Acute Ischemic Stroke

An ischemic stroke occurs when the blood supply to part of the brain is interrupted or reduced,
preventing brain tissue from getting oxygen and nutrients. Brain cells begin to die in __________,
corresponding with loss of neurologic function.

__________th leading cause of death (behind heart disease, cancer, chronic lower respiratory disease,
and unintentional injuries/accident). It is also the leading cause of adult disability.

 Ischemic stroke: blood clot (most often) stops the flow of blood to an area of the brain
o Ischemic strokes can be further classified (see below)
 Hemorrhagic stroke: weakened blood vessels rupture and blood leaks into brain tissue
 Transient ischemic attack (TIA): episode of focal ischemic neurologic deficit lasting <24 hours
o “Mini strokes”
o Can still lead to brain damage
o Warning sign - precedes an ischemic stroke in 60% of patients

 Normal blood flow ~50 mL/100 g/min

 Penumbra – blood flow ~10-20 mL/100 g/min
o The term used for the ____________injured brain tissue around ischemic core – cells
are in danger of dying
o The goal to treat ischemic stroke is to salvage the penumbra as much and early as
possible
 Infarct - blood flow < ________ mL/100 g/min
Risk Factors

Modifiable CV diseases that increase risk for embolic strokes

_____________________ _____________________
Diabetes mellitus Valvular disease
Bioprosthetic/mechanical heart valves
______________________
Previous stroke _______________________
Lifestyle – excessive alcohol intake, tobacco Atrial or ventricular thrombus
use, illicit drug use, physical inactivity Recent MI
Obesity CABG
Oral contraceptive/postmenopausal
hormone use

Clinical Presentation- Think FAST!

F = facial droop (ask the patient to smile for you)

A = arm droop (ask the patient to raise their hands out to you)
S = slurred speech (ask the patient to say “You can’t teach an old dog new tricks”)
T = time! Every minute is critical for brain tissue
Diagnosis

Goal: Imaging within 20 minutes after a patient with suspected stroke arrives at the hospital

 ________________
o Most important initial diagnostic test (quick, easy, accurate)
 MRI
o More sensitive to show ischemic stroke than CT (useful to exclude tumors and ID
hemorrhaging)
 Cerebral angiography
o Typically only used if CT or MRI are inconclusive

Differential

 Seizures
 Hypoglycemia
o MUST obtain a blood glucose reading and treat if <60 mg/dL before diagnosing
 CNS abscess
 CNS tumor
 Encephalopathy
 Drug toxicity
 Complicated migraine

Management

Determine if patients with acute ischemic stroke are candidates for IV thrombolytics or endovascular
thrombectomy:

 Establish time of symptom onset

 Therapeutic window:

IV thrombolytics < ________ hours from symptom onset

Mechanical thrombectomy < ________ hours from symptom onset

Acute Pharmacological Therapy – Fibrinolytics

 Alteplase
o Extended eligibility window – 3 to 4.5 hours from symptom onset
 The earlier the treatment is initiated, the better the success
o Inclusion and exclusion criteria must be considered (see below)
o Goal is to complete evaluation to begin fibrinolytic therapy within _________ of
presenting to ED - “door to needle time”
MOA: tPA converts plasminogen to plasmin, which then lyses fibrin as well as fibrinogen

Inclusion Criteria

 Diagnosis of ischemic stroke causing measurable neurological deficit

 Onset of symptoms
< 4.5 hours before starting IV alteplase
o If unsure about time of stroke onset, it is defined as the last time patient was known to
be at neurological baseline – “last known normal”
 Age ≥ 18 years old

Exclusion Criteria

First Considerations

 Blood glucose < 50 mg/dL (treat, then re-evaluate for alteplase)

 CT imaging
o Demonstrates multi-lobar infarction (> 1/3 cerebral hemisphere)
 “Extensive regions consistent with irreversible injury”
o Signs and symptoms suggestive of subarachnoid hemorrhage (SAH)
o Current intracranial hemorrhage (ICH)
o Active internal bleeding

Patient History

 Prior ischemic stroke in previous ________ months

 History of previous intracranial hemorrhage (ICH)
 Intracranial neoplasm, arteriovenous malformation, or aneurysm
 GI malignancy
 GI hemorrhage in previous 21 days
 Severe head trauma or intracranial/spinal surgery in previous 3 months
 _______________________administration in previous 24 hours
 Arterial puncture at non-compressible site in previous 7 days
 Clinical Factors

 Persistent elevated blood pressure (systolic > ________mmHg or diastolic > ________ mmHg)
 Signs and symptoms consisted with infective endocarditis
 Stroke known to be suspected or associated with aortic arch dissection
 Acute bleeding diathesis, including but not limited to:
o Platelet count < 100,000/mm3
o aPTT > 40 seconds or heparin received within __________, resulting in abnormally
elevated aPTT
o Current use of anticoagulant with INR > 1.7 or PT > 15 seconds
o Current use of direct thrombin inhibitors or factor Xa inhibitors with elevated
laboratory tests (i.e. PTT, INR, platelet count, or factor Xa activity assays as appropriate)

If between the 3- 4.5 hour onset, additional relative exclusion criteria to consider:

 Age greater than 80 years

 National Institute of Health Stroke Scale (NIHSS) greater than 25 (indicating severe stroke)
 Taking an oral anticoagulant regardless of INR
 History of both diabetes and prior ischemic stroke

tPA Dosing:
Total dose: __________ mg/kg (not to exceed_______ mg)
Bolus dose: 0.09 mg/kg (_________ of the total dose) over _____ min
Infusion: 0.81 mg/kg (__________ of the total dose) over ______ min

*If patient weight is >100 kg, will use the max dosing:
Total dose: 90 mg
Bolus dose: 9 mg over 1 minute
Infusion: 81 mg over 60 minutes

Endovascular treatment/mechanical thrombectomy

Procedure where a catheter is inserted into a large blood vessel inside the head and a device is used to
pull out a clot

 Indicated for patients with acute ischemic stroke due to _______________ (LVO) in the anterior
circulation
o Within 24 hours of symptom onset
 DAWN and DEFUSE 3 trials showed a clear benefit of “extended window”
mechanical thrombectomy for certain patients with large vessel occlusion who
could be treated out to 16-24 hours
o Examples of large vessels for “LVO”
 Internal carotid arteries
 Middle, anterior, or posterior cerebral arteries
 Basilar artery
Monitoring

 Neuro checks: q15 min for first 2 hours, then q30min for 6 hours, then hourly for 24 hours
 BP checks: q15 min for first 2 hours, then q30min for 6 hours, then hourly for 24 hours

Management after Stroke

 Administration of aspirin is recommended in acute stroke patients within 24-48 hours after
stroke onset
 For patients treated with IV tPA, aspirin administration is generally delayed for 24 hours
 Urgent anticoagulation (e.g., heparin drip) for most stroke patients is not indicated and does not
reduce the risk of recurrent stroke
o Increased risk of bleeding complications with early administration of UFH or LMWH after
stroke
o Do not give anticoagulation within __________ hrs of tPA
 Blood pressure management
o For every 10 mmHg increase >180mmHg:
 Risk of neurological deterioration increased 40%
 Risk of poor outcome increased by 23%
 Eskenazi Health Inpatient Stroke ONE
Protocol, 701-3031
1. Call a Rapid Response *99 (refer to Policy 600-056, Rapid Response Team) and activate the
Stroke ONE Protocol if:

a. An inpatient develops acute stroke symptoms of less than 24 hours duration where
the last time known to be normal or well can be clearly identified.

b. If an inpatient meets BEFAST symptoms and Point of Care (POC) Glucose >50ml/dl.

2. To activate a Stroke ONE, call 3-3278 or 3-FAST. Provide the patient location, MRN and call back
number to the Health Connections staff.

Current inpatients that are experiencing acute neurological changes suggesting an ischemic or
hemorrhagic stroke need quick response for diagnostic testing and treatment within 24 hours of last
known well time.

BEFAST:

 B: Balance-Sudden loss of balance or sudden severe headache without known cause

 E: Eyes-vision changes (loss of vision/partial or total, blurred or doubled vision)

 F: Face- facial droop or asymmetry

 A: Arm-unilateral weakness/numbness

 S: Speech-slurred, garbled or abnormal speech

 T: Time- within previous 24 hours

The Rapid Response Team (RRT) arrives and determines if patient is medically stable and addresses life-
threatening concerns first. Once the patient has been deemed stable, protocol as follows:

1. Within 10 minutes of Stroke ONE activation:

a. The RRT Physician utilizes the Stroke ONE Order set.

b. Lab studies/ECG ordered/drawn as needed based on acute stroke symptoms at the

responding neurologist discretion.

c. The Neurologist completes the neurological evaluation and determines further

course of treatment. The RRT Physician must remain at the patient's bedside until
the Neurologist has arrived.
 d. Place patient on telemetry (if not already on) and take vital signs (including blood
pressure, heart rate and respiratory rate) and repeat every 30minutes per order
set.

2. Within 20 minutes of Stroke ONE activation:

a. Transport patient to Radiology for "Stat Head CT w/o Contrast for Stroke ONE" per
order set.

b. Hold the patient in CT/Radiology until the Neurology Physician determines if

patient will return to current inpatient placement or if level of care will be
upgraded to critical care. Communicate with Patient Placement if upgrade in care
is needed.
c. A Critical Care level RN, such as the RRT registered nurse (RN) or Critical Care Shift
Coordinator will remain with patient until treatment course is determined and safe
patient hand-off is completed

3. Within 45 minutes of Stroke ONE activation:

a. Neurologist or Radiologist completes and documents the preliminary reading of

the Head CT.

4. Within 60 minutes, If Alteplase is ordered by the Neurology Physician:

a. Neurology Physician will write order and verbalizes to Critical Care RN that
Alteplase is ordered.

b. RN will notify main pharmacy of: Alteplase order, patient location, and patient
weight for accurate medication dosing.

c. Prior to administration of Alteplase, the initial assessment including the NIHSS and
Neurological Exam must be completed.
d. RN will obtain infusion pump, start infusion, and document as soon as possible. Do
not delay initiation of Alteplase.
e. Alteplase may be initiated in Radiology if decision to treat is made while in
Radiology.

f. After initiation of Alteplase, notify the Neurology Physician as soon as possible for
any changes in the NIHSS of 2 points or more.

g. Complete a medication incident report if Alteplase is stopped for any reason prior
to completion of infusion. Refer to Policy 950-007, Patient/Visitor Incident
Reporting/Sentinel Event Process.

5. Place patient on nothing by mouth (NPO-Strict) until Barnes Stroke Dysphagia Screen has been
completed. Refer to Policy 600-084, Barnes Stroke Dysphagia Screen.

6. Canceling a Stroke One will only be done by the responding Neurologist.