Diagnosis

The roles of emergency medical services, emergency department personnel, and neurologists in combination and concord are essential for recognizing strokes and administering the appropriate therapy in a timely manner. In the emergency department, and after establishing an accurate time of symptom onset, intravenous access should be established, and a blood sample should be obtained for a complete metabolic panel and coagulation studies. Hypoglycemia should be identified and treated without delay. For all stroke patients, vital signs should be recorded, and airway, breathing, and circulation should be secured, including providing oxygen to patients with oxygen saturation less than 94%.

Thereafter, a computed tomographic (CT) scan of the brain should be obtained on an emergent basis to exclude hemorrhage. A noncontrast brain CT scan should be obtained within 25 minutes. Meanwhile, a neurologic evaluation ascertaining the time of symptom onset, past medical history, and National Institutes of Health Stroke Scale (NIHSS) score should be obtained (also within 25 minutes). An electrocardiogram (ECG) is important to recognize possible sources of embolic strokes, which include recent myocardial infarction or arrhythmias (most importantly, atrial fibrillation).

Treatment

Recombinant tissue plasminogen activator (rtPA) is currently the only FDA-approved intravenous fibrinolytic therapy for acute ischemic stroke. Patients should be screened promptly for inclusion and exclusion criteria (Box 1), and a repeat NIHSS score should be obtained before administering the drug. Spontaneous improvement of symptoms back to baseline condition automatically excludes the patient from being a candidate for rtPA therapy.

BOX 1   Inclusion and Exclusion Characteristics of Ischemic Stroke Patients Who Could Be Treated with rtPA

Within 3 Hours from Symptom Onset

Inclusion Criteria

• Ischemic stroke diagnosis causing measurable neurologic deficit

• Symptom onset <3 hours before beginning treatment

• Age ≥18 years

Exclusion Criteria

• Head trauma or prior stroke in previous 3 months

• Symptoms suggesting subarachnoid hemorrhage

• Arterial puncture at noncompressible site within previous 7 days

• History of previous intracranial hemorrhage

• Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)

• Evidence of active bleeding on examination

• Acute bleeding diathesis, including but not limited to the following:

• Platelet count <100,000/mm³

• Heparin received within 48 hours, resulting in activated partial thromboplastin time greater than upper limit of normal

• Current use of anticoagulation with international normalized ratio >1.7 or prothrombin time >15 seconds

• Blood glucose concentration <50 mg/dL (2.7 mmol/L)

• CT scan demonstrating multilobar infarction (hypodensity >⅓ cerebral hemisphere)

Relative Exclusion Criteria and Contraindications

• Only minor or rapidly improving stroke symptoms (clearing spontaneously)

• Seizure at onset with postictal residual neurologic impairments

• Major surgery or serious trauma within previous 14 days

• Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)

• Recent acute myocardial infarction (within previous 3 months)

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