What are the interventions for acute stroke in the emergency room (ER)?

Emergency Interventions for Acute Stroke

Intravenous tissue plasminogen activator (tPA) should be offered to acute ischemic stroke patients who meet National Institute of Neurological Disorders and Stroke (NINDS) inclusion/exclusion criteria and can be treated within 3 hours after symptom onset to improve functional outcomes. 1

Initial Assessment and Stabilization

• Ensure airway, breathing, and circulation are stabilized while simultaneously beginning the stroke evaluation protocol 2
• Determine the exact time of symptom onset (when the patient was last known to be at their baseline or symptom-free), which is crucial for treatment decisions 2
• Use a validated stroke rating scale, preferably the National Institutes of Health Stroke Scale (NIHSS), to assess stroke severity and guide treatment decisions 2
• Designate an acute stroke team including physicians, nurses, and laboratory/radiology personnel to expedite evaluation 2
• Triage patients with suspected stroke with the same priority as patients with acute myocardial infarction or serious trauma, regardless of the severity of neurological deficits 1

Diagnostic Imaging and Laboratory Evaluation

• Perform non-contrast CT scan of the brain within 25 minutes of arrival to exclude hemorrhage and identify early signs of ischemia 2
• Aim for CT interpretation within 45 minutes of arrival (door-to-interpretation time) for patients who are candidates for thrombolytic therapy 2
• Consider multimodal imaging approaches including CT perfusion and CT angiography in selected cases to evaluate cerebral blood flow and vessel status 2
• Obtain essential laboratory tests including blood glucose, electrolytes, renal function tests, and coagulation studies (PT/INR, aPTT) 2
• Perform a 12-lead ECG due to the high incidence of heart disease in stroke patients 2

Acute Treatment Options

Intravenous Thrombolysis

• Administer intravenous tPA at a dose of 0.9 mg/kg (maximum dose 90 mg) with 10% given as bolus and the remainder infused over 60 minutes for eligible patients 1
• Consider tPA for patients who can be treated within 3-4.5 hours after symptom onset if they meet European Cooperative Acute Stroke Study (ECASS) III inclusion/exclusion criteria 1
• Be aware that tPA treatment is associated with a risk of symptomatic intracerebral hemorrhage (approximately 6.4% vs 0.6% with placebo) 3
• Monitor for and manage complications of tPA, including bleeding and hypersensitivity reactions 4
• Once the decision is made to administer IV tPA, treat the patient as rapidly as possible to maximize benefit 1

Endovascular Therapy

• Consider endovascular thrombectomy for patients with large vessel occlusion who meet eligibility criteria 1
• The technical goal of thrombectomy should be a TICI grade 2b/3 angiographic result to maximize the probability of a good functional clinical outcome 1
• Consider salvage technical adjuncts, including intra-arterial fibrinolysis, to achieve optimal angiographic results if completed within 6 hours of symptom onset 1
• Endovascular therapy requires the patient to be at an experienced stroke center with rapid access to cerebral angiography and qualified neurointerventionalists 1

Systems of Stroke Care

• Transport patients rapidly to the closest available certified primary stroke center or comprehensive stroke center 1
• Develop regional systems of stroke care consisting of facilities that provide initial emergency care and centers capable of performing endovascular stroke treatment 1
• Ensure that any hospital in the stroke system that provides emergency department services can function as a primary stroke center or rapidly transfer appropriate patients 1
• Develop strategies that incorporate hospitals that do not intend to seek stroke center status, including predetermined plans to collaborate with other facilities via telemedicine or transport protocols 1

Early Management and Monitoring

• Admit patients to a dedicated stroke unit with monitored beds for at least the first 24 hours 2
• Control blood pressure carefully, especially in patients receiving thrombolytic therapy 2
• Monitor neurological status frequently to detect early deterioration 2
• Treat fever aggressively as it can worsen neurological damage 2
• Begin venous thromboembolism prophylaxis with intermittent pneumatic compression devices within 24 hours for immobile patients 2
• Assess swallowing function before initiating oral intake to prevent aspiration 2
• Begin early mobilization within 24 hours if there are no contraindications 2

Common Pitfalls and Caveats

• Delays in door-to-needle time significantly impact outcomes - for every 15-minute reduction in door-to-needle time, there is a 5% lower odds of in-hospital mortality 1
• Only a small proportion of eligible stroke patients receive tPA therapy, with rates ranging from 5% in the US to 14% in some European centers 5
• The effectiveness of tPA is less well established in institutions without systems in place to safely administer the medication 1
• Barriers to timely treatment include lack of guideline awareness, stressful working conditions, and lack of resources 1
• Avoid excessive pressure when administering tPA to prevent complications 4
• Be aware of contraindications to tPA, including active internal bleeding, recent surgery, thrombocytopenia, and other hemostatic defects 4