Acute stroke:

Every Second Counts!

A stepwise demystified approach

to the patient with acute stroke

J. Leonard Pascual MD FPNA

 Objective
• To be aware of common myths and
misconceptions about stroke
 Objective
• To present a rapid step by step practical
approach to the patient with acute stroke
 Objectives
• To present a rapid step by step practical
approach to the patient with acute stroke
– Quick screening for stroke and its mimics
– Quick triaging of ischemic stroke patients'
eligible for thrombolysis
– Organized stroke care
Step 1: Is the patient having a stroke?
What is Stroke?
 STROKE
is a
“BRAIN ATTACK”

Definition: Sudden onset of focal neurological

deficit lasting for more than 24 hours due to an
underlying vascular pathology
Time lost
is brain lost
 Take a good quick history!
• Time of symptom onset

Important data: When was the patient last seen

well?
 Take a good quick history!
• Circumstances surrounding ictus (other
possible causes other than stroke)

Important data: Any systemic illnesses and

medications being taken?
 Take a good quick history!
• Circumstances surrounding ictus (other
possible causes other than stroke)

Guidelines for the early management of adults with ischemic stroke. Circulation 2007; 115: e478 - e534.
 Does the patient have a
Stroke?
• Rapid screening tests have been
validated as useful in the prehospital
setting by medical and paramedical staff
alike
 Does the patient have a
Stroke?
• Rapid screening tests have been
validated as useful in the prehospital
setting by medical and paramedical staff
alike
– Cincinnati Prehospital Stroke Scale
– Los Angeles Prehospital Stroke Screen
 All patients with
suspected acute stroke
should be triaged with
the same priority as
patients with acute MI or
serious trauma,
regardless of the severity
of the deficits
ROSIER
Problems at this stage
Step 2: What kind of stroke does the patient
have?
Step 3: Can we thrombolyse the patient?
 Is the patient eligible for
thrombolysis?
• Ischemic stroke with clearly defined time
of onset
• Neurologic deficits (measurable by
NIHSS)
• Baseline cranial CT without evidence of
intracranial hemorrhage
 Why thrombolyse?

Answer: given within 3 hours from stroke

onset, it is safe and effective and can save 1
in 10 patients from disability and
dependency
 CBF and Brain Ischemia/Infarction
Cerebral Blood Flow 30
(ml/100 gm/min)

20
Ischemia

10 Infarction

Duration
 How much time do I have?
• For intravenous thrombolysis with rTPA:
3 hours (up to 4.5 hours)
 How to administer rTPA IV
• Total dose = body weight (kg) x 0.9 mg/kg
Problems at this stage
Problems at this stage
 Problems at this stage
• Stroke patients may not be a hospital
priority
– ER procedures and diagnostics may be
slow (labs, CT scan)
– Beds may not be available
– CT scan may not be available after office
hours
 Problems at this stage
• Even when patients do arrive in time and
ER procedures are done swiftly
– Some neurologists can be overly
conservative in judging the patients'
eligibility for rTPA
– Using contraindications to rTPA as an
excuse to not give it, just because it is
inconvenient at the time
 Problems at this stage
• Even when patients are judged to be
eligible for thrombolysis
– Trained staff are not always available for
intensive monitoring at the ASU
– It is EXPENSIVE (no health coverage)
Step 4: Admit the patient to the ASU
 What is an acute stroke unit?
• Hospital unit that cares for stroke
patients (almost) exclusively
• Has specially trained staff
• Uses multidisciplinary approach
• Has facilities for noninvasive vital signs
monitoring
 What is an acute stroke unit?
• Best type of ASU's:
– Combined acute stroke / rehabilitation unit
– Dedicated rehabilitation unit
What if we don't have an
acute stroke unit?

Refer to specialist
(ENT) for fiberoptic
endoscopic
evaluation of
swallowing (FEES)
What if we don't have an
acute stroke unit?

Test swallowing to
water and to fluids
of increasing
viscosity
What if we don't have an
acute stroke unit?
What if we don't have an
acute stroke unit?
What if we don't have an
acute stroke unit?
What if we don't have an
acute stroke unit?
What if we don't have an
acute stroke unit?
What if we don't have an
acute stroke unit?
What if we don't have an
acute stroke unit?
 Towards More Effective
Stroke Care
• Educate both the public and health
professionals (this means YOU)

“Teaching the public about the symptoms and signs of

stroke is one of the highest priorities of public medical
education.”
– EUSI executive committee
 Towards More Effective
Stroke Care
• Educate both the public and health
professionals (this means YOU)
– Health care professionals need to learn that
they are “important and competent
partners in the team providing acute
stroke care”
 Towards More Effective
Stroke Care
• We must ensure that stroke patients get
priority treatment
– Protocols and agreements must be put in
place within and outside the hospital
– Infrastructure must be in place (staff,
financing, and medical resources)
THANK YOU FOR YOUR KIND ATTENTION