimics: Pearls and Pitfalls, http://www.emdocs.net/stroke-mimics-pearls-and-pitfalls/ em 07/05/2019
Cite this article as: Jule Santos, "Acute Ischemic Stroke Management in the ED – Part 1," in International Emergency Medicine Education Project, August 9, 2019, https://iem-student.org/2019/08/09/acute-ischemic-stroke-management-in-the-ed-part-1/, date accessed: October 18, 2019

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