Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
A 52-year-old police officer, with a history of hypertension and smoking, is having
dinner with his wife when he develops sudden onset of difficulty speaking, with
drooling from the left side of his mouth, and weakness in his left hand. The family
noted that the symptoms began just as the evening news was starting. His wife
asks him if he is all right and the patient denies any difficulty. His symptoms
progress over the next ten minutes until he cannot lift his arm and has trouble
standing. The patient continues to deny any problems. The wife sits the patient in
a chair and calls 911.
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
Page 2 of 21
Ischemic Anterior Circulation Stroke
Case Details
PMHX
+ HTN No history of migraines, seizures, prior stroke, diabetes
MEDS
ACE inhibitor
VS
BP 150/80
P 89 R 20 T 98.9 SaO2 95%
Physical Exam
Well appearing, awake middle-aged male, in no acute distress.
HEENT:
NC/AT, no contusions Neck supple, NT. No JVD or bruits
CV:
RRR, φ MRG
Lungs:
CTA, φ WRR
Abd:
Soft, non-tender.
Extremities:
Warm and dry. No clubbing, cyanosis, or edema
Neuro:
Mental status Awake, responsive, and appropriate
Patients answers correctly, and follows commands
Cranial nerves Mild left facial droop. Forehead moves symmetrically
PERRL / EOMI except for slight difficulty crossing midline to left
Visual fields Intact bilaterally but difficult to assess
Motor
Right arm and leg extremity with 5/5 strength
Left arm cannot resist gravity, left leg with mild drift
Sensation
Intact bilaterally to fine touch.
Neglect
Mild neglect to left side of body however can be corrected.
Ataxia
None with heal to shin and finger to nose
Language
Expressive and receptive language intact
Mild to moderate dysarthria. Able to protect airway
NIHSS 8
Laboratory Evaluation
CBC, renal, and ECG unremarkable. Glucose 100
Noncontrast head CT (performed 1.5 hours from symptom onset)
No intracranial hemorrhage or mass lesions. Suggestion of early ischemic changes in right
hemisphere (mild loss of insular ribbon and subtle loss of gray-white matter interface) but no
large areas of hypodensity or mass effect.
Impression
52 year old Caucasian male, with several risk factors for cardio and cerebrovascular disease, with
symptoms consistent with a right middle cerebral artery distribution ischemic stroke, now 2
hours from symptom onset. What would you do?
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
Page 3 of 21
Ischemic Anterior Circulation Stroke
Introduction
Despite recent medical advances, stroke remains as one of the most feared disease to strike
adults. Over 700,000 Americans suffer strokes each year, and it has a societal cost of over $40
billion dollars. Stroke remains the third leading cause of death and the number one cause of
adult disability. Of all strokes, nearly 85% are ischemic; the remainder are intracerebral and
subarachnoid hemorrhages. Within the past decade, care for all these forms of stroke, and
especially ischemic, has evolved from being largely supportive and passive to being acutely
interventional – attempting to limit and sometimes reverse the injury. Much of acute stroke care
is and will remain the responsibility of the Emergency Physician, for “time is brain”.
Ischemic stroke are often classified by the vascular distribution involved. Anterior circulation
strokes, involving the territory served by the carotid arteries, represent over two thirds of all
ischemic strokes. In the Lausanne stroke registry, 96% of all anterior circulation strokes
involved the middle cerebral artery (MCA) distribution, 3% involved the anterior cerebral artery
(ACA), and 1% involved the entire internal carotid (ICA) distribution. Posterior circulation
strokes on the other hand involve regions supplied by the vertebral arteries and represent
approximately one quarter of all strokes. The vascular distribution involved will determine the
clinical features of the stroke and often produce typical “stroke syndromes” discussed later in the
text.
Emergency Department Evaluation
In the past several years, stroke advocates have been stressing the importance of the “Seven Ds”.
(Table 1)[1,2,3,4] This mnemonic highlights the essential aspects of acute stroke care delivery.
Remarkably, almost all of the steps can and will involve the Emergency Physician.
Table 1.
Detection
Dispatch
Delivery
Door
Data
Decision
Drug
The 7 “D’s” of Stroke Management
The awareness of stroke signs and symptoms by the patient
Activation of EMS systems, priority dispatch, and rapid EMS response
Rapid transport to the appropriate facility, en-route assessment,
and prehospital notification
Emergency department triage
Emergency department evaluation
(Neurologic evaluation - NIH stroke scale, glucose, head CT)
Selection of appropriate therapy
Delivery of therapeutics
EMS systems play a crucial role in acute stroke care. Since the approval of tPA for stroke, EMS
personnel have been one of the first groups to change their approach to stroke patients. In
general, they now view stroke as an emergency, on par with acute myocardial infarction (AMI)
and trauma. Dispatch priorities now place stroke at the top and rapid transport to the hospital the
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
Page 4 of 21
rule. Prehospital care providers can begin the process of stroke evaluation, with tools such as the
Cincinnati Prehospital Stroke scale, and can save the receiving physician significant time.[5,6]
The Emergency Department (ED) and ED physician play a crucial role in timely and effective
stroke care delivery. Similar to trauma and acute myocardial infarction (AMI), acute stroke
patients should receive the highest priority in the ED. To achieve the time targets set forth by the
NINDS consensus panel and recommended by the AHA in the ACLS guidelines, pathways or
protocols that are well known and rehearsed need to be in place before the stroke patient arrives.
[4,7,8,9] This requires a team approach, analogous to the trauma team, comprised of physicians
and nurses from emergency medicine as well as neurology and radiology. It is difficult to
effectively treat acute stroke patients without this team approach and to ensure continuity of care
once the patients are admitted to the hospital.[10,11]
The rapid evaluation and treatment of stroke patients occurs in parallel, requiring the history of
present illness, physical exam, and initial management all to proceed simultaneously. As with all
patients presenting to the ED, the ABCs remain paramount. Ischemic strokes, unless very large,
tend not to cause immediate problems with airway patency, breathing abnormalities, or
circulation issues. On the other hand, intracerebral and subarachnoid hemorrhage patients will
frequently require intervention with both airway protection and ventilation. Regardless of the
stroke etiology, attention to the ABCs is first and foremost.
History of Present Illness
The history alone can be very suggestive as to the cause of the patient’s symptoms and will help
create a focused differential diagnosis. Frequently the potential stroke patient cannot provide
much of the history surrounding the event so family members, coworkers, bystanders, and EMS
professionals are very important sources of information. Essential elements of the history
include: the exact time of onset or the last time the patient was last seen at baseline, whether any
seizure activity was noted to precede the onset of symptoms, recent migraine headaches, any
trauma or neck injury in the preceding days, and if the patient had any recent illnesses. Not only
are these important to making the correct diagnosis but will also dictate which therapies will be
available to the patients.
The exact time of symptom onset or the last time the patient was seen at their baseline is the
most crucial piece information. Currently ischemic strokes that are greater than 3 hours from
symptom onset are not eligible for thrombolytic therapy. From animal and human data, neuronal
tissue suffers irreparable injury after relatively brief periods of ischemia, and by 3 hours, little
viable tissue remains. Advanced neuroimaging techniques, including Xenon CT and diffusion /
perfusion weighted MRI may identify patients beyond the 3 hour window who may still have
salvageable penumbral tissue.
The past medical history and current medications are of importance. This information can not
only help prioritize items on the differential diagnosis but may determine eligibility for specific
therapeutic interventions. Medical records, primary care physicians, family members, and EMS
personnel again play a vital role.
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
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Physical Examination
It is worth restating that the ABCs are paramount. Stroke patients can quickly deteriorate and
constant reassessment is critical and strict attention to vitals signs equally important. Many
stroke patients are hypertensive at baseline and their blood pressure can be even more elevated
after stroke. Cardiac arrhythmias, such as atrial fibrillation, are commonly found in stroke
patients.
The physical examination must investigate all the major organs systems. Ischemic strokes can
originate in the major vessels of the chest or neck, arise from cardiac sources, or develop in-situ.
The physical examination can help determine the potential cause of the stroke. Commonly
strokes occur concurrently with other acute conditions such as AMI, congestive heart failure,
atrial fibrillation/flutter, carotid or vertebrobasilar dissections, and less commonly with thoracic
aortic dissections.
The neurologic examination is paramount and yet is perhaps the weakest area of training in most
Emergency Medicine residencies. While a thorough neurologic examination similar to those
taught in medical school can take nearly an hour to perform, a directed and focused exam can be
performed in minutes and provide great insight into not only the potential cause of the patients
deficits, but help determine the intensity of treatment required. A very useful tool in measuring
neurologic impairment is the National Institutes of Health Stroke Scale (NIHSS).[12] This scale
is easily performed, reliable and has been validated in several studies of both neurologist, and
non-neurologist physicians and nurses. The NIHSS provides insight to the location of vascular
lesions and is correlated with outcome in ischemic stroke patients. It focuses on 5 major areas of
the neurologic examination: level of consciousness, visual function, motor function, sensation
and neglect and cerebellar function. The NIHSS is used by most stroke teams and stroke
neurologists, and quickly describes to the consultant the severity and possible location of the
stroke. It is strongly associated with outcome with and without thrombolytics, and can predict
those patients likely to respond to or develop hemorrhagic complications from thrombolytic use.
Differential Diagnosis
The history and physical examination, combined with neuro-imaging, narrows the differential
diagnosis and can usually identify the cause of the patients’ symptoms. As noted in table 2, many
disease processes may mimic a stroke. One of the most common stroke mimics is hypoglycemia.
Rapid serum glucose measurement, frequently in the prehospital setting, can identify these
patients before the stroke protocol is even activated. Complicated migraines present a particular
challenge to physicians. These tend to occur in younger patients, typically women, and may
appear very much like a stroke. Advanced imaging techniques can help clarify the cause of the
patients’ symptoms. Lastly, Todd’s paralysis can resemble an acute stroke, and only a history of
seizure by the patient or more commonly, by the family who was with the patient at the symptom
onset, indicates seizures as the cause of the focal neurologic deficits.
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
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Table 2.
Differential Diagnosis of Potential Stroke Patients
Most Common
Less Common
Encephalitis / Meningitis
Complicated migraine
Hyponatremia
Intracerebral hemorrhage
Neoplasm
Hyperglycemia
Psychiatric
Hypertensive encephalopathy
Subdural hematoma
Hypoglycemia
Toxicologic
Post-ictal paralysis (Todd’s)
Trauma
Stroke Syndromes
Most ischemic strokes involve the anterior circulation, especially the middle cerebral artery.
Clinical symptoms in ischemic stroke can be explained by understanding the cerebral arterial
distributions of the cortices, cerebellum, and brainstem (Table 3). Neurologic symptoms that
correspond to a specific vascular distribution further support the diagnosis of stroke and help
guide the intensity of treatment. Lacunar strokes have the best functional outcomes, with more
than 80 percent of patients having minimal or no impairment at 1 year. Dominant hemispheric
strokes are especially disabling since the patients expressive and receptive language is impacted.
Furthermore, occlusions of the entire MCA or ICA distributions have very poor prognoses with
early mortality approaching 50% and nearly all patients left with severe disability. While the
NINDS trial showed modest benefit to patients with these large strokes, more recent studies
suggest better response to intra-arterial thrombolysis versus intravenous thrombolysis alone.
Table 3.
Stroke Syndromes
Vascular Territory
Anterior cerebral
Middle cerebral
– dominant
Middle cerebral
– nondominant
Posterior cerebral
Lacunar
– Pure motor
– Pure sensory
– Clumsy hand /
dysarthria
Typical Neurologic Symptoms
Contralateral hemiparesis leg > arm, face;
Contralateral sensory loss;
Change in personality, speech perserveration;
Bilateral occlusions produce paraplegia, anarthria, akinetic mutism
Contralateral hemiparesis arm, face > leg;
Contralateral sensory loss;
Contralateral homonymous hemianopia; Ipsilateral eye deviation;
Broca’s and Wernicke’s aphasias
Contralateral hemiparesis arm, face > leg;
Contralateral sensory loss with extinction;
Contralateral homonymous hemianopia; Ipsilateral eye deviation;
Ipsilateral hemineglect, inattention, extinction on double stimulation
Contralateral hemianopia (patient frequently unaware);
Brain stem findings (varied);
Bilateral occlusions produce cortical blindness
- Contralateral paresis or plegia of face, arm, leg
- Contralateral decreased sensation of face, arm, leg
- Slurred speech, and weakness and ataxia of the arm
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
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Emergency Department Treatment
General Care
The goal of Emergency Department acute stroke management is speed and efficiency, stroke
patient evaluation and treatment should be performed within 1 hour from presentation. Again,
the general management is a team effort with the nursing and physician staff working closely
together (Table 4).
Table 4.
General Management of Acute Stroke Patient
Treat hypoglycemia with D50;
Blood glucose
Treat hyperglycemia with insulin if serum glucose over 300 mg%
See recommendations for thrombolytic and nonthrombolytic candidates
Blood pressure
Observe for ischemic changes or atrial fibrillation
Cardiac monitor
Intravenous fluids Avoid D5W and excessive fluid administration
IV normal saline at 50 cc / hr unless otherwise required
Aspiration risk is great, avoid oral intake until swallowing assessed
NPO
Supplement if indicated (Sa02 < 90%)
Oxygen
Temperature
Avoid hyperthermia, oral or rectal acetaminophen as needed
While not as “sophisticated” as thrombolytics, these basic care issues are of great importance in
stroke care. Hypoglycemia and hyperglycemia need to be identified and treated early in the
evaluation. Not only can both produce symptoms that closely mimic an ischemic stroke, but also
both can aggravate ongoing neuronal ischemia. Administration of glucose in hypoglycemia
produces profound and prompt improvement, while insulin should be started on those stroke
patients with hyperglycemia. Hyperthermia is infrequently associated with stroke but can cause
increased morbidity. Administration of acetaminophen, by mouth or per rectum, is indicated in
the presence of elevated temperature. Lastly, supplemental oxygen is needed only when the
patient has a documented oxygen requirement. No evidence to date suggests that supernormal
oxygenation improves outcome, and some studies suggest it may worsen it.
Blood pressure management
From prehospital care to Emergency Department staff, there is a preoccupation with
hypertension. The current guidelines for blood pressure management in acute stroke are shown
in table 5. As shown, unless there is significant hypertension, or other comorbid conditions that
require hypertensive control, most patients equilibrate over the first several hours, and many
older patients with longstanding hypertension actually require supernormal pressures and will
worsen if they are artificially made normotensive, as penumbral tissue will be compromised and
potential watershed infracts may arise.
The exception to hypertension “tolerance” is in those patients who may be thrombolytic
candidates. Because hypertension is an exclusion criterion to thrombolytic therapy, “gentle”
attempts may be made to bring the stroke patient to within treatable ranges. Patients who require
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
Page 8 of 21
more “aggressive” management, such as nitroprusside or labetalol drips, are not eligible for
thrombolytic therapy.
Table 5.
Blood Pressure Management (adopted from ACLS guidelines)
Fibrinolytic candidates
Labetalol 10-20 mg IVP 1-2 doses or
Pretreatment
Nitropaste 1-2 inches or
SBP > 185 or
Enalapril 1.25 mg IVP
DBP > 110 mm Hg
1. Sodium nitroprusside (0.5 µg/kg/min)
Post-treatment*
2. Labetalol 10-20 mg IVP over 1 to 2 minutes
1. DBP > 140 mm Hg
and consider a labetalol drip at 2-8 mg/min
2. SBP > 230 mm Hg or
3. Labetalol 10 mg IVP, may repeat and
DBP 121 to 140 mm Hg
double every 10 to 20 minutes up to a maximum
3. SBP 180-230 mm Hg or
dose of 150 mg
DBP 105-120 mm Hg
Non-fibrinolytic candidates
1. DBP > 140 mm Hg
2. SBP > 220 or
DBP 121 to 140 mm Hg or
MAP > 130 mm Hg
3. SBP < 220 mm Hg or
DBP 105 to 120 mm Hg or
MAP < 130 mm Hg
1. Sodium nitroprusside 0.5 µg/kg/min
Reduce approximately 10-20%
2. Labetalol 10-20 mg IVP over 1-2 minutes.
May repeat and double every 20 minutes up to
a maximum of 150 mg.
3. Antihypertensive therapy is indicated only if acute
myocardial infarction , aortic dissection, severe
CHF or hypertensive encephalopathy are present.
∗ Monitor vital signs every 15 minutes for 2 hours, then every 30 minutes for 6 hours,
then every hour for 16 hours.
Patient Selection
The NINDS trial and subsequent post-hoc analyses have shown that patients should be selected
to receive thrombolytic therapy according to the original guidelines in the NINDS trial (Table
6).[13,14,15] No pretreatment patient information significantly affected patients’ response to
thrombolytics. In general, increasing age, a history of diabetes, larger strokes based on the NIH
stroke scale (>20), and early CT findings (edema, hypodensity) are associated with worse
outcome regardless of therapy, but no subgroup has been found to have a differential response to
thrombolytics.
Patients at increased risk for post-thrombolytic intracerebral hemorrhage include those again
with larger strokes (NIHSS > 20) and early CT changes. Other factors associated with increased
risk of hemorrhage include thrombolytic administration beyond the 3 hour window, incorrect
dosing of tPA (> 0.9 mg/kg or 90 mg maximum), elevated post-thrombolytic blood pressure, and
possibly post-thrombolysis anticoagulation.[16,17,18,19] Strict adherence to the protocol will
minimize these preventable errors.
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
Table 6.
Page 9 of 21
Indications and Contraindications to tPA Therapy in Acute Ischemic Stroke
Indications:
1. Acute ischemic stroke within 3 hours from symptom onset
2. Age greater than 18 years old (rt-PA has not been studied in pediatric stroke)
Contraindications:
1. Evidence of intracranial hemorrhage on pretreatment evaluation
2. Suspicion of subarachnoid hemorrhage
3. Recent stroke, intracranial or intraspinal surgery, or serious head trauma in the past 3 mos
4. Major surgery or serious trauma in the previous 14 days*
5. Arterial puncture at a non-compressible site or lumbar puncture in the previous 7 days*
6. Major symptoms that are rapidly improving or only minor stroke symptoms*
7. History of intracranial hemorrhage
8. Uncontrolled hypertension at the time of treatment
9. Seizure at the stroke onset
10. Active internal bleeding
11. Intracranial neoplasm, arteriovenous malformation, or aneurysm
12. Known bleeding diathesis including but not limited to:
• Current use of anticoagulants (e.g., warfarin) or an International Normalized Ratio
(INR) > 1.7 or a prothrombin time (PT) > 15 seconds
• Administration of heparin within 48 hours preceding the onset of stroke and an elevated
activated partial thromboplastin time at presentation
• Platelet count < 100,000/mm3
*In the NINDS trial, not present in current package insert
Fibrinolytic Therapy – How To
Key to timely thrombolytic delivery is to calculate and prepare the t-PA dose early on in the
evaluation. To minimize complications adherence to the correct dose is very important. The
correct dosing of rt-PA is 0.9 mg/kg (90 mg maximum); a bolus of 10% of the total dose over 12 minutes, and then the remaining 90% as an infusion over 1 hour.
If thrombolytics are administered, no concomitant heparin, warfarin, or aspirin should be used
during the first 24 hours after treatment. If heparin or any other anticoagulant is indicated after
24 hours, a non-contrast CT scan or other neuroimaging method should be performed to rule out
any intracranial hemorrhage before starting an anticoagulant.
Fibrinolytic Therapy – After rt-PA: Blood pressure management
Patients who have received rt-PA for their ischemic stroke, either IV or IA, require strict blood
pressure control (table 5). Unlike most instances in the ICU where repeat readings are performed
for an elevated blood pressure, prompt action must be taken the very first time a blood pressure
elevation is obtained. The greatest risk to patients within the first 12 to 24 hours post
thrombolysis is hemorrhage, and elevated blood pressure contributes to this risk. The choice of
antihypertensive agent is largely dependent on the severity of the hypertension.
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
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Fibrinolytic Therapy – After rt-PA: Suspected intracerebral hemorrhage
Physicians who administer thrombolytics need also to prepare for intracerebral hemorrhage.
While the risk is relatively small, the consequences of hemorrhage after thrombolytics are grave,
with nearly half of all patients dying shortly afterward. Preparation is key and constant
monitoring and patient reassessment crucial in identifying and treating ICH.
Other Interventions
While the “Decade of the Brain” began with much fanfare and high expectation, the results of
most clinical trials for acute stroke have been disappointing. To date, no pharamacologic agent,
aside from rt-PA, has been approved for the treatment of acute ischemic stroke. Except perhaps
in special situations, such as critical carotid stenoses, stuttering symptoms, or posterior
circulation strokes, unfractionated and low molecular weight heparins are not indicated in acute
ischemic stroke. Aspirin on the other hand has been shown to provide some benefit, both short
and long term. In patients not suited for thrombolytics, aspirin should be administered within 24
hours.
Seizures and Increased Intracranial Pressure
Two complications of acute stroke, seizures and increased intracranial pressure, rarely occur
within the time the stroke patient is being evaluated in the Emergency Department but are
important to remember. Seizures are not uncommon, occurring in 1-10% of all strokes. Seizures
can cause early clinical deterioration and are associated with higher in-hospital mortalities.
Strokes with cortical involvement, larger strokes, and hemorrhagic strokes have a higher
incidence of seizures. Studies suggest seizures will develop early, with roughly a quarter
occurring within the first 24 hours from stroke onset. Benzodiazepines are the drugs of choice
and are used in a similar fashion to non-stroke related seizures.
Increased intracranial pressure (ICP) is a life-threatening event associated with up to 20% of all
strokes, and more commonly found in large strokes. Edema and herniation produces significant
mortality in patients with hemispheric stroke. Similar to increased ICP secondary to closed head
injury, position, hyperventilation, hyperosmolar therapy, and rarely barbiturate coma can be
used. More recently, preliminary studies of hemicraniectomy to immediate reduce lifethreatening ICP have suggested benefit if performed before clinical deterioration.[20]
Disposition
Establishing pathways and protocols for acute stroke treatment not only assist in the immediate
management of the stroke patient while in the E.D., but also assure attention to preventing the
early complications of stroke and begins the evaluation for the cause of the current stroke as well
as initiation of risk factor reduction to prevent reoccurrence. Stroke pathways often include
carotid ultrasound, speech assessment, and cerebrovascular evaluation, often within the first day.
This organized approach not only decreases length of hospitalization and total expenditures, but
also leads to better outcome and lower morbidity.
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
Page 11 of 21
All patients who receive rt-PA require admission to an intensive care unit (ICU) setting. There
they will: 1) receive intensive neurologic monitoring for signs of deterioration due to edema,
infarct extension, or intracerebral hemorrhage, 2) undergo strict blood pressure control, 3) be
observed for systemic hemorrhagic complications, and 4) treated for many of the co-morbid
illness that coexist with stroke patients. Patients that do not receive thrombolytics should receive
aspirin and may be admitted to locations with lower levels of acuity appropriate for the general
condition of the patient.[21,22] Lastly, early mobilization, swallowing assessment, and physical
therapy / occupational therapy translates into shorter hospitalizations and more rapid recovery.
Future Directions
The future remains bright for the development of new therapies for stroke. While initial trials of
pharamacologic agents, such as neuroprotectives and low molecular weight heparins, were
negative, newer agents are in Phase II and III clinical trials. Ongoing stroke trials involve newer
neuroprotectives and antiplatelet agents, such as the IIb IIIa glycoprotein. The newest large
NINDS funded trial is the Interventional Management of Stroke trial, investigating thrombolytic
delivery via intra-arterial catheterization in combination with a lower intravenous dose given
prior to angiography.[23] Recent small trials have demonstrated superior rates of restoring
vessel patency with improved outcome. Again, mimicking the cardiac arena, catheters for
mechanical clot removal are also under investigation.
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Edward C. Jauch, MD, MS
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Ischemic Anterior Circulation Stroke
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21. Chen ZM, Sandercock P, Pan HC, Counsell C, Collins R, Liu LS, Xie JX, Warlow C, Peto
R Indications for early aspirin use in acute ischemic stroke : A combined analysis of
40 000 randomized patients from the Chinese acute stroke trial and the international
stroke trial. On behalf of the CAST and IST collaborative groups. Stroke. 2000
Jun;31(6):1240-9.
22. CAST: randomized placebo-controlled trial of early aspirin use in 20,000 patients with
acute ischaemic stroke. CAST (Chinese Acute Stroke Trial) Collaborative Group.
23. Lewandowski, C. A., Frankel, M., Tomsick, T. A., Broderick, J., Frey, J., Clark, W.,
Starkman, S., Grotta, J., Spilker, J., Khoury, J., Brott, T. (1999). Combined
Intravenous and Intra-Arterial r-TPA Versus Intra-Arterial Therapy of Acute
Ischemic Stroke : Emergency Management of Stroke (EMS) Bridging Trial. Stroke
30: 2598-2605.
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
Page 14 of 21
Ischemic Anterior Circulation Stroke
Case Outcome
The emergency physician, in collaboration with the Stroke Team, concluded that the patient’s
symptoms were the results of an ischemic stroke. The patient met the time window for
thrombolytics and had no exclusion to the therapy. After discussing the options with the patient
and his family, he elected to receive thrombolytic therapy. He was given IV t-PA 0.9 mg/kg
dose per protocol and admitted to the ICU. The next 24 hours were largely uneventful. He
required a single, 10 mg dose of labetalol for an episode of elevated blood pressure. His
symptoms began to improve an hour after the infusion, and continued over night. His
examination at 24 hours post stroke revealed only a mild right arm drift and a mild right facial
droop for a NIH stroke scale of 2. His leg weakness, visual field cut, and gaze palsy had all
resolved. His 24 hour CT scan revealed two very small areas of developing hypodensity in the
left parietal cortex, reflective of his residual deficits.
On the first hospital day, his swallowing was assessed by a screening tool and found to be intact.
A carotid duplex study revealed a stenosis of over 90% and after balancing the risk of recurrent
stroke from surgery or recanalization vs. new embolic stroke from the stenosis, a carotid
endarterectomy was performed on day 4. The patient continued physical therapy while
hospitalized and was discharged home on day 7. Three months after his stroke, his only
complaint was that his very mild right arm weakness had cost him several strokes in his
previously scratch golf game.
Final Thoughts
Stroke was once a disease of little hope. For the first time ever in the history of medicine we can
now begin to prevent the long-term morbidity and mortality of stroke and actively intervene
before the damage is irreversible. Emergency Physicians and ED staffs are on the front line of
this battle but we should not be alone in this fight. Hospital wide collaboration is essential to
give stroke patients the best chance at a good outcome and a future without disability.
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
Page 15 of 21
Ischemic Anterior Circulation Stroke
Annotated Bibliography
1.
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study
Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med..
1995;333:1581-1587.
This is the sentinel article describing the data that lead to the approval of tPA for stroke.
This was a two-part study in which both independent parts showed sustained benefit for
tPA in acute ischemic stroke within the first three hours from symptom onset.
2.
Haley EC Jr, Lewandowski C, Tilley BC. Myths regarding the NINDS rt-PA Stroke
Trial: setting the record straight. Ann Emerg Med. 1997 Nov;30(5):676-82.
This brief commentary highlights several of the misconceptions regarding the NINDS
trial. The authors, from Emergency Medicine and Neurology, provide a very insightful
review and interpretation regarding the NINDS data.
3.
Adams HP Jr, Brott TG, Crowell RM,et al. Guidelines for the management of
patients with acute ischemic stroke: a statement for healthcare professionals from a
special writing group of the Stroke Council, American Heart Association. Stroke..
1994;25:1901-1914.
American Heart Association Stroke Update. Part 7: The Era of Reperfusion. Circulation
2000;102(suppl I):I.204-216. (in press)
The American Heart Association provides leadership in the establishment of treatment
guidelines for cerebrovascular and cardiovascular diseases. This initial consensus paper
established the basic treatment steps regarding acute ischemic stroke. The newer update
utilizes information gained over the past 4 years of thrombolytic use and makes
modifications to the original recommendations.
4.
Adams HP, Brott TG, Furlan AJ, et al. Guidelines for Thrombolytic Therapy for
Acute Stroke: A Supplement to the Guidelines for the Management of Patients With
Acute Ischemic Stroke. Circulation 1996 94: 1167-1174.
This is an evidence based medicine supplement to the ischemic stroke guidelines that
reviews the data for thrombolytics stroke and establishes recommendations for
thrombolytic administration.
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
5.
Page 16 of 21
Spilker JS, Knogable G, Barch J, et al. Using the NIH Stroke Scale to assess stroke
patients. The NINDS rt-PA Stroke Study Group. J Neurosci Nurs. 1997 Dec;
29(6):384-92.
The NIH stroke scale has been shown to be not only an efficient and reproducible
measure of neurologic deficit, but also highly correlates with not only outcome but also
identifies patients at higher risk of hemorrhage after thrombolytics.
6.
Kothari RU, Pancioli A, Liu T, et al. Cincinnati Prehospital Stroke Scale:
reproducibility and validity. Ann Emerg Med.1999; 33:373 -8.
Prehospital care plays a critical role in the treatment of acute stroke. One component is
to recognize potential stroke patients. Without burdening the prehospital care providers
the Cincinnati Prehospital Stroke Scale is a quick and easy neurologic assessment tool
with good sensitivity for anterior circulation stroke. EMS personnel can provide early
notification and consider triage to appropriate hospitals.
7.
Donnan GA, Davis SM, Chambers BR, et al. Streptokinase for acute ischemic
stroke with relationship to time of administration: Australian Streptokinase (ASK)
Trial Study Group. JAMA. 1996 Sep 25; 276(12):961-6.
Hacke W, Kaste M, Fieschi C, et al Intravenous thrombolysis with recombinant
tissue plasminogen activator for acute hemispheric stroke. The European
Cooperative Acute Stroke Study. JAMA. 1995 Oct 4; 274(13):1017-25.
Hacke W, Kaste M, Fieschi C, Randomized double-blind placebo-controlled trial of
thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS
II). Second European-Australasian Acute Stroke Study Investigators. Lancet. 1998
Oct 17; 352(9136):1245-51.
Randomized controlled trial of streptokinase, aspirin, and combination of both in
treatment of acute ischaemic stroke. Multicentre Acute Stroke Trial--Italy (MASTI) Group. Lancet. 1995 Dec 9; 346(8989):1509-14.
Thrombolytic therapy with streptokinase in acute ischemic stroke. The Multicenter
Acute Stroke Trial--Europe Study Group. N Engl J Med. 1996 Jul 18; 335(3):14550.
These five papers represent the major streptokinase and rt-PA publications regarding
acute treatment of stroke. Frequently, they will be used for comparison with the NINDS
trial or used in meta-analyses. They do provide insight on the evolution of the current
stroke recommendations and how the NINDS protocol was developed and later accepted.
For more information, please refer to the Thrombolytic Therapy for Stroke presentation.
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
8.
Page 17 of 21
Donnan GA, Davis SM, Chambers BR, et al The rt-PA (alteplase) 0- to 6-hour acute
stroke trial, part A (A0276g) : results of a double-blind, placebo-controlled,
multicenter study. Thrombolytic therapy in acute ischemic stroke study
investigators. Stroke. 2000 Apr; 31(4):811-6.
Hacke W, Kaste M, Fieschi C, et al. Randomized double-blind placebo-controlled
trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke
(ECASS II). Second European-Australasian Acute Stroke Study Investigators.
Lancet. 1998 Oct 17; 352(9136):1245-51.
These two studies / substudies demonstrated the need to administer thrombolytics within
3 hours. Attempts to extend the therapeutic window were met with no change in outcome
compared with placebo, and exposed the patients to increased of hemorrhagic
complications.
9.
Solomon NA, Glick HA, Russo CJ, et al. Patient preferences for stroke outcomes.
Stroke. 1994 Sep;25(9):1721-5.
Solomon was one of the first (and few) authors who looked at patients’ perceptions of
stroke outcomes. This article is key to understanding the risks of stroke treatment
options. The risks belong to the patient, and an act of omission (i.e. no treatment) can
lead to worse outcomes than an act of commission. Food for thought.
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
Page 18 of 21
Ischemic Anterior Circulation Stroke
Questions
1. Which is not a typical symptom of anterior circulation ischemic strokes?
a. Unilateral arm, face, and leg weakness
b. Hemianopia
c. Headache
d. Slurred speech
e. Aphasia
2. Which is a contraindication to thrombolytic therapy?
a. A stroke 2 weeks prior
b. A history of seizures
c. Serum glucose of 80 mg/dl
d. Age greater than 80 years old
e. NIH stroke scale of 5
3. Which CT findings are signs of early ischemia?
1. Loss of the insular ribbon
2. Hypodensity
3. Dense middle cerebral artery sign
4. Loss of gray – white matter differentiation
a. 1, 2
b. 2, 4
c. 1, 2, 3
d. All the above
4. The degree of neurologic deficit measured by the NIHSS is correlated with:
1. Size of infarct seen on follow-up CT
2. Risk of hemorrhage in patients receiving thrombolytics
3. Outcome
4. Likelihood of effect from tPA
5. Need for blood pressure control
a. 1, 2
b. 2, 4
c. 1, 2, 3, 4
d. All the above
5. Which of the following is true:
a. A blood pressure of 200/110 in a non-thrombolytic stroke patient requires
immediate treatment
b. A blood pressure of 160/100 in a patient who is receiving thrombolytics
requires immediate treatment
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
Page 19 of 21
c. Oral clonidine is safe to use in acute stroke patients
d. One or two doses of IV labetalol is an effective method to "gently" lower
a stroke patient's blood pressure to allow them to receive thrombolytics
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
Page 20 of 21
Ischemic Anterior Circulation Stroke
Answers
1.
Answer c.
Headache is not typical found in patients with ischemic stroke. Intracerebral hemorrhage
and subarachnoid hemorrhages do have headache as part of their presenting signs and
symptoms.
2.
Answer a.
A stroke two weeks prior would expose the patient to a high risk of hemorrhage into the
area of previous stroke. tPA use within 3 months of prior stroke is not recommended.
3.
Answer d.
All are findings of ischemia. Only a large area of hypodensity (greater than one third of
the middle cerebral artery distribution, is a contraindication to thrombolytics. If
significant changes are seen within the first three hours from symptom onset, question the
time of stroke onset.
4.
Answer c.
The NIHSS is a very useful tool to access the size of stroke but also provide insight into
the likely prognosis of the patients and the chance for both effect from receiving
thrombolytics but also the risk of hemorrhage afterwards. It has not been shown to
correlate with the need for blood pressure control.
5.
Answer d.
Aggressive lowering of hypertension, with continuous IV infusions, is not recommended
for patients who may be eligible for thrombolytics. Single boluses of labetalol or
enalapril are commonly used agents to help gently lower blood pressure in patients who
may be eligible for thrombolytic therapy. Most non-thrombolytic patients do not require
aggressive blood pressure management and an ischemic stroke can be worsened by over
treatment of blood pressure. Many stroke patients have long standing hypertension and
relative iatrogenic hypotension may increase the region of ischemia. Other comorbid
conditions, such as acute myocardial infarction, aortic dissection, and congestive heart
failure, may require more aggressive blood pressure management. Oral agents should not
be used due to the risk of aspiration.
Ischemic Anterior Circulation Stroke
Edward C. Jauch, MD, MS
Appendix A
Category
1a
Level of Consciousness
1b
LOC Questions
(Month, Age)
1c
LOC Commands
(Open-close eyes, show thumb)
2
Best Gaze
(Follow finger)
3
Best Visual
(Visual fields)
4
Facial Palsy
(Show teeth, raise brows, squeeze eyes shut)
5
Motor Arm Left*
(Raise 90o, hold 10 seconds)
6
Motor Arm Right*
(Raise 90o, hold 10 seconds)
7
Motor Leg Left*
(Raise 30o, hold 5 seconds)
8
Motor Leg Right*
(Raise 30o, hold 5 seconds)
9
Limb Ataxia
(Finger-nose, heel-shin)
10
Sensory
(Fine touch to face, arm, leg)
11
Extinction / Neglect
(Double simultaneous testing)
12
Dysarthria
(Speech clarity to “mama, baseball, huckleberry,
tip-top, fifty-fifty”)
13
Best Language **
(Name items, describe pictures)
Page 21 of 21
NIH Stroke Scale
Description
Score
Alert
Drowsy
Stuporous
Coma
Answers both correctly
Answers 1 correctly
Incorrect on both
Obeys both correctly
Obeys 1 correctly
Incorrect on both
Normal
Partial gaze palsy
Forced deviation
No visual loss
Partial hemianopia
Complete hemianopia
Bilateral hemianopia
Normal
Minor
Partial
Complete
No drift
Drift
Can’t resist gravity
No effort against gravity
No movement
No drift
Drift
Can’t resist gravity
No effort against gravity
No movement
No drift
Drift
Can’t resist gravity
No effort against gravity
No movement
No drift
Drift
Can’t resist gravity
No effort against gravity
No movement
Absent
Present in one limb
Present in two limbs
Normal
Partial loss
Severe loss
No neglect
Partial neglect
Complete neglect
Normal articulation
Mild to moderate dysarthria
Near to unintelligible or worse
No aphasia
Mild to moderate aphasia
Severe aphasia
Mute
0
1
2
3
0
1
2
0
1
2
0
1
2
0
1
2
3
0
1
2
3
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
0
1
2
0
1
2
0
1
2
0
1
2
3
0 - 42
Total
*
For limbs with amputation, joint fusion, etc. score a “9”and explain.
** For intubation or other physical barrier to speech, score a “9” and explain