Chapter 8
Acute Ischemic Stroke
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Objectives
Discuss the links in the Stroke Chain of
Survival.
Discuss the brain’s arterial blood supply.
Describe the major types of stroke.
Explain what a transient ischemic attack
(TIA) is and how it differs from stroke.
Explain why rapid identification of stroke is
critical.
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Objectives (Cont.)
Differentiate between the hyperacute and acute phases of
stroke care.
Describe the initial emergency care for acute ischemic stroke.
Compare elements of acute stroke care facilities in the United
States.
State the recommended target times for key interventions
during the hyperacute phase of acute stroke care.
Give examples of medical conditions that mimic stroke.
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Introduction
Stroke is the second leading cause of death
worldwide, yearly deaths of about 5.5 million.
Each year, about 1 person every 40 seconds in the
United States experience a new or recurrent stroke.
Stroke Chain of Survival
1. Detection
2. Dispatch
3. Delivery
4. Door
5. Data
6. Decision
7. Drug
8. Disposition
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Pathophysiology and Anatomy
Strokes involving the carotid arteries are called anterior
circulation strokes or carotid territory strokes.
Strokes affecting the vertebral arteries are called posterior
circulation strokes or vertebrobasilar territory strokes.
Stroke Types
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Hemorrhagic Stroke
Blood in the subarachnoid space
may be the result of trauma or
nontraumatic causes such as a
ruptured cerebral aneurysm or an
arteriovenous malformation.
About 3% of all strokes are the
result of SAH.
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Ischemic Stroke (Cont.)
Thrombotic
Embolic
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Ischemic Penumbra
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Transient Ischemic Attack
A transient episode of neurologic dysfunction caused
by focal brain, spinal cord, or retinal ischemia,
without acute infarction
Important warning signs of acute stroke
Most last less than 2 hours, but prolonged episodes
do occur
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Initial Assessment and Management
Stabilize the patient’s airway, breathing, and
circulation (ABCs).
Ask when the patient was last known to be symptom-
free (ie, last known normal or last known-well time).
Collect and document all medications that the patient
is currently taking.
Ascertain if the patient has a history of conditions
that increase the likelihood that his or her symptoms
are caused by stroke.
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Prehospital Assessment and Management
(Cont.)
Cincinnati Prehospital
Face Arm Speech Test
Stroke Scale
Three Ds Facial droop
Drift (arm) Arm drift
Droop (facial Speech (dysarthria
weakness) and aphasia)
Dysarthria (slurred Time of onset
speech)
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Stroke Centers
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Stroke Centers
Acute stroke care in the United States consists of a
tiered system of hospitals
Non-stroke hospitals
Acute stroke–ready hospitals
Primary stroke centers (PSCs)
Comprehensive stroke centers (CSCs)
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Stroke Target Times
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Triage and Initial Evaluation
Be familiar with both typical and unusual stroke presentations.
Ensure that the patient has a secure airway and adequate
breathing.
Assess vital signs, including oxygen saturation.
Give oxygen if needed to maintain an oxygen saturation above
94%.
Supplemental oxygen is not recommended in nonhypoxic patients with
acute ischemic stroke.
Perform a fingerstick glucose test; give dextrose if the blood
glucose is less than 60 mg/dL.
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Triage and Initial Evaluation (Cont.)
Establish a minimum of two IV lines if it is
anticipated that the patient will receive fibrinolytic
therapy.
All patients with suspected acute stroke should
receive continuous ECG monitoring.
Monitoring should be continued for at least the first 24
hours after stroke.
Obtain a 12-lead ECG.
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Patient History
Verify the patient’s last known-well time.
Review the patient’s past medical history and
determine the presence of stroke risk factors.
Find out the medications the patient is currently
taking and his or her allergies to medications.
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Physical Examination
When performing a physical examination,
consider the presence of conditions that mimic
stroke.
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Conditions That Mimic Stroke
Bell’s palsy Encephalitis, meningitis
Central nervous system Hypertensive
abscess or tumor encephalopathy
Complicated migraine Metabolic disorders
Concussion with head Positional vertigo
injury Seizures
Conversion disorder Subdural hematoma
Drug toxicity Wernicke’s
Eclampsia encephalopathy
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Neurologic Examination
Perform a brief neurologic screening assessment
using a validated stroke scale.
If the initial history, physical examination, and
neurologic examination are suggestive of stroke, the
stroke team should be mobilized.
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Laboratory Studies for Suspected Stroke
Activated partial thromboplastin time
Cardiac biomarkers; troponin is preferred
Complete blood count, including platelet count
Prothrombin time or international normalized ratio
Renal function tests
Serum electrolytes
Serum glucose
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Brain Imaging
A noncontrast brain CT or brain MRI scan should be
obtained for all patients with suspected acute
ischemic stroke to confirm or exclude the presence of
cerebral hemorrhage.
Brain imaging should be completed within 25
minutes and interpreted within 45 minutes of
emergency department arrival.
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Non contrast CT scan
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Non contrast CT scan
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Non contrast CT scan
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MRI
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CT PERFUSION IMAGING
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IV Fibrinolysis
Fibrinolytic therapy with IV tPA is recommended for
selected patients who may be treated within 3 hours
of onset of ischemic stroke.
The AHA recommends that physicians review current
inclusion and exclusion criteria to determine patient
eligibility.
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IV Fibrinolysis (Cont.)
IV tPA is recommended for administration to a select
group of eligible patients who present within a 3- to
4.5-hour window after the onset of acute stroke
symptoms.
The eligibility criteria for treatment in this time frame
are similar to those for patients treated within 3 hours
of symptom onset, with additional exclusion criteria.
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Management of Mild Stroke
Avoid the 5 “H”
Hypotension
Hypoxemia
Hypoglycemia
HyperthermiaA
Management of Mild Stroke
Avoid the 5 “H”
Hypotension
Hypoxemia
Hypoglycemia
HyperthermiaA
Management of Mild Stroke
Avoid the 5 “H”
Hypotension
Hypoxemia
Hypoglycemia
HyperthermiaA
Management of Moderate Stroke
Avoid the 5 “H”
Hypotension
Hypoxemia
Hypoglycemia
HyperthermiaA
Management of Severe Stroke
Avoid the 5 “H”
Hypotension
Hypoxemia
Hypoglycemia
HyperthermiaA
Other Therapies
Intraarterial (IA) fibrinolysis
Mechanical thrombectomy
Balloon angioplasty with or without stent placement
These therapies require stroke centers with the
resources and physician expertise to safely perform
these procedures.
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Questions?
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Other Therapies
Intraarterial (IA) fibrinolysis
Mechanical thrombectomy
Balloon angioplasty with or without stent placement
These therapies require stroke centers with the
resources and physician expertise to safely perform
these procedures.
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Questions?
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