What are the Cincinnati Prehospital Stroke Scale (CPSS) guidelines?

From the Guidelines

The Cincinnati stroke guidelines prioritize early diagnosis and pre-hospital care, emphasizing the importance of public education programs, emergency transportation systems, and first responders' use of validated pre-hospital stroke assessment tools, as outlined in the 2023 systematic review and synthesis of global stroke guidelines 1.

Key Recommendations

• Public education programs about identification of stroke signs and the need to seek emergency care should be designed and implemented in the community, as they are essential for early diagnosis and treatment 1.
• First responders should rapidly evaluate airway, breathing, and circulation, use a validated pre-hospital stroke assessment tool, and ascertain the time of onset of stroke symptoms, to ensure timely and appropriate care 1.
• Patients with a possible stroke should be immediately transported to the closest hospital capable of providing emergency stroke care, including IV thrombolysis, and emergency responders should notify the hospital to prepare the appropriate resources 1.

Hyperacute Hospital Care

• Hospitals caring for patients with acute stroke should have an organized protocol for emergency evaluation using a validated stroke screening tool, and telemedicine/telestroke resources should be supported to ensure 24/7 availability of stroke expertise 1.
• Tracheal intubation is indicated for compromised airway or insufficient ventilation, and supplemental oxygen should be provided to maintain oxygen saturation ≥94% 1.
• Hypotension and hypovolemia should be corrected to maintain systemic perfusion levels, and emergency treatment of hypertension is indicated in specific situations, such as concomitant acute myocardial ischemia or aortic dissection 1.

Reperfusion Therapy

• Patients eligible for IV thrombolysis should have the treatment initiated as soon as possible, and IV alteplase is recommended for selected patients who can be treated within 4.5 hours of ischemic stroke symptom onset or last known well 1.
• Eligible patients should receive IV thrombolysis even if mechanical thrombectomy is being considered, and patients with clinically suspected large vessel occlusion (LVO) should have non-invasive angiography (e.g., CTA) 1.

From the Research

Cincinnati Stroke Guidelines

• The guidelines for stroke treatment are based on various studies, including those on tissue plasminogen activator (tPA) administration 2, 3, 4, 5, 6.
• tPA is the only therapeutic agent approved to treat patients with acute ischemic stroke, with clinical benefits manifesting when administered within 4.5 hours of stroke onset 2.
• The American Heart Association and American Stroke Association recommend intravenous tPA for eligible patients within 3-4.5 hours of stroke onset 3.
• Other treatment options include intra-arterial recombinant tissue plasminogen activator, mechanical thrombectomy, clot retrieval, or a combination of these approaches 4.
• The use of tPA in patients with atrial fibrillation has been studied, with results showing improved clinical outcomes in patients treated with tPA within 4.5 hours of stroke onset 5.
• The optimal dose of tPA remains a topic of debate, with some studies comparing the efficacy and safety of standard-dose and low-dose regimes 6.

Key Considerations

• Time of tPA administration: within 4.5 hours of stroke onset 2, 3.
• Patient eligibility: based on factors such as age, medical history, and stroke severity 4, 5.
• Dose of tPA: standard-dose (0.9 mg/kg bodyweight; maximum 90 mg) versus low-dose (0.6 mg/kg bodyweight; maximum 60 mg) regimes 6.
• Monitoring for complications: such as intracranial hemorrhage and hemorrhagic transformation 2, 5.