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Health Care Guideline:
Diagnosis and Initial Treatment of Ischemic Stroke
Acute Ischemic Stroke Algorithm
Eleventh Edition Patient presents with
Initial assessment
Exam: vitals, O2 (oxygen), monitor, record weight, NIHSS
Labs:
1) Glucose
2) INR/Cr/CBC (including platelets) – if there is no
Text in blue in this document suspicion that these are abnormal, do not delay head
CT or tPA
indicates a link. Unless emergently indicated do not delay imaging/IV tPA to
obtain EKG, CXR or place foley
Within 4.5 hours Symptom > 4.5 hours or time of onset is unknown
onset?
Neurology consultation
Neurology consultation
(if available and timely)
yes
no
yes
• Place 2 IVs of adequate size for
contrast administration Perform CTA head and
• Treat SBP if > 185, DBP if > 110 neck if not already
• Administer IV tPA (avoid significant obtained on initial
delays seeking consult, IV tPA is imaging
standard of care)
• Post IV tPA monitoring
yes
yes
Treat
Table of Contents
Work Group Algorithm (Acute Ischemic Stroke)......................................................................................1
Co-Leaders Evidence Grading..................................................................................................................3
David Anderson, MD Foreword............................................................................................................................... 4-6
Neurology, University of
Minnesota Physicians and Introduction...........................................................................................................................4
Hennepin County Medical Endorsement of American Heart Association (AHA)/American Stroke Association (ASA)
Center Stroke Documents........................................................................................................ 4-6
David Larson, MD
Emergency Medicine,
Recommendations............................................................................................................ 7-47
Ridgeview Medical Center Prehospital..................................................................................................................... 7-10
Work Group Members Public Stroke Education and Prehospital Stroke Management................................... 7-8
Fairview Health Services
Designation of Stroke Centers and Stroke Care Quality Improvement
Ann Ferguson, MD Process................................................................................................................... 8-10
Internal Medicine Evaluation/Diagnosis................................................................................................... 10-13
HealthEast Care System Emergency Evaluation and Diagnosis of Acute Ischemic Stroke............................ 10-11
Tess Sierzant, MS, RN Early Diagnosis: Brain and Vascular Imaging: Recommendations for Patients With
Neurology Nursing Acute Cerebral Ischemic Symptoms That Have Not Yet Resolved..................... 12-13
Lakeview Hospital Acute Management...................................................................................................... 14-47
Bjorn Peterson, MD General Supportive Care and Treatment of Acute Complications........................... 14-17
Emergency Medicine Intravenous Fibrinolysis (Endorsed Recommendations from the 2016 Scientific
Mayo Clinic Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute
James Klaas, MD Ischemic Stroke)...................................................................................................... 18-33
Neurology Endovascular Interventions (Recommendations from the 2015 American Heart
Minneapolis Clinic of Association/American Stroke Association Focused Update of the 2013 Guidelines
Neurology for the Early Management of Patients With Acute Ischemic Stroke Regarding
Ruth Marie Thomson, DO Endovascular Treatment).................................................................................... 34-40
Vascular Neurology Anticoagulants...............................................................................................................41
Park Nicollet Health Antiplatelet Agents.................................................................................................. 41-42
Services Admission to the Hospital and General Acute Treatment
Fadoua Kushner, PharmD (After Hospitalization)........................................................................................ 42-45
Pharmacy Treatment of Acute Neurological Complications.................................................... 45-47
University of Minnesota Quality Improvement Support................................................................................... 48-52
Physicians
Christopher Streib, MD Aims and Measures.............................................................................................................49
Vascular Neurology Measurement Specifications.................................................................................... 50-52
ICSI Staff Supporting Evidence..................................................................................................... 53-64
Jodie Dvorkin, MD, MPH References..................................................................................................................... 54-56
Project Manager/Health
Appendix A – Literature Search Terms by Topic...........................................................57-58
Care Consultant
Appendix B – ICSI Shared Decision-Making Model....................................................59-64
Senka Hadzic, MPH
Clinical Systems Disclosure of Potential Conflicts of Interest........................................................... 65-67
Improvement Facilitator
External Review and Acknowledgements.....................................................................68
Document History and Development....................................................................... 69-70
Document History...............................................................................................................69
ICSI Document Development and Revision Process..........................................................70
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Diagnosis and Initial Treatment of Ischemic Stroke
Eleventh Edition/December 2016
Evidence Grading
The American Heart Association (AHA)/American Stroke Association (ASA) uses its own system for clas-
sifying recommendations and evaluating the levels of evidence. This system is explained in the AHA/ASA
stroke documents. Since this is an endorsement document, ICSI did not use its own system to evaluate the
levels of evidence or classify recommendations. In one instance where the level of evidence for a recom-
mendation was upgraded, the work group used AHA/ASA's system. In all other instances, where new
literature was available to support the existing recommendations or qualification statement for an existing
recommendation, the new literature was cited. If there was no new literature on the topic, and the recom-
mendation was still valid based on the existing practice and previous literature, no literature was cited.
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Diagnosis and Initial Treatment of Ischemic Stroke
Eleventh Edition/December 2016
Foreword
The American Heart Association/American Stroke Association (AHA/ASA) is not a sponsor of or affiliated
with, nor does it endorse ICSI or the ICSI Diagnosis and Initial Treatment of Ischemic Stroke work group.
AHA/ASA has not reviewed ICSI's process for endorsement of guidelines. The following ICSI endorsement
and conclusions are solely the consensus of the ICSI Diagnosis and Initial Treatment of Ischemic Stroke
work group using the ICSI Endorsement Process.
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Introduction
Stroke is the fifth leading cause of death in the United States and a leading cause of serious long-term
disability (Mozzafarian, 2015; Kochanek, 2014). Annually, approximately 800,000 people in the United
States have a stroke, and 130,000 die (Centers for Disease Control and Prevention, 2016). Of all strokes,
87% are ischemic strokes (Mozaffarian, 2015). In Minnesota, ischemic stroke death rate – regardless of
gender and age group – is at 19 per 100,000, compared to the national rate of 20 per 100,000, for years 2011-
2013 per the Centers for Disease Control and Prevention's Interactive Atlas of Heart Disease and Stroke.
In the United States, one person dies from stroke every four minutes, on average (Mozaffarian, 2015).
Therefore, time is of the essence in getting appropriate early care for persons with an onset of stroke symp-
toms. The recommendations in this guideline are for early management of stroke due to ischemic brain
ischemia/infarction. This guideline does not address stroke prevention, transient ischemic stroke (TIA) or
management of hemorrhagic stroke.
To increase access to appropriate early care for stroke, Minnesota passed legislation to authorize the
Minnesota Department of Health (MDH) to designate hospitals as Acute Stroke-Ready Hospitals, Primary
Stroke Centers and Comprehensive Stroke Centers. In addition to hospital designation, the legislation
also included data collection and reporting, and standardization of EMS protocols. These changes have
led to 91 hospitals in Minnesota getting designated as stroke hospitals as of January 1, 2016, and 87% of
residents living within 30 minutes of a designated stroke center, per MDH data. MDH provides training,
education and other resources to the hospitals that want to become designated as stroke centers. The ICSI
Diagnosis and Initial Treatment of Ischemic Stroke guideline work group strongly encourages the hospitals
to participate in this process.
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Endorsement of American Heart Association (AHA)/American Stroke
Association (ASA) Stroke Documents
The ICSI Diagnosis and Initial Treatment of Ischemic Stroke guideline work group endorsed the content
and recommendations from three AHA/ASA documents (see below). For detailed explanation and evidence
supporting the recommendations, see the original documents. AHA/ASA provided writing group and
reviewer group conflict of interest disclosures. These were reviewed and taken into consideration by the
ICSI Diagnosis and Initial Treatment of Ischemic Stroke work group. The AHA/ASA's original documents
can be accessed at http://www.strokeassociation.org/STROKEORG/.
1. 2013 AHA/ASA Guidelines for the Early Management of Patients with Acute Ischemic Stroke.
Full citation: Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P,
McMullan PW Jr, Qureshi AI, Rosenfeld K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas
H; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing,
Council on Peripheral Vascular Disease, and Council on Clinical Cardiology. Guidelines for the early
management of patients with acute ischemic stroke: a guideline for healthcare professionals from the
American Heart Association/American Stroke Association. Stroke 2013;44:870-947.
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Diagnosis and Initial Treatment of Ischemic Stroke
Foreword Eleventh Edition/December 2016
The literature search was conducted for studies published between January 2012 and March 2016 for any
new studies to update the recommendations in this document. For information on the types of studies
searched and the literature search terms, please see Appendix A, "Literature Search Terms by Topic."
The following sections content and recommendations were reviewed and endorsed:
• Public Stroke Education and Prehospital Stroke Management
• Designation of Stroke Centers and Stroke Care Quality Improvement Process
• Emergency Evaluation and Diagnosis of Acute Ischemic Stroke
• Early Diagnosis: Brain and Vascular Imaging: Recommendations for Patients With Acute Cerebral
Ischemic Symptoms That Have Not Yet Resolved
• General Supportive Care and Treatment of Acute Complications
• Anticoagulants
• Antiplatelet Agents
• Admission to the Hospital and General Acute Treatment (After Hospitalization)
• Treatment of Acute Neurological Complications
The following sections content and recommendations were reviewed and endorsed:
• Early Diagnosis: Brain and Vascular Imaging: Recommendations for Patients With Cerebral
Ischemic Symptoms That Have Resolved
• Intravenous Fibrinolysis
• Endovascular Interventions
• Volume Expansion, Vasodilators, and Induced Hypertension
• Neuroprotective Agents
• Surgical Interventions
2. 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients
With Acute Ischemic Stroke Regarding Endovascular Treatment.
Full citation: Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, Johnston KC, Johnston
SC, Khalessi AA, Kidwell CS, Meschia JF, Ovbiagele B, Yavagal DR; on behalf of the American Heart
Association Stroke Council. 2015 American Heart Association/American Stroke Association focused
update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding
endovascular treatment: a guideline for healthcare professionals from the American Heart Association/
American Stroke Association. Stroke 2015;46:3020-35.
ICSI did not conduct literature search on the recommendations in this guideline since AHA/ASA's update
was recent. However, it was brought to the attention by work group members to include in the review
two studies published in 2016 on this topic. Those studies are Goyal, 2016 and Schönenberger, 2016.
Refer to the reference section for full citations on these studies.
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Diagnosis and Initial Treatment of Ischemic Stroke
Foreword Eleventh Edition/December 2016
3. 2016 Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in
Acute Ischemic Stroke. Full citation: Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk
AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL,
Smith EE; on behalf of the American Heart Association Stroke Council and Council on Epidemiology
and Prevention. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in
acute ischemic stroke: a statement for healthcare professionals from the American Heart Association/
American Stroke Association. Stroke 2016;47:581-641.
ICSI did not conduct literature search on the recommendations in this guideline, since AHA/ASA's
update was recent.
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Diagnosis and Initial Treatment of Ischemic Stroke
Eleventh Edition/December 2016
Recommendations
Note: In this document, qualification statement signifies substantial qualification/change to the original AHA/ASA
recommendation, and recommendations with qualifications statements are labeled as "agree with qualification." Statements that
are comments only do not significantly change the original recommendation, and those recommendations are labeled as "agree."
Prehospital
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Diagnosis and Initial Treatment of Ischemic Stroke
Recommendations Eleventh Edition/December 2016
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Diagnosis and Initial Treatment of Ischemic Stroke
Recommendations Eleventh Edition/December 2016
Evaluation/Diagnosis
AHA/ASA Recommendation AHA/ASA Class ICSI Work Group New Literature
Consensus Support
Qualification Statement/
Comment
Emergency Evaluation and Diagnosis of Acute Ischemic Stroke
1. An organized protocol for the Class I: Benefit>>>Risk Agree
emergency evaluation of patients with
Procedure/Treatment
suspected stroke is recommended
SHOULD be
(Class I; Level of Evidence B). The goal
performed/administered.
is to complete an evaluation and to
begin fibrinolytic treatment within 60
minutes of the patient’s arrival in an
ED. Designation of an acute stroke
team that includes physicians, nurses,
and laboratory/radiology personnel is
encouraged. Patients with stroke
should have a careful clinical
assessment, including neurological
examination. (Unchanged from the
previous guideline)
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Diagnosis and Initial Treatment of Ischemic Stroke
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AHA/ASA Recommendation AHA/ASA Class ICSI Work Group Consensus New Literature
Support
Qualification Statement/
Comment
5. In intravenous fibrinolysis Class I: Benefit>>>Risk Agree Spokoyny, 2014;
candidates, the brain imaging study Demaerschalk,
Procedure/Treatment
should be interpreted within 45 2012b
SHOULD be
minutes of patient arrival in the ED by
performed/administered.
a physician with expertise in reading
CT and MRI studies of the brain
parenchyma (Class I; Level of
Evidence C). (Revised from the previous
guideline)
6. CT perfusion and MRI perfusion Class IIb: Benefit ≥ Risk Disagree Albers, 2015;
and diffusion imaging, including Borst, 2015;
Procedure/Treatment The ICSI Diagnosis and Initial
measures of infarct core and Burton, 2015;
MAY BE Treatment of Ischemic Stroke
penumbra, may be considered for the Galinovic, 2014;
CONSIDERED work group concluded that
selection of patients for acute Sanelli, 2014;
evidence of value of
reperfusion therapy beyond the time Schroeder, 2014;
core/penumbra imaging remains
windows for intravenous fibrinolysis. Lin, 2014;
unproven, and its use in
These techniques provide additional Kidwell, 2013;
selecting patients for treatment
information that may improve Michel, 2012;
with IV tPA beyond
diagnosis, mechanism, and severity of Nagakane, 2012
recommended time window of
ischemic stroke and allow more
4.5 hours from onset is not
informed clinical decision-making
recommended outside a
(Class IIb; Level of Evidence B).
clinical trial per
(Revised from the 2009 imaging
recommendation 3 in Wake-
scientific statement)
up/Unclear Onset Time Stroke
section of Intravenous
Fibrinolysis recommendations
table. Recommendation 3
pertains to the use of imaging
criteria to determine
administration of IV tPA but in
the setting of “wake-up stroke”
(or onset time unknown). Please
also see recommendation 3 in
Imaging section of Endovascular
Interventions recommendations
table pertaining to selection for
endovascular thrombectomy
beyond recommended window
of 6 hours from onset.
7. Frank hypodensity on NECT may Class III: Harm or No Agree
increase the risk of hemorrhage with Benefit
fibrinolysis and should be considered
in treatment decisions. If frank
hypodensity involves more than one
third of the MCA territory,
intravenous rtPA treatment should be
withheld (Class III; Level of Evidence
A). (Revised from the 2009 imaging
scientific statement)
Acute Management
AHA/ASA Recommendation AHA/ASA Class ICSI Work Group Consensus New Literature
Support
Qualification Statement/
Comment
General Supportive Care and Treatment of Acute Complications
1. Cardiac monitoring is recommended Class I: Agree
to screen for atrial fibrillation and other Benefit>>>Risk
Further studies are required to
potentially serious cardiac arrhythmias
Procedure/Treatment determine patient selection,
that would necessitate emergency cardiac
SHOULD be performed/ optimal timing, method and
interventions. Cardiac monitoring should
administered. duration of cardiac
be performed for at least the first 24
monitoring, which are
hours (Class I; Level of Evidence B).
important issues relevant to
(Revised from the previous guideline)
long-term secondary stroke
prevention that is beyond the
purview of this guideline.
2. Patients who have elevated blood Class I: Agree Berge, 2015;
pressure and are otherwise eligible for Benefit>>>Risk For approaches to arterial Lee, 2015;
treatment with intravenous rtPA should hypertension in acute ischemic Bath, 2014;
Procedure/Treatment
have their blood pressure carefully stroke, refer to Table 9 He, 2014
SHOULD be performed/
lowered (Table 9) so that their systolic (Potential Approaches to
administered.
blood pressure is <185 mmHg and their Arterial Hypertension in Acute
diastolic blood pressure is <110 mmHg Ischemic Stroke Patients Who
(Class I; Level of Evidence B) before are Candidates for Acute
fibrinolytic therapy is initiated. If Reperfusion Therapy) on page
medications are given to lower blood 891 in the 2013 AHA/ASA
pressure, the clinician should be sure that Guidelines for the Early
the blood pressure is stabilized at the Management of Patients with
lower level before beginning treatment Acute Ischemic Stroke.
with intravenous rtPA and maintained
below 180/105 mmHg for at least the first
24 hours after intravenous rtPA
treatment. (Unchanged from the previous
guideline)
3. Airway support and ventilatory Class I: Agree Minnerup, 2012
assistance are recommended for the Benefit>>>Risk
treatment of patients with acute stroke
Procedure/Treatment
who have decreased consciousness or who
SHOULD be
have bulbar dysfunction that causes
performed/administered.
compromise of the airway (Class I; Level
of Evidence C). (Unchanged from the
previous guideline)
4. Supplemental oxygen should be Class I: Agree Bennett, 2014
provided to maintain oxygen saturation > Benefit>>>Risk
94% (Class I; Level of Evidence C).
Procedure/Treatment
(Revised from the previous guideline)
SHOULD be
performed/administered.
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Diagnosis and Initial Treatment of Ischemic Stroke
Recommendations Eleventh Edition/December 2016
AHA/ASA Recommendation AHA/ASA Class ICSI Work Group Consensus New Literature
Support
Qualification Statement/
Comment
Wake-Up/Unclear Onset Time Stroke
1. Intravenous alteplase is not Class III: Harm or Agree
recommended in ischemic stroke No Benefit
patients who awoke with stroke with
time last known to be at baseline state >
3 or 4.5 hours (Class III; Level of
Evidence B).
2. Intravenous alteplase is not Class III: Harm or Agree
recommended in ischemic stroke No Benefit
patients who have an unclear time and/
or unwitnessed symptom onset and in
whom the time last known to be at
baseline state is > 3 or 4.5 hours (Class
III; Level of Evidence B).
3. Use of imaging criteria to select Class III: Harm or Agree with Qualification
ischemic stroke patients who awoke with No Benefit
The ICSI Diagnosis and Initial
stroke or have unclear time of symptom
Treatment of Stroke work group
onset for treatment with intravenous
agrees with this recommendation.
alteplase is not recommended outside a
Please also see recommendation 6
clinical trial (Class III; Level of Evidence
in “Early Diagnosis: Brain and
B).
Vascular Imaging:
Recommendations for Patients
With Acute Cerebral Ischemic
Symptoms That Have Not Yet
Resolved” recommendations table
also pertaining to IV tPA but in the
setting of patient selection for
treatment beyond the
recommended window of 4.5 hours
from onset and recommendation 3
in “Imaging” section of
“Endovascular Interventions”
recommendations table pertaining
to selection for endovascular
thrombectomy beyond the
recommended window of 6 hours
from onset.
Menstruation and Menorrhagia
1. Intravenous alteplase is probably Class IIa: Agree
indicated in women who are Benefit>>Risk
menstruating who present with acute
IT IS
ischemic stroke and do not have a
REASONABLE to
history of menorrhagia. However,
perform
women should be warned that alteplase
procedure/administer
treatment could increase the degree of
treatment.
menstrual flow (Class IIa; Level of
Evidence C).
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Diagnosis and Initial Treatment of Ischemic Stroke
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Diagnosis and Initial Treatment of Ischemic Stroke
Recommendations Eleventh Edition/December 2016
AHA/ASA Recommendation AHA/ASA Class ICSI Work Group Consensus New Literature
Support
Qualification Statement/
Comment
5. In carefully selected patients with Upgraded Class: Agree with qualification Goyal, 2016
anterior circulation occlusion who Class I: The ICSI work group recommends
have contraindications to Benefit>>>Risk that based upon the most recent trial
intravenous rtPA, endovascular
Procedure/Treatment evidence, endovascular stroke
therapy with stent retrievers
SHOULD be treatment should be pursued even in
completed within 6 hours of stroke
performed/administered. patients with contraindications for IV
onset is reasonable (Class IIa; Level
tPA (Goyal, 2016). Therefore, the
of Evidence C). Inadequate data are
class and level of evidence should be
available at this time to determine
upgraded to Class I, Level of
the clinical efficacy of endovascular
Evidence A.
therapy with stent retrievers for
those patients whose
contraindications are time based or
not time based (e.g., prior stroke,
serious head trauma, hemorrhagic
coagulopathy, or receiving
anticoagulant medications). (New
recommendation)
6. Although the benefits are Class IIb: Benefit ≥ Agree with qualification Goyal, 2016;
uncertain, the use of endovascular Risk Lemmens, 2016;
The ICSI Diagnosis and Treatment of
therapy with stent retrievers may be Sarraj, 2016
Procedure/Treatment Ischemic Stroke guideline work group
reasonable for carefully selected
MAY BE agrees that it may be reasonable to
patients with acute ischemic stroke
CONSIDERED. treat causative occlusions in the M2
in whom treatment can be initiated
division of the MCA, anterior cerebral
(groin puncture) within 6 hours of
artery, vertebral artery, basilar artery
symptom onset and who have
or posterior cerebral artery (Goyal,
causative occlusion of the M2 or M3
2016; Lemmens, 2016; Sarraj, 2016).
portion of the MCAs, anterior
cerebral arteries, vertebral arteries, Endovascular treatment of more distal
basilar artery, or posterior cerebral MCA occlusions such as the M3 or
arteries (Class IIb; Level of Evidence M4 division is not well
C). (New recommendation) studied. Interventions on very distal
occlusions are less likely to result in
clinical benefit than more proximal
occlusion (Lemmens, 2016). It is
consensus of the ICSI work group to
not recommend routine endovascular
intervention of occlusion more distal
than the M2 division of the MCA.
7. Endovascular therapy with stent Class IIb: Benefit ≥ Agree
retrievers may be reasonable for Risk
some patients < 18 years of age with
Procedure/Treatment
acute ischemic stroke who have
MAY BE
demonstrated large-vessel occlusion
CONSIDERED.
in whom treatment can be initiated
(groin puncture) within 6 hours of
symptom onset, but the benefits are
not established in this age group
(Class IIb; Level of Evidence C).
(New recommendation)
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Quality Improvement Support:
Diagnosis and Initial Treatment of Ischemic Stroke
The Aims and Measures section is intended to provide protocol users with a menu
of measures for multiple purposes that may include the following:
• population health improvement measures,
• quality improvement measures for delivery systems,
• measures from regulatory organizations such as Joint Commission,
• measures that are currently required for public reporting,
• measures that are part of Center for Medicare Services Physician Quality
Reporting initiative, and
• other measures from local and national organizations aimed at measuring
population health and improvement of care delivery.
This section provides resources, strategies and measurement for use in closing
the gap between current clinical practice and the recommendations set forth in the
guideline.
The subdivisions of this section are:
• Aims and Measures
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Diagnosis and Initial Treatment of Ischemic Stroke
Aims and Measures Eleventh Edition/December 2016
Measurement Specifications
Measurement #1a
Percentage of eligible patients with ischemic stroke treated with tPA.
Population Definition
Patients age 18 years and older initially presenting with acute symptoms of ischemic stroke who are eligible
for tPA.
Data of Interest
# of patients treated with tPA
# of patients eligible for tPA
Numerator/Denominator Definitions
Numerator: Number of patients who were treated with tPA.
Denominator: Number of patients eligible for tPA treatment.
Notes
This is a process measure, and improvement is noted as an increase in the rate.
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Diagnosis and Initial Treatment of Ischemic Stroke
Aims and Measures Eleventh Edition/December 2016
Measurement #2a
Percentage of patients with ischemic stroke with paralysis or other reason for immobility receiving appro-
priate prevention for venous thromboembolism (subcutaneous heparin or pneumatic compression device).
Population Definition
Patients age 18 years and older initially presenting with acute symptoms of ischemic stroke with paralysis
or other reason for immobility.
Data of Interest
# of patients who have appropriate prevention for VTE
# of patients who present with acute symptoms of ischemic stroke and paralysis or other reason for
immobility
Notes
This is a process measure, and improvement is noted as an increase in the rate.
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Diagnosis and Initial Treatment of Ischemic Stroke
Aims and Measures Eleventh Edition/December 2016
Measurement #2b
Percentage of ischemic stroke patients who are assessed with a swallow screening test before receiving
food, fluids or medications by mouth.
Population Definition
Patients age 18 years and older initially presenting with acute symptoms of ischemic stroke.
Data of Interest
# of patients who receive an early swallow evaluation
# of patients who present with acute ischemic stroke
Notes
This is a process measure, and improvement is noted as an increase in the rate.
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Supporting Evidence:
Diagnosis and Initial Treatment of Ischemic Stroke
Kidwell CS, Wintermark M, De Silva DA, et al. Multiparametric MRI and CT models of infarct core and
favorable penumbral imaging patterns in acute ischemic stroke. Stroke 2013;44:73-79.
Kochanek KD, Murphy SL, Xu J, Arias E. Mortality in the United States, 2013. NCHS Data Brief
2014;(178):1-8.
Lee M, Ovbiagele B, Hong KS, et al. Effect of blood pressure lowering in early ischemic stroke: meta-
analysis. Stroke 2015;46:1883-89.
Lemmens R, Hamilton SA, Liebeskind DS, et al. Effect of endovascular reperfusion in relation to site
of arterial occlusion. Neurology 2016;86:762-70.
Lin L, Bivard A, Levi CR, Parsons MW. Comparison of computed tomographic and magnetic reso-
nance perfusion measurements in acute ischemic stroke: back-to-back quantitative analysis. Stroke
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Diagnosis and Initial Treatment of Ischemic Stroke
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Institute for Clinical Systems Improvement 56
Diagnosis and Initial Treatment of Ischemic Stroke
Eleventh Edition/December 2016
Early Diagnosis: Brain and Vascular Imaging: Recommendations for Patients With Acute
Cerebral Ischemic Symptoms That Have Not Yet Resolved
Brain imaging for acute ischemic stroke, non-contrast-enhanced computed tomography in acute ischemic
stroke patients, NECT and rtPA administration, MRI and rTPA administration, exclusion of intracranial
hemorrhage in stroke patients, intravenous fibrinolytic therapy for early ischemic changes on CT, non-
invasive intracranial vascular study and imaging for acute stroke patients, non-invasive intracranial study
and intra-arterial fibrinolysis, non-invasive intracranial study and mechanical thrombectomy, What is the
time frame for the brain imaging study interpretation in intravenous fibrinolysis candidates?, perfusion CT,
perfusion MRI, wake-up stroke, penumbra imaging, frank hypodensity on NECT.
stroke, prevention of recurrent stroke in the acute ischemic stroke patient, aspirin for DVT prophylaxis for
stroke patients unable to receive anticoagulants, nasogastric (NG) versus percutaneous endoscopic gastros-
tomy (PEG) tube feeding after stroke onset, intermittent external compression device for DVT prophylaxis
in stroke patients unable to take anticoagulants, nutritional supplements in acute stroke patients, prophylactic
antibiotics in acute stroke patients, indwelling bladder catheter in acute stroke patients.
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Institute for Clinical Systems Improvement 58
Diagnosis and Initial Treatment of Ischemic Stroke
Eleventh Edition/December 2016
Collaborative Conversation™
A collaborative approach towards decision-making is a fundamental tenet of Shared Decision-Making (SDM).
The Collaborative Conversation™ is an inter professional approach that nurtures relationships; enhances
patients' knowledge, skills and confidence as vital participants in their health; and encourages them to
manage their health care. Within a Collaborative Conversation™, the perspective is that the patient, rather
than the clinician, knows which course of action is most consistent with the patient's values and preferences.
Use of Collaborative Conversation™ elements and tools is even more necessary to support patient, care
clinician and team relationships when patients and families are dealing with high stakes or highly charged
issues. A diagnosis of a life-limiting illness is one example of such a circumstance.
The overall objective for the Collaborative Conversation™ approach is to create an environment in which
the patient, family and care team work collaboratively to reach and carry out a decision that is consistent
with the patient's values and preferences, along with the best available evidence. A rote script, completed
form or checklist does not constitute this approach. Rather it is a set of skills employed appropriately for
the specific situation. These skills need to be used artfully to address all aspects of the person involved in
making a decision: cognitive, affective, social and spiritual.
Key communication skills help build the collaborative conversation approach. These skills include (Adapted
from O'Connor, Jacobsen Decisional Conflict: Supporting People Experiencing Uncertainty about Options
Affecting their Health [2007], and Bunn H, O'Connor AM, Jacobsen MJ Analyzing decision support and
related communication [1998, 2003])
1. Listening skills
Encourage patient to talk by providing prompts to continue such as go on, and then? and uh huh
or by repeating the last thing a person said, It's confusing.
Paraphrase content of messages shared by patient to promote exploration, clarify content and
to communicate that the person's unique perspective has been heard. The clinician should use their
own words rather than just parroting what they heard.
Reflection of feelings usually can be done effectively once trust has been established. Until the clini-
cian feels that trust has been established, short reflections at the same level of intensity expressed by
the patient without omitting any of the message's meaning are appropriate. Reflection in this manner
communicates that the clinician understands the patient's feelings and may work as a catalyst for
further problem solving. For example, the clinician identifies what the person is feeling and responds
back in his or her own words like this: "So, you're unsure which choice is the best for you."
Summarize the person's key comments and reflect them back to the patient. The clinician should
condense several key comments made by the patient and provide a summary of the situation. This
assists the patient in gaining a broader understanding of the situation rather than getting mired
down in the details. The most effective times to do this are midway through and at the end of the
conversation. An example of this is "You and your family have read the information together,
discussed the pros and cons, but are having a hard time making a decision because of the risks."
Perception checks ensure that the clinician accurately understands a patient or family member
perspective, and may be used as a summary or reflection. They are used to verify that the clinician
is interpreting the message correctly. The clinician can say, "So you are saying that you're not
ready to make a decision at this time. Am I understanding you correctly?"
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Diagnosis and Initial Treatment of Ischemic Stroke
Appendix B – ICSI Shared Decision-Making Model Eleventh Edition/December 2016
2. Questioning Skills
Open and closed questions are both used, with the emphasis on open questions. Open questions ask
for clarification or elaboration and cannot have a yes or no answer. An example would be, "What
else would influence you to choose this?" Closed questions are appropriate if specific information
is required, such as "Does your daughter support your decision?"
Other skills such as summarizing, paraphrasing, and reflection of feeling can be used in the ques-
tioning process so that the patient doesn't feel pressured by questions.
Verbal tracking, referring back to a topic the patient mentioned earlier, is an important foundational
skill (Ivey & Bradford-Ivey). An example of this is the clinician saying, "You mentioned earlier…"
3. Information-Giving Skills
Providing information and providing feedback are two methods of information giving. The
distinction between providing information and giving advice is important. Information giving
allows a clinician to supplement his or her knowledge and helps to keep the conversation patient
centered. Giving advice, on the other hand, takes the attention away from the patient's unique goals
and values, and places it on those of the clinician.
Providing information can be sharing facts or responding to questions. An example is "If we look
at the evidence, the risk is…" Providing feedback gives the patient the clinician's view of the
patient's reaction. For instance, the clinician can say, "You seem to understand the facts and value
your daughter's advice."
Table 1
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Diagnosis and Initial Treatment of Ischemic Stroke
Appendix B – ICSI Shared Decision-Making Model Eleventh Edition/December 2016
The Collaborative Conversation™ Map is the heart of this process. The Collaborative Conversation Map™
can be used as a stand-alone tool that is equally applicable to clinicians and patients, as shown in Table 2.
Clinicians use the map as a clinical workflow. It helps get the shared decision-making process initiated and
provides navigation for the process. Care teams can use the Collaborative Conversation™ to document team
best practices and to formalize a common lexicon. Organizations can build fields from the Collaborative
Conversation™ Map in electronic medical records to encourage process normalization. Patients use the
map to prepare for decision-making, to help guide them through the process and to share critical informa-
tion with their loved ones.
Table 2
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Diagnosis and Initial Treatment of Ischemic Stroke
Appendix B – ICSI Shared Decision-Making Model Eleventh Edition/December 2016
Copyright © 2012, 2016 by Institute for Clinical Systems Improvement. All rights reserved.
8009 34th Avenue South, Suite 1200 • Bloomington, MN 55425 • Phone: 952-814-7060 • www.icsi.org
© 2012 Institute for Clinical Systems Improvement. All rights reserved.
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Institute for Clinical Systems Improvement 64
Disclosure of Potential Conflicts of Interest:
Diagnosis and Initial Treatment of Ischemic Stroke
ICSI has long had a policy of transparency in declaring potential conflicting and
competing interests of all individuals who participate in the development, revision
and approval of ICSI guidelines and protocols.
In 2010, the ICSI Conflict of Interest Review Committee was established by the
Board of Directors to review all disclosures and make recommendations to the board
when steps should be taken to mitigate potential conflicts of interest, including
recommendations regarding removal of work group members. This committee
has adopted the Institute of Medicine Conflict of Interest standards as outlined in
the report, Clinical Practice Guidelines We Can Trust (2011).
Where there are work group members with identified potential conflicts, these are
disclosed and discussed at the initial work group meeting. These members are
expected to recuse themselves from related discussions or authorship of related
recommendations, as directed by the Conflict of Interest committee or requested
by the work group.
The complete ICSI policy regarding Conflicts of Interest is available at
http://bit.ly/ICSICOI.
Funding Source
The Institute for Clinical Systems Improvement provided the funding for this
guideline revision. ICSI is a not-for-profit, quality improvement organization
based in Bloomington, Minnesota. ICSI's work is funded by the annual dues
of the member medical groups and three sponsoring health plans in Minnesota.
Individuals on the work group are not paid by ICSI but are supported by their
medical group for this work.
The only exception to this, patient and public members of a work group, are
provided with a small stipend to cover meeting attendance.
ICSI facilitates and coordinates the guideline development and revision process.
ICSI, member medical groups and sponsoring health plans review and provide
feedback but do not have editorial control over the work group. All recommenda-
tions are based on the work group's independent evaluation of the evidence.
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Diagnosis and Initial Treatment of Ischemic Stroke
Disclosure of Potential Conflicts of Interest Eleventh Edition/December 2016
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Institute for Clinical Systems Improvement 67
External Review and Acknowledgements:
Diagnosis and Initial Treatment of Ischemic Stroke
ICSI seeks review from members and the public during the revision process.
Member Review
All ICSI documents are available for member review at two points in the ICSI revision process.
The ICSI Response Report is sent to members at the beginning of a document revision. The
goal of this report is to solicit feedback about the guideline, including but not limited to the
algorithm, content, recommendations, and implementation. Members are also welcome to
participate in the public comment period (see below).
The work group would like to thank the following organizations for participating in the Diag-
nosis and Initial Treatment of Ischemic Stroke pre-revision review:
• Hudson Physicians
Invited Reviews
For some guidelines, ICSI will invite experts in the community to comment on a guideline
draft prior to finalization. This is done during the public comment period.
No invited review was done for the Diagnosis and Initial Treatment of Ischemic Stroke guideline.
Document History
• 2012 implemented the GRADE methodology to identify and evaluate recommendations.
• 2016: Original content was discontinued.
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