Protocol for evaluation and management of acute ischemic stroke



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Stroke Team

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PROTOCOL FOR EVALUATION AND MANAGEMENT OF ACUTE ISCHEMIC STROKE


Arrival to ED physician assessment = 10 min. Arrival to stroke team assessment = 15 min.
Acute Stroke Work-up Details

Acute stroke diagnostics and care are initiated via the “ED Stroke Protocol” order set.



  1. All patients presenting to the ED with probable stroke will be triaged as a Code 2.

  2. ED physician determines Code Stroke eligibility based on last time know well, and focal deficit.

  3. Initiate ED Stroke Protocol order set

    • Point of Care Testing: I-Stat6+ (Sodium, Chloride, Potassium, Glucose, BUN, and Hematocrit), and Troponins

Note: Only the assessment of blood glucose must precede the initiation of IV tPA

    • Special Acute CTA Head and Neck

      1. Patients unable to get CTA receive non-contrast CT

    • Serum coagulation studies should be ordered for patients on anticoagulant therapy of any kind, history of bleeding diathesis or coagulopathy

PT, PTT, Fibrinogen, INR

    • Select patients based on clinical judgment may require additional stat serum lab testing

Hepatic Function Test

Toxicology Screen

Blood Alcohol Level

Pregnancy Test

Arterial Blood Gases (if hypoxia suspected)


    • Establish 2 IV lines

    • Obtain 12-lead ECG

    • Place on cardiac monitoring

    • Obtain O₂ saturation, treat O₂ per NC. Titrate to keep saturations equal to or greater than 94%

    • Vital signs q 15 minutes while in the Emergency Department

  1. Obtain patient's weight in kg. Estimation per family or medical personnel acceptable only if patient is unable to stand with minimal assist.

  2. ED nurse to perform and document neuro assessment on arrival and with any change in condition

  3. Stroke Team to perform and document baseline NIH Stroke Scale ASAP.

  4. If patient meets IV thrombolytic criteria, proceed with IV tPA administration.

  5. Neuro Radiology to notify Neurovascular team of large vessel occlusion

    • Distal Intracranial ICA, M1, M2, basilar, and vertebral occlusion.

    • ASPECTS Score > 6.

  6. Patients with treatable large vessels occlusion by CTA to be evaluated in Neuroendovascular team for possible endovascular therapy.

  7. Stroke Team MD to initiate “Neurology Acute Ischemic Stroke Order Thrombolytic Treatment” order set for eligible patients.



CRITERIA FOR THROMBOLYTIC AND REPERFUSION THERAPY

Verbal consent for IV thrombolytic therapy up to 4.5 hours and intra-arterial mechanical reperfusion will be documented in the electronic medical record along with the patient/family risk/benefit discussion.



CONTRAINDICATIONS

Do not administer Activase to treat acute ischemic stroke in the following situations in which the risk of bleeding is greater than the potential benefit [see Warnings and Precautions (5.1)]:



  • Current intracranial hemorrhage

  • Subarachnoid hemorrhage

  • Active internal bleeding

  • Recent (within 3 months) intracranial or intraspinal surgery or serious head trauma

  • Bleeding diathesis

  • Current severe uncontrolled hypertension.



WARNINGS or Relative Exclusion Criteria

When Activase is prescribed in the following conditions, the risks of bleeding are increased and should be weighed against the anticipated benefits:



  • Recent major surgery or procedure, (e.g., coronary artery bypass graft, obstetrical delivery, organ biopsy, previous puncture of non-compressible vessels)

  • Cerebrovascular disease

  • Recent intracranial hemorrhage

  • Presence of intracranial conditions that may increase the risk of bleeding (e.g., some neoplasms,

  • arteriovenous malformations, or aneurysms)

  • Recent gastrointestinal or genitourinary bleeding

  • Recent trauma

  • Hypertension: systolic BP above 175 mm Hg or diastolic BP above 110 mm Hg

  • High likelihood of left heart thrombus, e.g., mitral stenosis with atrial fibrillation

  • Acute pericarditis

  • Subacute bacterial endocarditis

  • Hemostatic defects including those secondary to severe hepatic or renal disease

  • Significant hepatic dysfunction

  • Pregnancy

  • Diabetic hemorrhagic retinopathy, or other hemorrhagic ophthalmic conditions

  • Septic thrombophlebitis or occluded AV cannula at seriously infected site

  • Advanced age [see Activase Prescribing Use in Specific Populations (8.5)]

  • Patients currently receiving anticoagulants (e.g., warfarin sodium, with INR > 1.7)

  • Any other condition in which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its



GUIDELINES FOR BLOOD PRESSURE MANAGEMENT POST INFUSION

BP Goal at or less than 180/105 mmHg

If Systolic > 180 to 230 mm Hg or diastolic > 105 to 120 mm Hg:


  • Labetalol 10 mg IV followed by an infusion at 2 to 8 mg/min

  • Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h

If BP not controlled or DBP > 140 mmHg, consider IV sodium nitroprusside
MANAGEMENT OF INTRACRANIAL HEMORRHAGE (ICH) POST IV t-PA INFUSION

  • STAT PT/INR, PTT, CBC with platelets, D-dimer, fibrinogen, electrolytes, BUN/Cr, glucose, liver function tests, type and screen to blood bank

  • Consult Neurosurgery

  • Infuse fresh frozen plasma (FFP) 2 units intravenously STAT every 6 hrs x 4 doses

  • Repeat PT/INR, CBC with differential in 30 min. and then every 6 hrs x 4

  • Cryoprecipitate10- 20 units intravenously STAT.

  • Recheck fibrinogen in one hour and re-administer cryoprecipitate if bleeding continues and fibrinogen < 100mg/dL


Warfarin Reversal intracerebral Hemorrhage

Vitamin K Antagonist (warfarin) Reversal



  1. Vitamin K 10 milligrams by slow IV infusion

  2. Fresh Frozen Plasma (FFP) 10-20ml/kg IV

  3. Repeat Protime/INR 30 minutes after completion of FFP, to verify INR correction to <1.2, then Protime/INR every 4 hours for 24 hours, then every 6 hours for 24 hours


Exclusion criteria for admission to the Observation Unit (2COBS)

  1. Persistent, fluctuating or recurrent neurologic signs/symptoms

  2. Non-focal symptoms

  3. New altered mental status

  4. Positive CT scan

  5. Severe headache

  6. Fever

  7. Uncontrolled hypertension

  8. Evaluation for TIA within last 6 months

  9. Suspected cardio-embolic episode

    • Atrial fibrillation with/without therapeutic INR

    • Dilated cardiomyopathy

    • MI within past 6 months

    • Mechanical heart valve

    • Mitral annular calcification

  10. Concurrent medical illness requiring hospitalization

  11. Evidence of CNS infection



MEDICAL/SURGICAL PROTOCOL FOR MALIGNANT CEREBRAL EDEMA

The Stroke Team will clarify the family’s wishes for an aggressive level of care which may include potential surgical intervention. This should be done in conjunction with clarifying the resuscitation status of the patient on admission.



  • PICC line or central line placement

  • Consider serial imaging with non-contrast Head CT

  • Osmotherapy with Mannitol or 3% hypertonic saline at a dose sufficient to reach a serum osmolality of 315-320 mOsm

    • Initial dosing of Mannitol of 0.5 – 1 gm/kg IV

    • Caution: Slowly withdrawal osmotic therapy to avoid rebound cerebral edema

    • Daily monitoring of serum Na+ and osmolality

    • Serum Na+ and K+ every 4-6 hours while employing osmotic therapy

    • Correction of Na+ more than 0.5mmol/L per hr (12mmol/L in 24h) may require a decrease in rate/volume/dose of osmotic therapy

  • Intubation and mechanical ventilation:

  1. If the patients Glasgow Coma Score is less than 9 or

  2. Signs of herniation on exam or

  3. Signs of respiratory insufficiency or

  4. Airway compromise

  • Hyperventilation as a rescue measure in the event of further neurological deterioration or an uncontrolled increase in intracranial pressure.

    • Target pCO2 of 28-32 mmHg.

    • Hyperventilation is to be used as a temporary measure until other modalities can be instituted (i.e. osmotic therapy, CSF drainage, decompressive surgery).

  • Invasive monitoring of intracranial pressure, preferably on the same side as the infarct can be considered.

  • Sedation in the case of mechanical ventilation or further neurological deterioration is discouraged unless an ICP monitor is in place.

  • Treatment of blood pressure higher than 220/120 mmHg with anti-hypertensive agents.

  • Treatment of hypotension or a reduction of cerebral perfusion pressure to maintain CPP greater than 60 mmHg.

  • Elevation of the head to 30-45 degrees.

  • Maintenance of normothermia, normoglycemia, and normovolemia.

  • Initiate early nutrition with special attention to osmotic concentration of tube feeds. Consider free water restrictions to keep serum Na+ stable and normal.


INDICATIONS FOR DECOMPRESSIVE CRANIECTOMY IN PATIENTS WITH ISCHEMIC STROKE

Hemispheric/supratentorial stroke (MCA stroke with malignant cerebral edema)

Indications:

Inclusion Criteria:



  1. Hemispheric stroke involving the middle cerebral artery territory with onset within 96 hours

    1. The anterior cerebral artery and the posterior cerebral artery territories may be involved.

  2. Ischemic changes on CT that affect two-thirds or more of the territory of the MCA, the formation of space-occupying edema and displacement of midline structures on imaging (volume 145 – 210 mL)

    1. Note: In patients with hemispheric stroke with volume > 210mL, the fatality rate is 100% without decompressive craniectomy.

  3. Good pre-stroke functional status (Karnofsky score > 80)

  4. Written informed consent by the patient or a legal representative


Relative Contra Indications:

  1. Dementia

  2. Multiple vascular risk factors

  3. Multiple co-morbidities

  4. Pre-stroke score on the modified Rankin scale of greater than 1 or less than 95 on the Barthel index


Exclusion Criteria:

  1. Bilateral fixed pupils

  2. Contralateral ischemia or other brain lesion that could affect outcome

  3. Life expectancy < 3 years

  4. Known coagulopathy or systemic bleeding disorder

  5. Decrease in consciousness from causes other than the formation of edema, such as metabolic disturbances or medication

In patients with malignant cerebral edema from a hemispheric stroke with any of the above relative contra indications, the overall outcome is very poor even with aggressive non-surgical edema/ICP management. Therefore, a palliative-care approach should be considered.


Posterior fossa/cerebellar stroke Indications:

  1. Post-ischemic cerebellar edema

  2. Neurologic decline from edema /mass effect

  3. Radiographic mass effect from edema

  4. No significant brainstem infarction (e.g. small posterolateral medullary stroke, Wallenberg’s, has relatively good prognosis so a patient with this stroke would be considered for surgery)

Age is less of a factor in the outcome of patients with cerebellar stroke treated with decompressive surgery. Patients with low GCS should be considered for surgery, but the clinical goal is to perform decompressive surgery prior to onset of brainstem compression or coma.




Code Stroke Nurse Role:

  • Set Vitals to q15min, O2>94%

  • NIH Assessment

  • Retrieve LTKW(last time known well)

  • Bedside POC glucose

  • Check IV lines-anticipate 2nd IV if necessary

  • Verify daily weight.

Assist Stroke Team Resident

-While Stroke Team is Assessing Patient: Anticipate orders for STAT labs: CBC, Platelets, BMP, Troponins, CKMB, PT/PTT, INR, Fibrinogen.. STAT CT Head or CTA. STAT EKG.



  • Monitor and assist to CT if patient is a possible tPA candidate or unstable.

  • Stay at bedside until tPA decision is made

  • With Pharmacist: Double check dosing and pump.

  • Post tPA protocol on transfer to ICU.

Resident Role for AIS transfer patient:

Resident Role for AIS transfer patient:

1.    Attending will provide patient specific information to resident after patient is accepted

2.   MRN number will be provided by PPU at time of acceptance if patient is in our system

3.   If MRN not originally know, the resident will need to call PPU at 9-2337 to obtain the new MRN

4.   Once MRN is known (prior to patient arrival) resident will enter orders for “Special Acute CTA head and neck: stat” to an orders only encounter.

5.   When patient gets to the ED; Access will arrive the patient and place arm band



6.   Patient will be taken immediately to CT without being placed in ED room (unless medically unstable then will be placed in ED room as priority)



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