Cardiac & Resuscitation, Patient Care

Acute Stroke: From Prehospital Care to In-Hospital Management

Issue 5 and Volume 43.

Early recognition of stroke by clinical presentation and prehospital stroke assessment tools facilitate rapid prehospital and ED diagnosis. CanStockPhoto/focalpoint

 

Stroke is a leading cause of morbidity and mortality in the United States and requires prompt recognition by prehospital providers to ensure rapid transport. Stroke can present in a variety of different ways, some more readily apparent than others.

Delays in diagnosis and treatment can have devastating effects on the outcomes for these patients. In this article, we describe a patient who initially presented with altered mental status and was subsequently determined to have an acute ischemic stroke.

We further review the etiology and pathophysiology of stroke, as well as the prehospital and ED diagnosis and management options available.

A case involving a patient who initially presented with concern for altered mental status and was subsequently determined to have had an ischemic stroke is discussed.

Prehospital Course

Medic 25 was called to a residential address for a 65-year-old male with altered mental status. On arrival, the patient was found to be awake but unable to speak. His wife stated he has hypertension and diabetes, but that he doesn’t like going to the doctor’s office and hasn’t seen his primary care doctor in many years.

She reported that after dinner he went to the living room to watch television. When she checked on him 20 minutes later, she found him sitting on the couch and unable to respond to her. This persisted, so she called 9-1-1.

The patient was still sitting on the couch, staring forward. He was placed on the cardiac monitor and found to be in an irregularly irregular rhythm with a pulse of 98, blood pressure of 160/110 mmHg, and O2 saturation of 94% on room air.

Physical exam revealed that he was awake, wouldn’t speak and didn’t follow commands. The patient had a prominent left-sided facial droop, and application of noxious stimuli to bilateral upper extremities showed that he didn’t move his left arm or left leg.

Fingerstick glucose was 154 mg/dL and the patient’s ECG showed atrial fibrillation without other acute abnormalities.

The EMS team suspected stroke and gathered additional rapid history while the patient was prepared for transport.

The patient was last seen well, without any neurologic deficits, at 6:30 p.m. (30 minutes prior to EMS arrival). He’d never had a stroke before, and he wasn’t prescribed any anticoagulant or antiplatelet medications.

While en route, an IV was established. The patient was then transported to the nearest hospital, which was also certified as a comprehensive stroke center. The receiving hospital was contacted for pre-notification given the concern for stroke.

Hospital Course

On arrival, the patient’s condition was largely unchanged. His last seen normal time was now 50 minutes prior.

Due to the pre-notification call, the physician at the receiving hospital met the patient at the EMS entrance to the ED. The patient’s hemodynamics remained stable during transport and the neurologic deficits noted earlier had persisted.

The physician performed a rapid assessment of the patient including a National Institutes of Health stroke scale. The CT scanner had been readied in anticipation of arrival, and the patient was rapidly transported for a CT scan of the head.

While the patient underwent CT imaging, the ED physician activated a multidisciplinary team, including members of the ED, a stroke specialist, and staff from radiology and pharmacy.

The CT of the head without contrast didn’t show any evidence of intracranial hemorrhage.

The ED physician discussed the findings with the stroke specialist and the decision was made that the patient was a good candidate for administration of IV tissue plasminogen activator (tPA). Door-to-needle time was 25 minutes, and time from last seen well was 75 minutes.

The patient subsequently had a CT scan of his brain and a neck angiogram which confirmed the suspicion of a left middle cerebral artery (MCA) occlusion. (See Figure 1.)

Figure 1: CT scan showing left middle cerebral artery occlusion

 

The patient was deemed a good candidate for endovascular thrombectomy, and was taken to the interventional radiology suite. The left MCA clot was removed. (See Figure 2.) Repeat imaging within the interventional suite demonstrated appropriate reperfusion.

Figure 2: Thrombus removed from patient’s left middle cerebral artery

 

The patient was then moved to the neurointensive care unit. Over the course of the next hour, the patient had improvement with his left-sided weakness and speech; however, continued to have difficulty with language.

In the ICU, the patient was closely monitored for any complications related to tPA or the endovascular procedure. During his stay in the hospital, he underwent MRI imaging, which was consistent with his known left MCA occlusion and did not show any other abnormalities.

He began rehabilitation while in the ICU, with physical, occupational and speech therapy. Due to the need for ongoing additional rehabilitation, the patient was discharged to a rehabilitation facility, rather than back home.

Over the course of his inpatient rehabilitation stay he experienced significant improvement, and was discharged to home. He continued to receive outpatient rehabilitation, and is now able to ambulate with the assistance of a walker.

He speaks slowly with some persistent mild word finding difficulties but is able to converse with his wife.

Epidemiology of Stroke

Stroke is the fifth leading cause of death for Americans. Each year, more than 795,000 people in the United States have a stroke, and 140,000 of these are deadly. This equates to someone in the U.S. having a stroke every 40 seconds, and someone dying due to a stroke every four minutes. Stroke is a leading cause of serious long-term disability, with reduced mobility occurring in greater than half of stroke survivors over the age of 65.1,2

Stroke affects all genders, ethnicities, and age groups; however, there are some differences that have been observed between demographic groups. Although men have a higher incidence of stroke, women are more likely to die from a stroke. African Americans are nearly twice as likely to have a stroke as Caucasians, and have the highest rate of death amongst all racial groups. Overall, rates of death in stroke patients have declined amongst all races except Hispanics, who have seen an increase in rates of death from stroke since 2013.1–3

Types of Stroke

There are two major types of strokes: clots and bleeds. Strokes due to clots are called ischemic strokes and strokes due to bleeds are called hemorrhagic strokes.

Ischemic strokes account for approximately 87% of all cases. They’re due to an obstruction within a cerebral artery. The obstruction may either be due to thrombosis or embolism. Thromboses develop within the blood vessel at the site of obstruction. This is most often due to atherosclerosis (fatty deposits developing within the lining of the vessels). An embolism occurs when a blood clot forms at one location in the circulatory system, dislodges, and travels to another vessel, leading to a blockage of that blood vessel.4

Hemorrhagic strokes account for approximately 13% of all cases of stroke. There are a variety of etiologies of hemorrhagic strokes, but they are most commonly caused by rupture of chronically damaged vessels.

The two main types of hemorrhagic stroke are intraparenchymal hemorrhage and subarachnoid hemorrhage.

Intraparenchymal hemorrhage is when bleeding occurs within the brain tissue. Subarachnoid hemorrhages (SAH) typically occur when intracranial aneurysms rupture.

Non-contrast CT scans of the brain assess for hemorrhage, while CT angiography studies are performed to assess the brain vasculature.

A transient ischemic attack (TIA) is an event where a blood vessel is temporarily blocked by a clot and the blockage resolves. A patient with a TIA may present with stroke-like symptoms; however, symptoms resolve shortly after their onset. TIAs must still be considered by EMS to be a medical emergency because approximately 15% of all strokes occur after a TIA.4

Common Clinical Presentations

Neurologic deficits depend on the part of the brain affected by the stroke. Any new neurologic deficit should receive immediate medical evaluation and be treated as a medical emergency.5

Right hemispheric strokes typically lead to left-sided deficits, including weakness or numbness of the left face, arms or leg. The patient can also neglect (i.e., ignore) stimuli coming from their left side, as well as not recognize their left side as being their own. For example, a patient with left-sided neglect could be shown his or her own left hand and not recognize it. Additionally, patients can often also have slurred speech and a right gaze preference.5

Left hemispheric strokes are similar to right hemispheric strokes; however, their deficits are to the right side of the body. Right facial, arm, or leg weakness or numbness is common. Right-sided neglect may be present. The patient may also have problems with comprehension or a left gaze preference.5

Brainstem strokes can lead to dizziness, vertigo, difficulties with speech, dysarthria, or swallowing. Patients may also have crossed findings, meaning that one side of the face is affected while the opposite side of the body is affected. Visual deficits and abnormal eye movements can also be seen.5

Patients who have had a hemorrhagic stroke are more likely to present with headache, nausea and vomiting. With intraparenchymal hemorrhage the area of the brain affected (right vs. left hemisphere) will lead to symptoms similar to those described above. SAH is often described as acute onset of the worst headache of life. Patients with an SAH may present with various levels of alertness.5

One of the most important components of stroke care that EMS can provide is a pre-notification report to the receiving hospital.

Prehospital Management

Rapid identification is paramount to promote a good outcome for a stroke patient. There are a variety of outreach campaigns targeted at raising community awareness of stroke symptoms to more rapidly engage EMS personnel and improve time to treatment.

The American Stroke Association promotes the FAST campaign an acronym constructed to instruct individuals to evaluate for Facial droop, Arm weakness, and Speech difficulty, and if these deficits are found, it’s Time to call 9-1-1.

There continues to be a push from both local and nationwide organizations to raise public awareness for stroke and research suggests that interventions are most successful when they target the general public as well as professionals such as EMS providers.6

The initial assessment of the stroke patient doesn’t differ from any other patient in the prehospital setting. Assessment of airway, breathing and circulation always take precedence.

Multiple stroke assessment tools, such as the Cincinnati Prehospital Stroke Scale, Los Angeles Prehospital Stroke Screen, and the Miami Emergency Neurologic Deficit Checklist are available to assist in prehospital stroke identification and triage. (See Table 1.)

 

Table 1: Cincinnati Prehospital Stroke Scale

Facial droop (Ask the patient to show their teeth or smile.)

Normal

Abnormal

Both sides of the face move equally.

One side of the face doesn’t move as well as the other.

Arm drift (Ask the patient to close their eyes and extend both arms straight out for 10 seconds.)

Normal

Abnormal

Both arms move the same, or both arms don’t move at all.

One arm either doesn’t move, or one arm drifts down compared to the other.

Speech (Ask the patient to repeat the phrase, “The sky is blue in Cincinnati.”)

Normal

Abnormal

The patient says the correct phrase with no slurring of words.

The patient slurs words, says the wrong words or is unable to speak.

 

EMS providers should refer to their local protocols for which assessment tools are recommended; however, the Cincinnati Prehospital Stroke Scale is most commonly used and has shown excellent reproducibility and good validity in identifying patients who are candidates for thrombolytic therapy.7 Most of the prehospital stroke assessment tools can be performed in less than one minute.

Once it’s been determined that the patient has stroke-like symptoms, it’s important to acquire a brief history, perform the basic necessary evaluation adjuncts, and begin transport to a facility capable of definitive therapy.

The history should be directed and focused to prevent delaying transport. Pay particular attention to the last time the patient is known to be well. In many instances, bringing a family member with the ambulance to the hospital will avoid delays in confirmation of last known well time and allow for initiation of advanced interventions for the patient.

A patient who woke up with new symptoms should be considered last known well at the last time he or she was last seen awake, even if that means it was the evening prior. Additionally, a medication list, with a focus on anti-coagulation, should be obtained.

Obtaining IV access, especially if proximal to the wrist, will assist in contrast CT imaging at the destination hospital.

Point-of-care testing for glucose can help rule out hypoglycemia as a common stroke mimic. Also, don’t delay transport to obtain an ECG.

One of the most important components of stroke care that EMS can provide is a pre-notification report to the receiving hospital. Pre-notification allows the receiving institution to activate local protocols, ready necessary medications, prepare and hold the CT scanner, and be prepared to assess the patient as soon as they arrive.

A retrospective study from 2012 showed that EMS hospital pre-notification improved evaluation, timelier stroke treatment, and increased the number of eligible patients who received thrombolytics.8

Determining Destination Hospital

The American Stroke Association and The Joint Commission classifies hospitals into four categories based upon the level of care they’re able to provide for stroke patients: 1) non-stroke center; 2) acute stroke-ready hospital; 3) primary stroke center; and 4) comprehensive stroke center.9,10

Acute stroke-ready hospitals tend to be smaller hospitals located in rural or suburban areas. An acute stroke-ready hospital differs from a non-stroke center in that they have 24/7 access to stroke expertise (either by telephone or in person) and have the ability to administer IV thrombolytics prior to transferring a patient for more advanced care.9,10

In addition to the ability to provide IV thrombolytics a primary stroke center will have a dedicated stroke unit capable of 24-hour continuous monitoring for stroke patients. These hospitals are capable of caring for the majority of stroke patients who don’t need endovascular therapy, neurosurgical interventions or neurologic-specific ICU-level care.9,10

Comprehensive stroke centers are able to provide all the care available at primary stroke centers with the addition of 24/7 ICU-level care for critically ill patients, endovascular therapy, and neurosurgical interventions. These hospitals are involved in research and local community outreach to further advance stroke patient care.9,10

STROKE CONFIRMATION

If pre-notification has been provided, the hospital team will be prepared to meet the EMS providers upon arrival in the ED.

The National Institutes of Health provides guidelines for initial assessment and interventions. The patient should be evaluated by the physician within 10 minutes. The stroke consultant should be notified within 15 minutes.

The patient should have a CT scan initiated by 25 minutes. CT and laboratory results should be interpreted within 45 minutes, and thrombolytics should be administered if the patient is eligible within 60 minutes. This is commonly referred to as the “golden hour.”11

CT imaging usually consists of a non- contrasted image to evaluate for hemorrhage or other abnormalities. Afterwards, contrast is administered via IV to enhance the arteries in the neck and brain to look for any occlusions.

Stroke Management

If the CT scan demonstrates a hemorrhagic stroke, acute treatment options are more limited. The initial components of therapy are centered around airway management and prevention of hemorrhagic expansion.

This may entail intubation, anticoagulation reversal and blood pressure control. Management of suspected high intracranial pressure is also warranted.

Blood pressure control may decrease the amount of hemorrhagic expansion in the setting of intracranial hemorrhage. For most patients, a systolic blood pressure goal that’s < 140 mmHg is considered appropriate.12,13

Intracranial pressure can be a major cause of morbidity and mortality for these patients. Basic interventions such as elevation of the head of bed to 30 degrees and pain control can be undertaken in the prehospital setting. More aggressive therapies include hypertonic saline or deep sedation or paralysis with medications to help decrease intracranial pressure.

Depending on the location of the hemorrhage, surgical evacuation or decompression may be a treatment option, but the majority of ICHs are non-operative.14

Patients with an acute ischemic stroke may be eligible for IV tPA. The decision to administer thrombolytics requires consideration of both inclusion and exclusion criteria specific to this intervention.

IV tPA carries a 2–6% risk of intracranial hemorrhage. Patients who receive tPA may have significant improvement in their stroke symptoms and prevention from permanent disability. Selecting the right patient with the greatest likelihood of benefit and the least likelihood of harm is important.

The National Institute of Neurological Disorders and Stroke performed a landmark study to determine the efficacy for tPA. This study demonstrated that approximately six out of 18 patients with an acute ischemic stroke not treated with tPA would recover without significant disability at three months. In the group treated with tPA, they found that eight out of 16 would recover without significant disability at three months; however, they also found that approximately one out of 16 treated with tPA would have an intracranial bleeding event, and 45% of those events would be fatal.15

The American College of Emergency Physicians position statement on tPA highlights the importance of regularly balancing the benefits and risks for an individual patient with appropriate patient and family input.16

The inclusion criteria for tPA incorporates patients with a debilitating stroke. An example of this includes significant weakness that would prevent walking without assistance, or the ability to perform the normal activities of daily life.

Additionally, the patient must have last been seen well within three hours (or 4.5 hours for a small subset of patients).

The exclusion criteria for tPA are significant head trauma or prior stroke in the last three months, recent surgery, prior intracranial bleeding, very low platelet count, severe hypertension, current use of anticoagulant medications, or known brain cancer. Additionally, caution is given to patients with very large or devastating strokes, as they’re more likely to have a poor outcome.

Endovascular therapies involve using a catheter that’s threaded from an artery in the groin up to the affected arteries in the brain. The catheter can then be used to manually remove the clot or directly apply tPA to the clot.

Based on multiple positive trials, endovascular therapies are reserved for patients who have a large vessel occlusion on preprocedural vessel imaging.17–22 One of the many benefits of this option is that patients can be considered for this procedure even after the three to 4.5-hour window of tPA has passed.

Typically, it’s preferred that this be performed within six hours; however, recent publications indicate that the benefit of endovascular therapy may be extended up to 24 hours in patients with favorable CT perfusion findings.23,24

CT perfusion imaging is used to compare the the infarct core (i.e., the part of the brain that’s been irrecoverably damaged due to the stroke) with the penumbra (i.e., the part of the brain that’s salvageable.

A patient with a small infarct core and relatively larger penumbra is considered a good candidate for endovascular intervention.

In the future, this may also impact EMS practice patterns and hospital decisions for acute stroke patients, even if initially it seems that they’re outside of the time window to administer tPA.

The 2015 American Stroke Association guidelines recommend strong consideration of endovascular therapy in eligible patients based upon the most recent literature. It’s important to note that eligible patients still receive tPA even if endovascular treatments are being considered, and this will not preclude them from being able to undergo endovascular therapy.17

The risks associated with endovascular therapy mainly center around complications of the procedure itself including vessel dissection, ischemic stroke, reperfusion hemorrhage and access site complications. Although it’s not considered a risk-free procedure, recent studies haven’t shown endovascular intervention to increase risks above those associated with IV tPA.25

Conclusion

Early recognition of stroke by clinical presentation and prehospital stroke assessment tools facilitate rapid prehospital and ED diagnosis, evaluation and management of patients who need time-critical care. Appropriate recognition will only help to improve patient outcomes and allow for advanced, specialized treatment, in the hopes of further reducing morbidity and mortality in stroke patients.

References

1. Yang Q, Tong X, Schieb L, et al. Vital signs: Recent trends in stroke death rates—United States, 2000–2015. MMWR Morb Mortal Wkly Rep. 2017;66(35):933–939.

2. Benjamin E, Blaha M, Chiuve S, et al. Heart disease and stroke statistics—2017 update: A report from the American Heart Association. Circulation. 2017;135(10):e145–e603.

3. Hall M, Levant S, DeFrances C. Hospitalization for stroke in U.S. Hospitals, 1989–2009. NCHS Data Brief. 2012;(95):1–8

4. Go A, Mozaffarian D, Roger V, et al. Heart disease and stroke statistics—2013 update: A report from the American Heart Association. Circulation. 2013;127(1):e6–e245.

5. Summers D, Leonard A, Wentworth D, et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: A scientific statement from the American Heart Association. Stroke. 2009;40(8):2911–2944.

6. Mellon L, Doyle F, Rohde D, et al. Stroke warning campaigns: Delivering better patient outcomes? A systematic review. Patient Relat Outcomes Meas. 2015;6:61–73.

7. Kothari RU, Pancioli A, Liu T, et al. Cincinnati Prehospital Stroke Scale: Reproducibility and validity. Ann Emerg Med. 1999;33(4):373–378.

8. Lin C, Peterson E, Smith E, et al. Emergency medical service hospital prenotification is associated with improved evaluation and treatment of acute ischemic stroke. Circulation. 2012;5(4):514–522.

9. Higashida R, Alberts D, Alexander D, et al. Interactions within stroke systems of care: A policy statement from the American Heart Association/American Stroke Association. Stroke. 2013;44(10):2261–2984.

10. Meretoja A, Roine R, Kaste M, et al. Effectiveness of primary and comprehensive stroke centers. PERFECT stroke: A nationwide observational study from Finland. Stroke. 2010;41(6): 1102–1107.

11. NINDS proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke, December 12– 13, 1996. (June 19, 2008.) National Institute of Neurological Disorders and Stroke. Retrieved Nov. 16, 2017, from https://stroke.nih.gov/resources/stroke_proceedings.

12. Gioia L, Kate M, Dowlatshahi D, et al. Blood pressure management in acute intracerebral hemorrhage: Current evidence and ongoing controversies. Curr Opin Crit Care. 2015;21(2):99–106.

13. Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015:46(7): 2032–2060.

14. Mendelow A, Gregson B, Rowan E, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): A randomised trial. Lancet. 2013;382(9890):397–408.

15. 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(24):1581–1587.

16. tPA for stroke: Potential benefit, risk and alternatives. (May 3, 2007.) American Academy of Emergency Medicine. Retrieved Nov. 16, 2017, from www.aaem.org/UserFiles/file/ tpaedtool-AAEM.pdf.

17. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11–20.

18. Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–1030.

19. Campbell BC, Mitchell PJ, Kleiniq TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009–1018

20. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285-2295.

21. Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296–2306.

22. Bracard S, Ducrocg X, Mas JL, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): A randomized controlled trial. Lancet Neurol. 2016;15(11):1138–1147.

23. Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378(1):11–21.

24. Albers GW, Marks MP, Kemp S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378(8):708–718.

25. Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment. Stroke. 2015;46(10):3020–3025.