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).
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