Acute Ischemic Stroke

Acute Ischemic Stroke - Early Management

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Diagnosis Emergency Evaluation and Diagnosis of Acute Ischemic Stroke ÎÎAn organized protocol for the emergency evaluation of patients with suspected stroke is recommended (I-B). Notes: The goal is to complete an evaluation and to begin fibrinolytic treatment within 60 minutes of the patient's arrival in an emergency department (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. ÎÎThe use of a stroke rating scale, preferably the National Institutes of Health Stroke Scale (NIHSS – Table 2), is recommended (I-B). ÎÎA limited number of hematologic, coagulation, and biochemistry tests are recommended during the initial emergency evaluation, and only the assessment of blood glucose must precede the initiation of IV rtPA (Table 3) (I-B). ÎÎBaseline electrocardiogram assessment is recommended in patients presenting with acute ischemic stroke but should not delay initiation of IV rtPA (I-B). ÎÎBaseline troponin assessment is recommended in patients presenting with acute ischemic stroke but should not delay initiation of IV rtPA (I-C). ÎÎThe usefulness of chest radiographs in the hyperacute stroke setting in the absence of evidence of acute pulmonary, cardiac, or pulmonary vascular disease is unclear. If obtained, they should not unnecessarily delay administration of fibrinolysis (IIb-B). Early Diagnosis: Brain and Vascular Imaging For patients with acute cerebral ischemic symptoms that have not yet resolved: ÎÎEmergency imaging of the brain is recommended before initiating any specific therapy to treat acute ischemic stroke (I-A). Notes: In most instances, non–contrast-enhanced CT will provide the necessary information to make decisions about emergency management. ÎÎEither non–contrast-enhanced CT or MRI is recommended before IV rtPA administration to exclude intracerebral hemorrhage (absolute contraindication) and to determine whether CT hypodensity or MRI hyperintensity of ischemia is present (I-A). ÎÎIV fibrinolytic therapy is recommended in the setting of early ischemic changes (other than frank hypodensity) on CT, regardless of their extent (I-A). 8

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