Part 11: Adult Stroke

2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care
Edward C. Jauch, Co-Chair*; Brett Cucchiara, Co-Chair*; Opeolu Adeoye; William Meurer;
Jane Brice; Yvonne (Yu-Feng) Chan; Nina Gentile; Mary Fran Hazinski

N early 15 years of increased stroke education and orga-
nization has produced significant strides in public
awareness and development of stroke systems of care. De-
American Stroke Association (ASA) guidelines for the manage-
ment of acute ischemic stroke.3,6,7

spite these successes, though, each year 795 000 people suffer Management Goals
a new or repeat stroke, and stroke remains the third leading The overall goal of stroke care is to minimize acute brain injury
cause of death in the United States.1 Many advances have and maximize patient recovery. The time-sensitive nature of
been made in stroke prevention, treatment, and rehabilitation, stroke care is central to the establishment of successful stroke
but arguably the greatest gains have been in the area of stroke systems, hence the commonly used refrain “Time is Brain.” The
systems of care. Integrating public education, 911 dispatch, AHA and ASA have developed a community-oriented “Stroke
prehospital detection and triage, hospital stroke system de- Chain of Survival” that links specific actions to be taken by
velopment, and stroke unit management have led to signifi- patients and family members with recommended actions by
cant improvements in stroke care. Not only have the rates of out-of-hospital healthcare responders, ED personnel, and in-
appropriate fibrinolytic therapy increased over the past 5 hospital specialty services. These links, which are similar to
years, but also overall stroke care has improved, in part those in the Adult Chain of Survival for victims of sudden
through the creation of stroke centers.2 To achieve further cardiac arrest, include rapid recognition of stroke warning signs
improvement in reducing the burden of stroke, healthcare and activation of the emergency response system (call 911);
providers, hospitals, and communities must continue to de- rapid EMS dispatch, transport, and prehospital notification;
velop systems to increase the efficiency and effectiveness of triage to a stroke center; and rapid diagnosis, treatment, and
stroke care.3 The “D’s of Stroke Care” remain the major steps disposition in the hospital.
in diagnosis and treatment of stroke and identify the key The AHA ECC stroke guidelines focus on the initial out-of-
points at which delays can occur.4,5 hospital and ED assessment and management of the patient with
acute stroke as depicted in the algorithm Goals for Management
● Detection: Rapid recognition of stroke symptoms of Patients With Suspected Stroke (Figure). The time goals of
● Dispatch: Early activation and dispatch of emergency the National Institute of Neurological Disorders and Stroke
medical services (EMS) system by calling 911 (NINDS)8 are illustrated on the left side of the algorithm as
● Delivery: Rapid EMS identification, management, and clocks. A sweep hand depicts the goal in minutes from ED arrival
transport to task completion to remind the clinician of the time-sensitive
● Door: Appropriate triage to stroke center nature of management of acute ischemic stroke.
● Data: Rapid triage, evaluation, and management within the The sections below summarize the principles and goals of
emergency department (ED) stroke system development and emergency assessment and man-
● Decision: Stroke expertise and therapy selection agement, as well as highlight new recommendations and training
● Drug: Fibrinolytic therapy, intra-arterial strategies issues. The text refers to the numbered boxes in the algorithm.
● Disposition: Rapid admission to stroke unit, critical-care unit
Stroke Systems of Care
This chapter summarizes the early management of acute The regionalization of stroke care was not widely considered
ischemic stroke in adult patients. It describes care from out-of- in the era before availability of effective acute therapies. With
hospital therapy through the first hours of in-hospital therapy. the NINDS recombinant tissue plasminogen activator (rtPA)
For additional information about the management of acute trial, the crucial need for local partnerships between academic
ischemic stroke, see the American Heart Association (AHA)/ medical centers and community hospitals became a reality.9

The American Heart Association requests that this document be cited as follows: Jauch EC, Cucchiara B, Adeoye O, Meurer W, Brice J, Chan Y-F,
Gentile N, Hazinski MF. Part 11: adult stroke: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2010;122(suppl 3):S818 –S828.
*Co-chairs and equal first co-authors.
(Circulation. 2010;122[suppl ]:S818 –S828.)
© 2010 American Heart Association, Inc.
Circulation is available at DOI: 10.1161/CIRCULATIONAHA.110.971044

Downloaded from at VA MED CTR BOISE on August 20, 2015

prehospital providers to triage patients with suspected stroke ment on primary stroke centers with recommendations for to designated stroke centers. In 2000 the Brain Attack Coalition provided a descrip. an area where further improvement is Downloaded from http://circ. There. of primary stroke centers and comprehensive stroke centers. and 3 centers is rational and quite tion of “primary stroke centers.7 The logic of having a multitiered Substantial progress has been made toward regionalization system such as that provided for trauma was evident. in an organized fashion. even in densely populated metropolitan centers.6 Following the establishment accuracy of dispatch. in 2005 the Brain Attack Coalition followed the state. Several states have passed legislation requiring fore. Goals for management of patients with suspected stroke. This is contingent on the comprehensive stroke centers. 2.ahajournals. This stroke-prepared hospital can access stroke Food and Drug Administration (FDA) approved rtPA for expertise via telemedicine. Jauch et al Part 11: Adult Stroke S819 at VA MED CTR BOISE on August 20. 2015 . The comparison with a trauma stroke. system with Level 1. of stroke care. The time-sensitive nature of stroke requires such an approach.” which would ensure that best intuitive to emergency care providers familiar with such practices for stroke care (acute and beyond) would be offered configurations. The idea of a the new concept of a stroke-prepared hospital has recently “stroke-prepared” hospital emerged after the United States emerged.

such as pronator drift. Educational efforts need to couple the facial smile or grimace.38 After receiving training in use of a EMS systems of care include both 911 emergency medical stroke assessment tool.35. or emergency nursing can also assist in with the other this process by determining which hospitals in their commu. or sudden severe headache then identify asymmetry in any of 3 examination categories: with no known cause. history of seizures. LOE B). a sensitivity of 59% and a specificity of 89% when scored by arm. the time of onset of symptoms is defined as the last for the use of air medical transport for patients with acute time the patient was observed to be normal.23 sensitivity and specificity. and just over half of all victims Stroke Assessment Tools of acute stroke use EMS for transport to the hospital. 2010 needed. It is imperative patients with stroke increased to 86% to 97%. perform on distance and the hospital’s stroke capability.33 Another assessment tool.14 ● Normal—patient uses correct words with no slurring ● Abnormal—patient slurs words.17–21 EMS providers can identify stroke patients with reasonable Stroke knowledge among the lay public remains poor.34. 2015 . may be helpful) stroke networks. This time represents time zero for the patient. trouble speaking or understanding. uses the wrong words.10.7. especially on one side of the body.22. dizziness. the probability of a Stroke Warning Signs stroke is 72%.40 We that the stroke system of care provide education and training recommend that all paramedics and emergency medical to 911 and EMS personnel to minimize delays in prehospital technicians-basic (EMT-basic) be trained in recognition of dispatch. Current literature suggests that 911 telecommunicators do not recognize stroke Prehospital Management and Triage (Box 2) well and that the use of scripted stroke-specific screens As with any other time-sensitive acute illness. sudden prehospital providers. ground transportation.37.11. EMS providers stroke and determine the most appropriate destination based must be able to support cardiopulmonary function. for 911 telecommunicators. prehospital notification should be per- vided within the first few hours from onset of symptoms. Most strokes occur at home.36 call 911.9. patch to patients with stroke symptoms. The presence of a single abnormality on the CPSS has stroke include sudden weakness or numbness of the face. ● Abnormal— one side of face does not move as well as the other side alization. Emergency medical tele. paramedic sensitivity for identifying dispatch centers and EMS response personnel. and speech abnormal- message is clear and succinct.35. especially in regions with ● Normal— both sides of face move equally relatively high population density and large critical mass of stroke centers to effectively create a model for stroke region. With standard training in stroke recognition. The signs and symptoms of ities. sudden trouble requires that the provider rule out other causes of altered level seeing in one or both eyes. or is unable to Stroke Recognition and EMS Care (Box 1) speak Interpretation: If any 1 of these 3 signs is abnormal. abbreviated out-of-hospital screen- communicators must identify and provide high-priority dis.13. establish time of onset of symptoms Downloaded from at VA MED CTR BOISE on August 20. As with rapid stroke assessment.16 formed to ensure appropriate activation of stroke resources. assessment. ing tool such as the CPSS or LAPSS (Class I.28 Studies are ongoing to providers must perform an initial assessment and intervene if investigate the effectiveness of such a stroke assessment tool necessary to provide cardiopulmonary support. hypoglycemia) and loss of balance or coordination. the LAPSS. Regional the patient wakes from sleep or is found with symptoms of a stroke resources work with EMS agencies to establish criteria stroke. Community and pro- (CPSS)31–34 (Table 1) or the Los Angeles Prehospital Stroke fessional education is essential22.S820 Circulation November 2. and transport. The Cincinnati Prehospital Stroke Scale is crucial for improvement of patient outcomes.30 for stroke.36. Abnormal speech (have the patient say “you can’t teach an old dog new nity offer care concordant with the Brain Attack Coalition tricks”) recommendations for primary stroke centers. grip.ahajournals. stroke using a validated.12 Although a large proportion of the US population Arm drift (patient closes eyes and holds both arms straight out for 10 is now within close proximity to a stroke center. The LAPSS knowledge of the signs and symptoms of stroke with action— has a sensitivity of 93% and a specificity of 97%. of consciousness (eg. The EMS provider checks for 3 physical fibrinolytic therapy.25–27 Patient education efforts are most effective when the findings: facial droop.11 Efforts have Facial droop (have patient show teeth or smile) been strong in many regions. air medical services may be used.39.24 and has successfully Screen (LAPSS). arm weakness. sudden trouble walking. ● Normal— both arms move the same or both arms do not move at all Additional work is needed to expand the reach of regional (other findings. In addition.10 The integration of EMS into regional stroke models Table 1. prehospital during a 911 call may be helpful.29. using abbreviated out-of-hospital These factors can delay EMS access and treatment. paramedics demonstrated a sensitivity of 61% to 66% for identifying 911 and EMS Dispatch patients with stroke. resulting tools such as the Cincinnati Prehospital Stroke Scale in increased morbidity and mortality. it is not clear seconds) how many stroke patients arrive at stroke-prepared hospitals. Identifying clinical signs of possible stroke is important because recanalization strategies (intravenous [IV] fibrinoly- sis and intra-arterial/catheter-based approaches) must be pro. ● Abnormal— one arm does not move or one arm drifts down compared emergency medicine. and arm strength. If potentially long. confusion.36 The CPSS is based on physical exam- increased the proportion of stroke patients treated with ination only. or leg.15. providers must clearly establish the time of onset of In settings where ground transport to a stroke center is symptoms. Healthcare professionals working in EMS.

stroke within 10 minutes of arrival in the ED. En route to the facility. over the CT scan but may identify a recent acute myocardial ceiving hospital should define its capability for treating patients infarction or arrhythmias (eg. The plan should detail the roles of healthcare professionals in the care of patients with acute stroke Assessment (Box 4) and define which patients will be treated with fibrinolytic The treating physician should review the patient’s history and therapy at that facility and when transfer to another hospital with verify time of onset of symptoms. studies examining the difference in rates of rtPA administra.ahajournals. porting patients directly to a stroke center has undergone breathing. oxygen saturation ⬍94%) stroke patients (Class survival rate. there are no data to support in managing stroke. to the most appropriate receiving hospital. stroke to appropriate facilities.50. atrial fibrillation) as the cause with acute stroke using the definitions established for stroke. 2015 . including bradycardia. ED staff should are transported directly to stroke centers. EMS. LOE C).7 and should communicate this information to premature atrial or ventricular contractions. These blood pressure is not recommended (Class III.50 Recently promptly identify and treat hypoglycemia. functional outcome. When such a facility is available within a EMS providers should consider transporting a witness.41– 44 LOE B). On arrival ED personnel should establish or confirm IV tion after implementation of a hospital bypass protocol for access and obtain blood samples for baseline studies (eg. The combination of tals are within similar transport distances.59 – 62 document consistent improvement in 1-year hypoxemic (ie. General care rapy. and provide prearrival notification stroke patients directly to designated stroke centers (Class I.46 – 48 Bypass of community hospitals in favor of trans. LOE B). or caregiver with the patient to verify the time of hospitalization should be admitted there (Class I. LOE C) or those with unknown oxygen saturation.63 hospital is capable of organizing the necessary resources to There is general agreement to recommend cardiac monitoring safely administer fibrinolytic therapy.41.48 Each re.65– 67 This may require a dedicated stroke unit is appropriate. stroke symptom onset. results should be relevant to the outcome of dedicated stroke units staffed with experienced multidisciplinary teams in the Transport and Destination Hospital United States. LOE C). and Initial ED Assessment and Stabilization (Box 3) provide prehospital notification. EMS personnel poor perfusion and hypoxemia will exacerbate and extend should consider triage to the stroke center with the highest ischemic brain injury and has been associated with worse capability of stroke care. order an emer- activation of stroke teams by EMS. Investigators in New York. stroke centers3.50. and family The role of stroke centers and in particular stroke units members to establish the time that the patient was last known continues to be defined. but a growing body of evi.51 gent computed tomography (CT) scan of the brain. Although the studies reported were initiation of hypertension intervention in the prehospital conducted outside the United States at in-hospital units that environment.47. moni. hypoventilation. every hospital with an ED during the first 24 hours of evaluation in patients with acute should have a written plan that is communicated to EMS ischemic stroke to detect atrial fibrillation and potentially systems describing how patients with acute stroke are to be life-threatening arrhythmias. coagulation studies. blood glucose).6.64 managed in that institution.52–58 indicates a favorable benefit from triage of and transport the patient. incorpo- Downloaded from http://circ. Protocols should be used in the ED to minimize delay to Prearrival hospital notification by the transporting EMS definitive diagnosis and therapy: “Time is Brain. and quality of life when I. and activate the EMS providers must rapidly deliver the patient to a medical stroke team or arrange for consultation with a stroke expert. Jauch et al Part 11: Adult Stroke S821 (or the last time the patient was known to be normal). All have found significantly larger percentages of complete blood count. may not be necessary. primary stroke centers. Although not every atrioventricular conduction block.46. prehospital intervention for outcomes were apparent very early in stroke care.49. includes assessment. Administration of oxygen to hypoxemic patients with stroke Canada. If the patient is hemodynamically prepared hospitals. providers should continue to support cardiopulmonary function. and comprehensive stable. circulation).org/ at VA MED CTR BOISE on August 20. witnesses. interviewing out-of-hospital providers. triage dence47. and Australia have performed before-and-after (oxygen saturation ⬍94%) is recommended (Class I. family reasonable transport interval. to be normal. and evaluation of baseline vital signs. facility capable of providing acute stroke care and provide A 12-lead electrocardiogram (ECG) does not take priority prearrival notification to the receiving facility. Neurologic assessment is performed. Unless the patient is hypotensive (systolic provided both acute care and rehabilitation. check blood glucose if possible. investigations that merit attention. or asymptomatic the EMS system and the community. The ED physician investigators have begun to examine the impact of direct should perform a neurologic screening assessment. treatment of other arrhythmias. When multiple stroke hospi- and (rarely) neurogenic pulmonary edema.31. outcome from stroke.”43 As a unit has been found to significantly increase the percentage goal. patients hospitalized with acute stroke are cared for in a Although blood pressure management is a component of dedicated stroke unit by a multidisciplinary team experienced the ED care of stroke patients.49. cardiopulmonary support (airway. the improved blood pressure ⬍90 mm Hg). preplan to enable EMS providers to direct patients with acute mise from aspiration. ED personnel should assess the patient with suspected of patients with acute stroke who receive fibrinolytic the. EMS systems should establish a stroke destination Patients with acute stroke are at risk for respiratory compro. Italy.45 Both out-of-hospital and in-hospital Multiple randomized clinical trials and meta-analyses in medical personnel should administer supplemental oxygen to adults50. stroke patients who require member. of an embolic stroke. If not patients with ischemic stroke treated with rtPA when patients already identified in the prehospital setting. upper airway obstruction. In-Hospital Care tor neurologic status.

Centers may perform more uncommon (0. or rhage.5 mg/hr every Fibrinolytic Therapy (Boxes 6.72 If the patient remains a candidate for fibrinolytic therapy Table 3. Management of blood pressure during and after rtPA or other acute If hemorrhage is not present on the initial CT scan and the reperfusion therapy: patient is not a candidate for fibrinolytic therapy for other ● Monitor blood pressure every 15 minutes for 2 hours from the start of reasons. 8.ahajournals. systolic blood pressure centers. the physician should discuss the risks and potential Stroke Patients Who Are Not Potential Candidates for Acute benefits of the therapy with the patient or family if available Reperfusion Therapy (Box 10). consider exclusion criteria for IV fibrinolytic therapy (Tables 4 and 5) sodium nitroprusside and perform a repeat neurologic examination incorporating the NIHSS or CNS. 2015 . acute hypotension. noncontrast CT scan may not indicate signs of brain ischemia. Careful dose calculation and removal of Consider blood pressure reduction as indicated for other concomitant organ excess rtPA help prevent inadvertent administration of excess system injury rtPA. if the patient/family elects to Consider lowering blood pressure in patients with acute ischemic stroke if proceed with fibrinolytic therapy.4%) and usually occurred at the site of femoral advanced neurologic imaging (multimodal magnetic reso. lower to 3 If the CT scan shows no evidence of intracerebral hemor- mg/hr. and 10) 5–15 minutes. ● Labetalol 10 mg IV followed by continuous IV infusion 2– 8 mg/min. or ● Nicardipine IV 5 mg/h. enalaprilat.64 ASA website: www. and be prepared to monitor and treat any potential ⱕ185 mm Hg systolic and ⱕ110 mm Hg diastolic to limit the complications. function is rapidly improving to rating either the National Institutes of Health Stroke Scale normal and is near baseline).2% of 2639 patients treated.70 have documented a higher likelihood first day of good to excellent functional outcome when rtPA is Downloaded from http://circ. administration of fibrinolytics (NIHSS) or the Canadian Neurological Scale (CNS) (see the may not be required (Box 6). This complication val from onset of stroke until effective treatment of stroke occurred in 6.15.4% of the 312 patients treated in the NINDS with rtPA is limited. begin the rtPA bolus and systolic blood pressure ⬎220 mm Hg or diastolic blood pressure infusion as quickly as possible and begin the stroke pathway ⬎120 mm Hg of care (see below). and systemic major systemic bleeding was within 45 minutes of ED arrival. The physician must verify that there are no dependent on fibrinolytic eligibility. 2010 Table 2.69 During the first few hours of an ischemic stroke the ● Nicardipine IV 5 mg/hr. Emergent CT or MRI scans of Patient otherwise eligible for acute reperfusion therapy except that blood patients with suspected stroke should be promptly evaluated pressure is ⬎185/110 mm Hg by a physician with expertise in interpretation of these ● Labetalol 10 –20 mg IV over 1–2 minutes. consider administration of aspirin (Box 9) either rtPA therapy. Consult a If blood pressure is not maintained at or below 185/110 mm Hg. titrate up to desired effect by 2. trials9 and 4. Because the maximum inter. and then every hour rectally or orally after the patient is screened for dysphagia for 16 hours (see below). then every 30 minutes for 6 hours. the appropriate patient is not a candidate for fibrinolytic therapy. CT perfusion. blood pressure must be patient. As with all medications.68 clinical practice showed a symptomatic hemorrhage rate of 5. fibrinolytics have potential ad- Management of hypertension in the stroke patient is verse effects. etc) may be considered when (Boxes 6 and 8). the patient may be a candidate for fibrinolytic therapy ● Other agents (hydralazine. Acute Ischemic Stroke Patients Who Are Potential Candidates but obtaining these studies should not delay initiation of IV for Acute Reperfusion Therapy rtPA in eligible patients. Approach to Arterial Hypertension in Acute Ischemic (Box 8).71 Other complications include Imaging (Box 5) orolingual angioedema (occurs in approximately 1. Admit the patient to a stroke unit (if available) If systolic BP 180 –230 mm Hg or diastolic BP 105–120 mm Hg for careful monitoring (Box 11).6% of the 1135 patients treated in 60 Canadian sion above these levels (ie. maximum 15 mg/h The treating physician should review the inclusion and If blood pressure not controlled or diastolic BP ⬎140 mm Hg. maximum 15 mg/hr. In one the patient’s arrival in the ED and should be interpreted large prospective registry.70. puncture for acute angiography.S822 Circulation November 2. do not neurologist or neurosurgeon and consider transfer as needed administer rtPA for appropriate care (Box 7). If hemorrhage is noted on the CT scan. consider the risks and benefits to the eligible for fibrinolytic therapy. The major complication of IV rtPA for stroke risk of bleeding complications. when desired blood pressure reached.70 A meta-analysis of 15 published case series on the ⬎185 mm Hg or diastolic blood pressure ⬎110 mm Hg) will open-label use of rtPA for acute ischemic stroke in general not be eligible for IV rtPA (Tables 2 and 3).5 mg/hr every 5–15 minutes.5% of Ideally the CT scan should be completed within 25 minutes of patients). For patients potentially exclusion criteria. Potential Approaches to Arterial Hypertension in nance imaging [MRI].org/ at VA MED CTR BOISE on August 20. is symptomatic intracranial hemorrhage. or studies. titrate up by 2. and CT angiography). If the patient’s neurologic signs are spontaneously clearing (ie. Typically neither anticoagulant nor antiplatelet treat- ● Acute myocardial infarction ment may be administered for 24 hours after administration ● Congestive heart failure of rtPA until a repeat CT scan at 24 hours shows no ● Acute aortic dissection hemorrhagic transformation.strokeassociation. After this discussion. may repeat ⫻1. A reasonable target is to lower blood pressure by 15% to 25% within the Several studies9. most patients with sustained hyperten.

Additional Inclusion and Exclusion Characteristics of With Ischemic Stroke Who Could Be Treated With rtPA Within 3 Patients With Ischemic Stroke Who Could Be Treated With rtPA Hours From Symptom Onset From 3 to 4. INR. These results have been supported by a subsequent ment (Class I. a knowledgeable team. ● Seizure at onset with postictal residual neurologic impairments randomized trial (ECASS-3) that specifically enrolled pa- ● Major surgery or serious trauma within previous 14 days tients between 3 and 4. ● Evidence of active bleeding on examination Recent guideline revisions have modified the original FDA criteria.5-hour window has not yet been FDA approved. LOE B). ECASS-3 eligibility criteria is recommended if rtPA is tals with a stroke protocol that rigorously adheres to the administered by physicians in the setting of a clearly defined eligibility criteria and therapeutic regimen of the NINDS protocol.78 Data ● Only minor or rapidly improving stroke symptoms (clearing spontaneously) supporting treatment in this time window come from a large. including but not limited to ● Onset time is either witnessed or last known normal –Platelet count ⬍100 000/mm3 ● In patients without recent use of oral anticoagulants or heparin. and institutional commit- protocol.74 verifying increased rate of complications. and PT. with a baseline NIHSS ⬎25. resulting in aPTT ⬎upper limit of with rtPA can be initiated before availability of coagulation study results normal but should be discontinued if INR is ⬎1. FDA.16. and institutional commitment to. international normalized ratio.5 Hours From Symptom Onset Inclusion criteria Inclusion criteria ● Diagnosis of ischemic stroke causing measurable neurologic deficit ● Diagnosis of ischemic stroke causing measurable neurologic deficit ● Onset of symptoms ⬍3 hours before beginning treatment ● Onset of symptoms 3 to 4. international normalized ratio. use of IV rtPA within the 3. treatment with rtPA can ● CT demonstrates multilobar infarction (hypodensity ⬎1/3 cerebral be initiated before availability of platelet count but should be discontinued hemisphere) if platelet count is ⬍100 000/mm3 Relative exclusion criteria rtPA indicates recombinant tissue plasminogen activator.78 Administration of IV rtPA to within 3 hours of onset of symptoms. except that ● Recent acute myocardial infarction (within previous 3 months) ECASS-3 excluded patients older than 80 years of age. suggesting that clinical Downloaded from http://circ. Inclusion and Exclusion Characteristics of Patients Table 5. Additional analyses experience in. A physician with expertise in acute stroke care may modify this list ● Acute bleeding diathesis.75 Evidence from prospective randomized in both community and tertiary care hospitals in clinical trials studies9. Consider risk to benefit of rtPA administration carefully if any of these relative outcome.80 Failure to adhere to protocol is associated with an investigators confirmed the validity of the results. treatment –Heparin received within 48 hours. National Institutes of Health Stroke Scale.15. prothrombin time.7 mmol/L) ● In patients without history of thrombocytopenia.81 There is a relation- even when imbalances in the baseline stroke severity among ship between violations of the NINDS treatment protocol and treatment groups is corrected. had a combination of diabetes and prior stroke.77 increased risk of symptomatic intracerebral hemorrhage and Treatment of carefully selected patients with acute ische.71 In Germany there was an increased risk of death after mic stroke with IV rtPA between 3 and 4. Food Recent experience suggests that under some circumstances—with careful and Drug Administration.ahajournals. taking oral anticoagulants.76 in adults also documents a greater likelihood of rtPA may be difficult to replicate in hospitals with less of benefit the earlier treatment is begun. Jauch et al Part 11: Adult Stroke S823 Table 4. NIHSS. particularly the risk of that improved outcomes in the rtPA treatment arm persist symptomatic intracranial hemorrhage. acute stroke of the original NINDS data by an independent group of care.79. or who rtPA indicates recombinant tissue plasminogen activator. death. INR.5 hours after onset administration of rtPA for acute ischemic stroke in hospitals of symptoms has also been shown to improve clinical that treated ⱕ5 patients per year. although the degree of clinical benefit is smaller contraindications is present than that achieved with treatment within 3 hours. 2015 . 1-year follow-up study.7 or PT is elevated by local –Current use of anticoagulant with INR ⬎1.5 hours before beginning treatment ● Age ⱖ18 years Exclusion criteria Exclusion criteria ● Age ⬎80 years ● Head trauma or prior stroke in previous 3 months ● Severe stroke (NIHSS ⬎25) ● Symptoms suggest subarachnoid hemorrhage ● Taking an oral anticoagulant regardless of INR ● Arterial puncture at noncompressible site in previous 7 days ● History of both diabetes and prior ischemic stroke ● History of previous intracranial hemorrhage Notes ● Elevated blood pressure (systolic ⬎185 mm Hg or diastolic ● The checklist includes some FDA-approved indications and ⬎110 mm Hg) contraindications for administration of rtPA for acute ischemic stroke. At present. aPTT. activated partial thromboplastin time. Criteria for inclusion in days) ECASS-3 were similar to the NINDS criteria. as well ● Recent gastrointestinal or urinary tract hemorrhage (within previous 21 as a meta-analysis of prior trials.5 hours after symptom onset. consideration and weighing of risk to benefit—patients may receive fibrinolytic therapy despite 1 or more relative contraindications.73 reanalysis of the NINDS data. prothrombin time.7 or PT ⬎15 seconds laboratory standards ● Blood glucose concentration ⬍50 mg/dL (2. These results are patients with acute ischemic stroke who meet the NINDS or obtained when rtPA is administered by physicians in at VA MED CTR BOISE on August 20.74. and PT.74 and It is important to note that the superior outcomes reported a meta-analysis.79. although it is recommended by a current administered to adult patients with acute ischemic stroke AHA/ASA science advisory.

Downloaded from http://circ. a meta-analysis83– 87 have demonstrated improved outcome from however. deep gist. an emergent CT scan is re. administered at a rate of approxi. posterior circulation stroke. if appropriate for the medication. management of hypertension. Current recom. administration of anticonvulsants is recom- responsible for the deterioration. Medications may be given in applesauce or jam. These mately 75 to 100 mL/h.100 –103 where resources and expertise are available. aspiration pneumonia. If the patient can sip and swallow without General stroke care. If there are no signs of coughing or aspiration optimal glucose control. nity for a return to previous quality of life and decrease the istration of IV normal saline boluses may be appropriate. prophylaxis is not recommended. To date. intra-arterial administration of fibrinoly. careful admin.104 In patients with severe edema should be started immediately as indicated. In efforts will provide stroke patients with the greatest opportu- stroke patients who may be relatively hypovolemic. and swallow. LOE C). including monitoring of blood screening evaluation involves asking the patient to sip water pressure and neurologic status and physiologic optimization.82 There is also strong evidence to avoid all come. however. Normal saline. there are limited data on the role of hypothermia specific to acute General Stroke Care ischemic stroke.88 –95 but there is no direct treated with fibrinolytic therapy and produce excellent clini. and begin tion (Table 3).72 Adding a dedicated stroke team to a community Hyperglycemia is associated with worse clinical outcome in hospital can increase the number of patients with acute stroke patients with acute ischemic stroke. overall societal burden of stroke. In carefully selected patients. then it is safe for the patient to have a tional support.5°F]). ideally within 3 hours from arrival.96. Thus. administration of intra-arterial fibrinolytics is reasonable (Class Temperature Control I. the utility of administration of IV or subcutaneous insulin to lower blood glucose in patients with acute ischemic intra-arterial fibrinolysis. patients should be admitted as quickly as Additional stroke care includes support of the airway.99 Current AHA/ASA recommendations call for the to ensure optimal patient outcomes. the patient is asked to take a large gulp of water cludes prevention of hypoxia. Any venous thrombosis. and nutri. centered on physiologic optimization. These findings insulin treatment of hyperglycemia in other critically ill show that it is important to have an institutional commitment patients. LOE C). and the positive effects of stroke unit the treatment of acute ischemic stroke (Class IIb.S824 Circulation November 2. more liberal acceptance of hypertension is recom. All patients with stroke should be screened for dysphagia Patients should be admitted to a stroke unit (if available) for before they are given anything by mouth. ultimate goal of stroke care is to minimize ongoing injury.8 If the patient’s genation and ventilation. such as aspirin rectally or. urinary tract infections) and initiation of patient who fails a swallow test may be given medications secondary stroke prevention. oxy- possible. Summary mendations for control of blood pressure in patients who receive Advances in stroke care will have the greatest effect on stroke IV rtPA or intra-arterial recanalization therapies are shown in outcome if care is delivered within a regional stroke system Table 2. evidence that active glucose control improves clinical out- cal outcomes. LOE B). care can persist for years. Hyperthermia in the setting of acute cerebral ischemia is asso- tics has not been FDA approved. fibrillation (VF) sudden cardiac arrest. maintenance of euthermia. stroke who are not candidates for standard IV fibrinolysis. from a at VA MED CTR BOISE on August 20. after 30 seconds. difficulty. and vital sign measurements. but for patients who expe- quired to determine if cerebral edema or hemorrhage is rience a seizure. Given the requirements for frequent neurologic assessment intravenously. provided no other comorbid conditions require interven.ahajournals.97 There is contradictory evidence for the benefit of delays and treat patients as soon as possible. mended. In those patients for whom recanalization is not designed to improve both efficiency and effectiveness. intramuscularly. 2015 . Additional efforts center on prevention of com. The benefits from treatment in a stroke Dysphagia Screening unit are comparable to the effects achieved with IV rtPA. Blood pressure management varies depending on whether or not fibrinolytic or intra-arterial therapies were used. in.98. is used to maintain euvolemia as needed. and nutritional support. ciated with increased morbidity and mortality and should be catheter-based thrombectomy is being performed at centers managed aggressively (treat fever ⬎37. emergently recanalize acute vascular occlusions. and in younger patients. secondary measures to maximize functional recovery.5°C [99. Treatment of hemorrhage or mended to prevent more seizures. The pending ASA Hypothermia has been shown to improve survival and functional acute ischemic stroke guidelines will provide greater detail about outcome in patients following resuscitation from ventricular intra-arterial strategies. or subcutaneously. At this time there is insufficient scientific Recent studies establish that stroke unit care is superior to care evidence to recommend for or against the use of hypothermia in in general medical wards. The planned. stroke. healthcare providers must observe for signs of increased Blood Pressure Management intracranial pressure. A simple bedside careful observation (Box 11). for patients with acute ischemic stroke when serum glucose is ⱕ185 mg/dL remains uncertain. especially after administration Other Stroke Management of IV rtPA. Seizure neurologic status deteriorates. 2010 experience is an important factor in ensuring adherence to Glycemic Control protocol. thickened diet until formally assessed by a speech patholo- plications associated with stroke (eg. use of insulin when the serum glucose level is greater than 185 Evidence from 3 prospective randomized studies in adults and mg/dL in patients with acute stroke (Class IIa.

Total Award to Temple. or 5% or more of the person’s gross income.000 2005–2010 NIH NINDS U01 NS40406-04 Albumin in Acute Ischemic Stroke (ALIAS) Trial. or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period. Total Award to Temple. Investigation of the effect of Pioglitazone on development of diabetes and stroke recurrence after ischemic stroke or TIA. †Significant. 2015 . which all members of the writing group are required to complete and submit. direct costs: $184. †Active Support: 5 NIH U01 None None None None None Department of Emergency Medicine NS044876–03. Perform research in the areas of EMS and stroke. direct costs: $225. Insulin Resistance Intervention after Stroke (IRIS) Trial. Perform clinical work in the emergency department. Downloaded from http://circ. *Modest.000 2008–2011 Mary Fran Vanderbilt University School of None None None None None None Hazinski Nursing— at VA MED CTR BOISE on August 20. AHA ECC Product Development–Senior Science Editor †Substantial consulting fees as a senior science editor for the AHA ECC Product Development. Jauch et al Part 11: Adult Stroke S825 Disclosures Guidelines Part 11: Stroke: Writing Group Disclosures Other Speakers’ Consultant/ Writing Group Research Bureau/ Ownership Advisory Member Employment Research Grant Support Honoraria Interest Board Other Edward C. This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire. Jauch Medical University of South NIH trials related to stroke None None None None None Carolina-Professor Brett Cucchiara University of Pennsylvania–Assistant †NIH RO1-migraine imaging None *Multiple CME None None *Occasionally Professor of Neurology research-significant talks at different serves as expert institutions witness for medicolegal cases Opeolu Adeoye University of Cincinnati–Assistant None None *Genentech EKR None None None Professor of Emergency Medicine Therapeutics and Neurosurgery William Meurer University of Michigan–Assistant None None None None None None Professor Jane Brice University of North Carolina: None None None None None None Associate professor in the department of emergency medicine. Human Serum Albumin will be compared to placebo on improving the 3 month outcome of ischemic stroke patients when administered within 5 hours of symptom onset. Teach in the School of Medicine–Associate Professor Yvonne (Yu-Feng) The Mount Sinai School of None None None None None None Chan Medicine–Assistant Professor of Emergency Medicine Nina Gentile Temple University–Professor. or (b) the person owns 5% or more of the voting stock or share of the entity.ahajournals.

S826 Circulation November 2. Pancioli A. Melluzzo S.119:107–115. Hurwitz AS. Leathley MJ. Acker JE III. Identifying interdisciplinary care of the acute ischemic stroke patient: a scientific stroke in the field. Haley EC Jr. accuracy of prehospital diagnosis of acute stroke. Mulligan D. Kothari R. 2010. Prehosp Emerg Care. Chan Shwayder P. 1999. 2005. Rosamond WD. Foraker RE. Alberts MJ. 2007. Meltzer NM. 2009. Liu T. Broderick J. Emergency medical P. Fieschi C. 33. Recommendations for the establishment of W. Emerg Med Clin North Am. Eckstein MK. Prehosp Emerg Care. Alexandrov AV. 1997. Isaacs M.40: Cincinnati Prehospital Stroke Scale by laypersons. Stranne SK. Stroke. von Kummer Prehosp Emerg Care. Daniels S. DE. eds. 1993. N Engl J Med. Stroke. Saver JL. Zachariah BS. hospital Stroke Scale: reproducibility and validity. Arnett DK. Brott T. Tissue plasminogen activator for acute ischemic stroke. Zorowitz RD. Frankel M.121:586 – 613. 10. Gorman M. Haley EC. Solis P. Temporal trends in public awareness of stroke: warning signs. BM.31:71–76. Tilley BC. Alberts MJ. Brice JH. Hock N. Schwamm LH. Jauch E. Brott TG. Evenson KR. Schwamm LH. Marler JR. Emr M. Schwamm LH. 1998. 2005. Heart Association. Evenson KR. Adeoye O. Prehosp Emerg Care. Kidwell CS. Spilker JA. 1995. Colby D. Groff J. 25. O’Connor R. Fazackerley J. acute stroke therapy: the TLL Temple Foundation Stroke Project. Starkman S. Stroke. Pepe PE. Morris DL. Bluhmki E. Gilpin BR. Staub L. 3102–3109. and 2003. Zorowitz RD. Alwell K. Lyden P. 37.26: Sand C. Bluhmki E. Stroke.21:43–55. King M. Saver JL. Lyden P. Bartholomew LK.33:160 –166. Kothari RU.2:106 –113. Stroke. Larrue V.4:187–199. Mo Med. Ellison SR. Miller R. Starkman S. Age Ageing. Curr 35. Morris DL. Care. logical Disorders and Stroke.27:141–145. 12. Emr M. Hazinski M. Weems K. Girgus M. 26. risk 4. 2009. Prehospital dispatch 15. Moyer P. Saver JL. Enhancing community delivery of tissue plasminogen activa- 8. Warren M. 17. Organizing regional stroke systems of care. eds. Pancioli A. Yancy CW. Walker MD. sensitivity in identifying stroke victims in the prehospital setting. Rapp K. Haley EC Jr. Eigel B. Leonard A. Arch Intern reduction: the American Heart Association’s strategic Impact Goal Med. Wahlgren N.9:19 –23. Roger V.ahajournals. Stranne SK. D-mystifying recognition and management of stroke. Frank J. Staub L. Stroke. Sorlie P. Kalra A. Corry MD. Booss J. Schwab RA. Eckstein M.8:384 –387. Cincinnati Pre- Stroke. 2000. JAMA. NINDS rt-PA stroke trials. Stroke knowledge 5. Panel on Emergency Medical Services Systems and the Stroke Council. Schroeder EB. 2008. Hadley MN. Federspiel W. Jones P. Lauer MS. Kissela B. 31. Identification and entry of the patient with acute cerebral infarction. von Kummer R. Levy Fonarow GC.38:3097–3115. Babcock T. Eckstein M. Isaacs SM. Hazinski M. 11.17:1192–1195. Robertson RM. Marler JR. Broderick J. Hamilton S. Broderick J.2:267–273. Acute stroke: current treatment and paradigms. 2009. 2015 . Labarthe D. Tex: American 2010. Guidetti D.163:2198 –2202. 40:1793–1802. Scott PA. Patel S. Chain of Recovery Writing EE. Prentiss SM. Ann Emerg Med. Brain Attack Coalition. Peterson E. Directed use of the Academy Medical Priority Dispatch System. Croft JB.3:207–210. Thrombolysis with alteplase 3 to 4. Crocco TJ. Levine SR. A compre- for patients hospitalized with acute stroke or transient ischemic attack. Shephard T. 21. N Engl J Med. Kissela 1078 –1091. 38. Walker MD. Schoeberl M. and retrospective analysis of the Los Angeles Prehospital Stroke Screen 14. Miller E. Overby BA. Grotta JC. Kothari R. Marler JR. 2009. assessment of stroke. Barsan W. Broderick J. Huang R. Kidwell CS. Broderick JP. Toni D. Magnis E. Johnston SC. Smith WS. Felberg RA. 2009. Brice JH.9:292–296. 1988. 2008. Jauch EC. Magnis Dis. Jones SP. Rodriguez D. Hong Y.283: increase acute stroke therapy. Todd HW. Gratton MC. Magdon-Ismail Z. Pancioli AM. Prospective validation of the Los Angeles prehospital statement from the American Heart Association. Eckstein M. 1999. triage. Bailey JR. Brott TG. Connors JJ. Jagoda A. 23. Duncan PW. services use by stroke patients: a population-based study. Sayre MR. Grotta at VA MED CTR BOISE on August 20. Dispatcher recognition of stroke using the National 30. Lu M. Smith R. 2005.4:986 –990. Lancet.40:2502–2506. Pancioli A. Summers D. Wojner AW. Davalos A. Rosamond WD. 2010 References R. Masoudi FA. Overby BA. Selman WR. Mergendahl WC. Albers Grotta JC. Starkman S.39:11–22. Am J Emerg Adams RJ. care. E. Improved paramedic 16. Liferidge AT. Donnan G. Morgenstern LB. Frequency and Larrabee H. Bartholomew LK. Emr M. care: recommendations from the American Stroke Association’s Task 22. Alwell K. 2004. Reeves MJ. Dallas. Cannon CP. Wentworth D. Paramedic and emergency department care of stroke: baseline G. 2009. Mitchell PH. 1996. MR. Grotta JC. Haines J. Machnig T. Park S. 2005. Circulation. 2911–2944. Morgenstern LB. Day D. Acker JE III. Levy DE. Horton KB. Evenson KR. Evenson KR. Persse D. Kleindorfer D. through 2020 and beyond. Lindsell C. Shephard TJ. Olinger CP. Emerg Cardiac Care. Early stroke recognition: medical services within stroke systems of care: a policy statement from developing an out-of-hospital NIH Stroke Scale. Saver JL. Smith WS. Chan W. the Guidelines–Stroke is associated with sustained improvement in care 20. 34. Latchaw RE. Association of outcome with data from a citywide performance improvement study. Design Opin Neurol. In: Cummins R. Burgin WS. Barsan WG. Setting New Directions for Stroke Care: tor in stroke through community-academic collaborative clinical Proceedings of a National Symposium on Rapid Identification and knowledge translation. 3. Schneider D. Tomaselli GF. Schubert GB. Prehosp Emerg Care. Fonarow GC. Kidwell CS. Corry MD. 19.7:8. Latchaw RE. J Stroke Cerebrovasc LM. Wilhelm M. Comprehensive overview of nursing and 36.153:2558 –2561. Ma OJ. Lewandowski C. Medeghri Z.5 hours after 1. Circulation. Liang L. Adams HP Jr. Nichol G. 2004. Ho PM. early stroke treatment: pooled analysis of ATLANTIS.2003:437– 482.40: stroke screen (LAPSS). Hacke W. 7.2:170 –175. Brice JH. Sustained benefit of a community and professional intervention to primary stroke centers. Flaherty Force on the Development of Stroke Systems.2:89 –95.33:373–378. 13. Barsan WG. Ability of laypersons Group. 1995. Brozman M. 1998. Brott T. Improving delivery of Attack Coalition. Johnson AM. Greenlund K. Ashbrock S. Pan W. Woo D. 2009. Dhingra A. Lees KR. Kwiatkowski T. 2004. Saldin K. Recommendations for the establishment of stroke systems of Med. Regional implementation of the stroke systems of care model: recom. (LAPSS).363:768 –774.27:115–136. Horton KB. Kleindorfer D.111: ML. to use the Cincinnati Prehospital Stroke Scale. Buck BH. Broderick JP. Schwamm LH. 39. Broderick JP. Field J. Schneider A. Floccare D. Moomaw CJ. Munn JW. Institute of Neurological Disorders and Stroke rt-PA Stroke Study 29. Ann Emerg Med. for comprehensive stroke centers: a consensus statement from the Brain Demchuk AM. 2009. Ensuring the chain of 2. Kaste M. Mozaffarian D. Bethesda. Rademacher E. of stroke and transient ischemic attack in the field. 28.36:1597–1616. Ellrodt G. Frankel MR. Viste KM. Calling emergency medical services for acute stroke: a study 9. Defining and 18. Rosamond WD. Lloyd-Jones DM. and awareness: an integrative review of the evidence. Appel LJ. ACLS: Principles and Practice. Hall K. Marler J. Marler JR. The National of 9-1-1 tapes. Mayberg Stroke. Smith recovery for stroke in your community. Stroke. Pancioli A. Simpson J. Get With Group. Brott T. Starke RD. et al. Md: National Institute of Neuro. 24. setting national goals for cardiovascular health promotion and disease Time of hospital presentation in patients with acute stroke. Brott T. Acad Emerg Med. Cawley CM. 1994. Hickenbottom SL. Gorelick Flaherty ML.333:1581–1587. Goldstein LB. 937–941. 2003. Int J Stroke. Kaste M. Downloaded from http://circ. and 6. Accuracy of paramedic identification mendations of the northeast cerebrovascular consortium. 2002. Jagoda A. Gropen T. Watkins CL. Horn L. Treatment of Acute Stroke. King Rose-DeRenzy JA. Curr factors. Arch Intern Med. 1998. Moomaw CJ. the American Heart Association/American Stroke Association Expert 1997. Schwamm LH. Morgenstern L. Labresh KA. Hacke W. Implementation strategies for emergency 32. Ultra-rapid identification. and treatment. Van acute ischemic stroke. Koroshetz W. Jenkinson AJ. Prehosp Emerg Care. Brass enrollment of stroke patients into clinical trials.12:411– 417. 2000.101:64 – 66. Hademenos G. 27. Wein TH. ECASS.359:1317–1329. Am J Crit Care. Prehosp Emerg 2027–2030. Saver JL. Shephard T. hensive review of prehospital and in-hospital delay times in acute stroke Circulation. Recommendations M. Khoury J.

Zhao S. Dunford J. Canadian 50. Harbaugh RE. acute stroke patient: making the right call. del Zoppo GJ. Stroke Unit Trialists’ Collabo. Clark MA. Riopelle RJ. Treatment of Acute Stroke. 67.34:e58 – e60.31: with acute ischemic stroke and the risk of in-hospital mortality: the 2920 –2924. 2002:CD000197. Villablanca P. Honeykutt LK. Page W. How do stroke units improve patient outcomes? A collaborative sys. Libman R. Brunet year. Clinical Cardiology Council. 78. Jauch EC. 1999. From research to the road: the devel. 1998. 44. O’Fallon WM. Stroke. Kasner SE. Vatankhah B. Early stroke treatment associated with better 58. Adelmann M. 2008. Guidelines for the early management of adults with ischemic stroke: a Levi CR. Rodriguez D. 2005. 55. improve care for ischemic stroke? Neurology. Kuhn J.40:3841–3844. plasminogen activator delivery in a comprehensive stroke center rehospital triage (resource document to NAEMSP position statement). community practice and patient care. Ingall TJ. 65. Jauch et al Part 11: Adult Stroke S827 40. Frankel MP. 2006. Azhar S. Schulzer M. Hertzberg VS. Daley MB. N Engl ischemic stroke intervention. Higashida RT. Russell genstern LB. Grubb RL. Chapman KM. 2000. Hachinski V. Neundoerfer B. Leifer D. Holtom D. community and rural stroke patients. Scott PA. Adams HP Jr. Lev MH. Floccare D. The impact of imbalances in baseline inpatient (stroke unit) care after stroke. Stroke Study. Marler JR. Langhorne P. Kwiatkowski T. Saver JL.340:1781–1787. Pepe PE. Frankel M. Tirschwell DL. J Med. Gunawardane R. 57. 2005. Mathews V. Yarbrough KL. Neurology. Alberts MJ. Warach S. 1991:29 –33. Kwiatkowski TG. Weaver DF. Stott DJ. Swor RA. A systems approach to immediate evaluation and management of ischemic stroke: a scientific statement from the Stroke Council of the hyperacute stroke. 2002. Wang YJ.45:377–384. Beckman J. 2000.99:810 – 817. tissue plasminogen activator for acute ischemic stroke treatment trial. Thrombolysis for acute opment of EMS specialty triage. 2001. Stroke. Stroke. Telemedicine for acute stroke: Stroke. Zoppo G. Bolton C. Blake CA. arrhythmias: cerebral electrocardiographic influences and their role in 42. 2003. Dispatch life support and the sudden death. improvement in acute stroke: the New York State Stroke Center Des- 70. Abdullah AR. Yang ZH. In: Emr M. Radiology and Intervention Council. Sayre MR. Connors JJ. Air Med J.35:2418 –2424.40:3646 –3678. Dostal J.34:1106 –1113. Tuden D. 2003. 2005. Association between physiological Schenkel J. Accuracy of paramedic diagnosis of stroke. Beck S. Koroshetz WJ. Levine SR. Disorders and Stroke Recombinant Tissue Plasminogen Activator 60. 41. window for treatment of acute ischemic stroke with intravenous tissue Downloaded from http://circ. Stroke. Zachariah B. 51. Intravenous tissue plasminogen activator for acute Kolominsky-Rabas PL. 2007. 61.7:446 – 448. Crarey P.ahajournals. Acad Emerg Med. Domeier R. Stroke. Improving access to acute stroke therapies: a controlled trial of guideline from the American Heart Association/American Stroke Asso- organised pre-hospital and emergency care. Graeb D. 2004. stroke severity on outcome in the National Institute of Neurological ration. administration of tissue-plasminogen activator. Attia J. Jauch EC. Brott T. Oppenheimer SM. Jauch EC. Lewandowski 352–358. Stroke. Van Cott CC. et al.47:513–519. Tong BL. Higashida R. Wagner C. 52.55: Grotta JC. Buecker-Nott HJ. shorter door-to-computed tomography time and increased likelihood of 69. Ann Emerg Med. Adams HP Jr. Cochrane Database Syst Rev. Summers D. Qureshi AI. Setting New Directions for Stroke Care: of stroke unit on early outcome of cerebral infarction patients]. 71. Kukla C. outcome: the NINDS rt-PA stroke study. Misselwitz B. and the Atherosclerotic Peripheral 48. 2000. Furlan A. Furlan A. Morrison LJ. Gillum LA. Bahouth MN. Sahlas DJ. Hachinski VC. Cross DT III. Mor- 47. Pre-hospital notification reduced the door-to-needle time for IV t-PA in 68. Brott T. 53. Teal PA. Hermanek P. J Neurosurg. Brass LM. Proceedings of a National Symposium on Rapid Identification and Zhonghua Nei Ke Za Zhi. Douglas VC. Demaerschalk B.28:1530 –1540. Stroke. Moore AG. Stroke. Wijdicks EF. Yamaguchi T. Zachariah BS. Melanson M. Wang CX. Parsons MW. Libman R. National Institute of Neurological Disorders and Stroke. Hill MD. Kim SK. Horn M. Berge E. Grotta JC. Kothari RU. Adams HP Jr. Lee SY. Stroke. 2009. Hu P. Kwiatkowski TG. Foell B. Jackson AC. Broderick JP.32:652– 655. CJ. Del Zoppo GJ. Levine SR. 2003. Haley EC Jr. Alexandrov AV. Libman RB.38:1655–1711. Vascular Disease and Quality of Care Outcomes in Research Interdis- Advance hospital notification by EMS in acute stroke is associated with ciplinary Working Groups. 2008. Qu H. Walters B. Bae HJ. Tilley BC. Gladstone DJ. 287–291. Hobson R. Morgenstern LB. Lyden PC. German Stroke Registers Study Group. Perry Alteplase for Stroke Effectiveness Study (CASES) Investigators. Wojner-Alexandrov AW. Black SE. Groll DL. Grotta JC. Derdeyn CP. Frequency of thrombolytic therapy in patients ischemic stroke: a Canadian hospital’s experience. Tilley BC. Kang MJ. Silver B. 2004. 2003:CD000213. Elson S. 1997. Haberl RL. Sacco RL. Lu M. Poncha F. Christianson TJ. 1990. Thurtchley D. clinical practice: a meta-analysis of safety data. Biddinger PD. Syst Rev. Brott TG. Crocco TJ. Prehospital identification and 62. Sayre MR.12:426 – 431. Prehosp Emerg Care. Chenkin J. Larmon BR. 2003. 45. EMS management of acute stroke–p. logical Disorders and Stroke (NINDS) rt-PA Stroke Study Group. BMJ. Alberts MJ. Stroke. Kalenderian D. Experience at eight centers and implications for American Stroke Association.172:1307.34:725–728.31: and extended use of thrombolysis in stroke: the Telemedic Pilot Project 2518 –2519. Kim SY. Spratt NJ. Kwiatkowski TP. Davis SM. LaMonte MP. Stroke Unit Trialists Collabo. Woolfenden AR. Stroke. Collaborative systematic review of the randomised trials of organised Lyden P. Extending tissue plasminogen activator use to Lu M. Horowitz SH. Wong E. Kidwell C. Tissue plasminogen activator for acute ischemic stroke in 2009. Expansion of the time ration. Royan AT.189: ciation Stroke Council. outcomes study (HoPSTO). Cechetto DF. Findings from the reanalysis of the NINDS ations according to hospital case volume in 18 states. Buchan AM. Tong DC. 2003. Marler JR. Ma RH. Lewandowski C. 2003. Goldfrank LR. Hullick CJ. Med J Aust. 77. protocol increases access to stroke thrombolysis in Toronto.67:88 –93. Howse DC. Marler JR. Do the Brain Attack Coalition’s criteria for stroke centers 2847–2850. Stroke. increases regional acute stroke interventions. Higashida RT. Tilley BC. Thrombolysis for acute ischemic stroke: results ignation Project.33:141–146. CA. Audebert HJ. Pathan MY. Clarmann von Claranau S. National Institute of Neurological Disorders and Stroke Recom- DG. del Zoppo G. Bhatt DL.34: Johnston SC. Latchaw RE. 72. Zhao XQ. Quain DA. Regional access to acute binant Tissue Plasminogen Activator Stroke Study Group. Effects of tissue plasminogen activator for acute ischemic stroke at one 54. 73. Lewandowski CA. for Integrative Stroke Care (TEMPiS) in at VA MED CTR BOISE on August 20. Rother J. Cerebrogenic cardiac logical Disorders and Stroke. Stroke. McElduff P.43:183–185. Leffmann C. of the Canadian Alteplase for Stroke Effectiveness Study. JR. Brass L. Scott P. Kidwell CS. acute ischemic stroke: a scientific statement from the American Heart Richmond NJ. Broderick recovery for stroke in your community. Moran 74. Wardlaw JM. 63. Adams RJ. Cha JK. Organised inpatient (stroke unit) care for stroke. 2007. Rosenwasser RH. Loudfoot AR. Houston paramedic and emergency stroke treatment and 1649 –1655. Persse D. Graham GD. Lyden PD. Merino JG. Ween JE. Cochrane Database J Stroke Cerebrovasc Dis. A citywide prehospital 2005. Eur J Neurol. 1997. tematic review of the randomized trials. 66. Md: National Institute of Neuro. Kidwell C. Tamayo A.64:422– 427. Bethesda. Expanded modes of tissue Saver JL. 2015 . Kwiatkowski T.28:2139 –2144. Schwamm LH.23:28 –31. Telemedicine for safe homeostasis and early recovery after stroke. 2009. In: Proceedings of the 64. Stroke. Berger K. triumphs and pitfalls. Brott T. Rodan LH. 1997.36:1512–1518. York D. Smith EE. Sayre MR. Heuschmann PU. Cardiovascular 429 – 433. Stroke. Miteff F. Dacey RG Jr. Ickenstein GW. Asplund K. Lee YS. 75. Goldstein National Institute of Neurological Disorders and Stroke. Neurology. 59.16:1331–1335. 1998. Bethesda.11:313–317. acute ischaemic stroke. Evans MK. Zweifler RM. ML. Ensuring the chain of 76. ischaemic stroke. Recommendations for imaging of 49.1997:35– 44. Gropen TI. Murray BJ. ed. Guidelines for the early management of patients with 43. The National Institute of Neuro. Gagliano PJ. Hademenos GJ. Grotta JC. Lee L. Mortality rates after subarachnoid hemorrhage: vari. Arch Neurol. Quality Association.5: JP. CMAJ. 2005. Grubb RL.34:1056 –1083. Stroke. Louis TA.36: 46. 56. Levine SR. Rymer MM. [The impact treatment. Johnston DC. Prehosp Emerg Care. Md: LB.314:1151–1159. 2004.

Higashida R. Hammel JP. for healthcare professionals from a special writing group of the Stroke 90. 1994. Tilling K. 1995. 1998. Thrombol. Neurology. Stroke. Katzan IL. Davis SM.347: M. Pathak P. Randomized trial of intraarterial R. N Engl J Med. Codina A. PROACT Investigators. Stroke. The PROACT II study: a ran. Clark WM. 12–16. Rivera F. Williams LS. Heritier S. Malmberg K. Kase C. Stroke. Sasaki M.30:793–799. Re G. at VA MED CTR BOISE on August 20. Henderson WR. Guidelines glycemia is independently associated with infarct expansion and worse for the management of patients with acute ischemic stroke: a statement clinical outcome. 2001. Dodek P. PROACT: a phase II randomized trial of recombinant pro-urokinase 410 – 414.59:67–71. 95. Christensen H. Takahashi A. Lopez-Yunez AM. tigators. Factors affecting haemorrhagic Protocol violations in community-based rTPA stroke treatment are asso- transformation in middle cerebral artery infarctions. Effects of admission hyperglycemia on 422– 425. Glucose potassium insulin infusions in the treatment of acute stroke experience. Cook D. C. Intra-arterial 97.35: domized controlled trial. Molina CA. Alvarez-Sabin J. DeGraba T. Woolson RF. Chambers BR. Scott JF. Gent M. Stroke. Zurru C. 122–126. Adams HP Jr. Bruno A. Lancet. Stroke. Espay A. Stress hyper- Association/American Stroke Association.283: A.34:2208 –2214. Bouillon R. van den Berghe G. del Zoppo GJ.162:1994 –2001. Baird TA. Jeppesen LL. Brott T. Prolyse in Acute Cerebral Thromboembolism. Qi R. Lattimore SU. G. Blair D. Callahan F. 2002.52:280 –284. Impact of establishing costs in acute ischemic stroke. 85. Utku U. 2001. Hajat C.35:904 –911. 89. Chittock DR. Mori E. French JM. Gray CS. Williams LS.S828 Circulation November 2. 2004. a primary stroke center at a community hospital on the use of 96. O’Connell JE. Parsons MW. Hebert PC. Huertas R. Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Stroke.31: M. Arenillas JF.38:2633–2639. Vignatelli L. study. Combined intravenous and intra-arterial recanalization for acute ische. Myburgh JA.34:e55– e57. glycemia and prognosis of stroke in nondiabetic and diabetic patients: a 79. Celik Y. Zivin J. McDonald E. Bravata DM. Bruyninckx F.13:95–101. Frank JI. Bassein L. 2007. Wolfe C.32:2426 –2432. 1999. Use of tissue-type plasminogen activator for 92. Effects of admission hyperglycemia on mortality and J. Adams HJ. Concato J. Barber PA.29:4 –11. 2000. Byrnes Council. Stroke. 1996. middle cerebral artery embolism local fibrinolytic intervention trial Potter J. Hallenbeck J. 84. Stroke. Harper DL. Tress 104. Capes SE. Rudd acute ischemic stroke: the Cleveland area experience. Boysen G. Taki W.32:413– 417. Olsen TS. Butcher KS. Grotta J.282:2003–2011. M. Lloyd LE. Ahuja A. Haymore SE. and outcome. 87. Ann KEY WORDS: emergency department 䡲 hemorrhage 䡲 ischemic stroke Neurol. 1999. Gent 100. Bruno A. Acute blood glucose level and outcome from ischemic 2002. Stroke. Minematsu K. 93. Ribo stroke severity. Furlan AJ. Rowley H. Furlan AJ. Clarke WR. 80. Stroke. 2007. mortality. 98. 2003. 2002. Arch Intern Med. Jorgensen HS. Effect of acute glycaemic index on clinical outcome after acute 1151–1158. Feinberg W. Quintana M. JAMA. by direct arterial delivery in acute middle cerebral artery stroke. McArthur C. Prolyse in Acute Cerebral Thromboembolism. Alberti GK. Baird AE. Su SY. Neurology. 2003. Ronco JJ. Rotich J. glycemia: natural history and immediate management. Mayberg M. Fineberg N. 2003. Williams LS. Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Inves- 81. Intensive insulin therapy in the critically ill patients. Saver JL. Stroke. Marler J. Asil T. Colman PG. Hunt D. Crowell R. Schetz M. American Heart Association. Stroke. Sharma P. Raaschou HO. 99. Stroke. systematic overview. Desmond PM. Bellomo Miyamoto S. in acute stroke. Tierney WR. Heyland infusion of urokinase within 6 hours of middle cerebral artery stroke: the DK. ysis for acute stroke in routine clinical practice. Furlan A. Montaner J. 101. Gray thrombolytic therapy: the NINDS Suburban Hospital Stroke Center CS. Yilmaz E. mic stroke: the Interventional Management of Stroke Study. infarct size. patients with mild to moderate hyperglycemia: the Glucose Insulin in 83. Wechsler L.34:1235–1241. Nyquist P. Intensive versus conventional glucose (MELT) Japan. Body temperature in acute stroke: relation to 88. Fineberg 82. Weekers F. Darby DG. Verwaest C. Helgason BM. Vlasselaers D. Ferdinande P. message of melt. Parsons MW. Alberti KG. 2015 . Nonino F. Nemoto S. Bhalla A. 2001. Nakayama H. Biller J. Stroke severity determines body temperature patients. Foster D. Persistent poststroke hyper. Poststroke hyper- prourokinase for acute ischemic stroke. Azzimondi G. Woolson R. Fiorani L. stroke outcome in reperfused tissue plasminogen activator–treated 103. Pessin MS. Ogawa A. stroke. Wouters P. A prospective Stroke. 2001. Rowley HA. Hajat S. Hinchey JA. Stroke. Tress BM. D’Alessandro R. 2009. 䡲 stroke Downloaded from http://circ. J Clin Neurosci. Ezzeddine M. 2002. Desmond PM. 1999. Lauwers P. Robinson BG. Reith J. Intra-arterial fibrinolysis for acute ischemic stroke: the 102. N Engl J Med.360:1283–1297. Pessin Stroke Trial (GIST). Mitchell I. Fever in acute stroke worsens prognosis. Inoue T. 94. Effects of poststroke pyrexia on stroke outcome: a meta-analysis of studies in patients. Robinson GM. Gomez C. Higashida RT. 2000. 86. stroke. Pedersen PM.52:20 –28. Norton R. Finfer S. Silver F. Dhingra V. Baird TA.40:2945–2948. Sankaralingam S. Balci K. Davis SM. Hildreth AJ.26:2040 –2043.11:656 – 658. Hansen MD. Chalela J.38:2627–2628.345:1359 –1367. Cerebrovasc Dis. O’Connell JE. Phanh T.ahajournals. Gerstein HC. Stroke. 2009. Warach S. Bruno A. Krumholz HM. Davis L. Furlan A. Swaminathan R.25:1901–1914. Brass LM. Kim N. 2010 plasminogen activator: a science advisory from the American Heart 91. JAMA. Biller J. ciated with symptomatic intracerebral hemorrhage. Sila CA.32: 2004. Qu A. control in critically ill patients.

) © 2011 American Heart Association. DOI: 10. On page S823. the Table 4 footnote read. “rtPA indicates .” 2. 2010. issue of the journal Circulation (2010. .” which published ahead of print on October 18. partial thromboplastin time.1161/ e404 .122[suppl 3]:S818 –S828). and PT. “rtPA indicates .org/cgi/content/full/122/18_suppl_3/S818. Inc. . prothrombin time. 2011. prothrombin time. . which is available at http://circ.ahajournals. . the following corrections were needed: 1. Correction In the article by Jauch et al. . Circulation is available at http://circ. partial thromboplastin time. and PT. . 2010. “rtPA indicates . “rtPA indicates .” It has been changed to read.” These corrections have been made to the current online version of the article. and PT. “Part 11: Adult Stroke: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.ahajournals. and appeared with the November 2. . On page S823.” It has been changed to read. .124:e404. the Table 5 footnote read. and PT.0b013e318235ce74 (Circulation.

110. is located on the World Wide Web at: http://circ. Please see the attached page for: http://circ. 2015 . Jauch.1161/CIRCULATIONAHA. All rights reserved. 7272 Greenville Avenue. click Request Permissions in the middle column of the Web page under Services. Inc.ahajournals.pdf Permissions: Requests for permissions to reproduce figures. Nina Gentile and Mary Fran Hazinski Circulation. Jane Brice. not the Editorial Office. Yvonne (Yu-Feng) Chan. a service of the Copyright Clearance Center. William Meurer. Opeolu Adeoye. 2010.ahajournals.Part 11: Adult Stroke: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Edward Downloaded from http://circ. or portions of articles originally published in Circulation can be obtained via RightsLink. Once the online version of the published article for which permission is being requested is at VA MED CTR BOISE on August 20.full.971044 Circulation is published by the American Heart Association. Further information about this process is available in the Permissions and Rights Question and Answer document. TX 75231 Copyright © 2010 American Heart Association. Reprints: Information about reprints can be found online at: Subscriptions: Information about subscribing to Circulation is online at: http://circ.122:S818-S828 doi: An erratum has been published regarding this article. Online ISSN: 1524-4539 The online version of this article. Dallas.ahajournals.ahajournals. Print ISSN: 0009-7322. along with updated information and services. Brett Cucchiara.