image by: Rebel EM

HWN Suggests

Stroke me, Code Stroke me

tPA: Let’s talk about the elephant in the room, does it work or not... It is estimated that 2-5% of all strokes will get tPA. Alteplase is first-line therapy, dosed at 0.9/mg/kg. You must confirm the following prior to tPA administration: persistent neurologic deficit on exam that is considered disabling (i.e. prevents basic daily life functions), serum glucose is normal, BP goals are met, >1 large-bore IV line is present, all eligibility criteria are met. 10% of the dose is given over 1 minute as a bolus and the rest is given over one hour.

What about those with an unwitnessed stroke or the “wake-up” stroke >4.5 hours symptom onset? There is mixed data, but promising,…

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Featured

 ED Stroke Management in the Age of Endovascular Therapy

Activating a “code stroke” on every patient that experiences any acute neurologic event within 24hrs of symptom onset based on the DIFFUSE 3 and DAWN trials [2,3] may outstrip resources, with only a tiny minority of these patients receiving potential benefit. There is currently an effort to identify those patients clinically who might be most likely to benefit from endovascular therapy so that not all stroke patients require transport to a stroke center with multiple imaging modalities and resource-heavy acute stroke team care.

 Thrombolytics for stroke: The evidence

Thrombolytics for stroke: undoubtedly the biggest controversy in emergency medicine.

 Time is Brain – Acute Ischemic Stroke Part 2: Mechanical Thrombectomy

Mechanical thrombectomy has revolutionized stroke care for patients with large vessel occlusions (LVOs). LVOs account for ~40% of all AIS, and prior to endovascular therapy more than half of these patients suffered significant post-stroke disability (modified Rankin Scale (mRS) 4-5) or death (mRS 6). This post reviews who qualifies for mechanical thrombectomy, the process of screening, and how the field of interventional neurology continues to evolve.

 Time is Brain – Acute Ischemic Stroke Part I: Vascular Syndromes and Thrombolysis

About ~800K people have a stroke in the US every year (1 person every 40 seconds) and stroke is a leading cause of serious long-term disability (PMID: 31992061). But prior to ~2015, outside of trials, the acute ischemic stroke patient either arrived within 4.5 hours and got tPA or they got supportive care. And, unfortunately, very few patients arrive within the 4.5 hour time window. Things are dramatically different now. The endovascular era in stroke care has revolutionized care for patients with large vessel occlusions (LVO) – which is the subgroup of patients that before the reperfusion era accounted for the highest stroke morbidity and mortality. There is now effective treatment for those who present within 24 hours.

Articles of Interest

Should we Consider Endovascular Therapy for Acute Basilar Artery Occlusion?

In patients with acute basilar artery occlusion is favorable functional outcome at 90 days improved with endovascular therapy vs standard medical care?

Stroke Care: A Balanced Approach to tPA

The question of the safety and efficacy of alteplase (tPA) for the treatment of acute ischemic stroke (AIS) has been debated by emergency physicians (EPs) for many years.

Resources

NIH Stroke Scale

0 Normal, 1-4 Minor, 5-15 Moderate, 15-20 Moderately Severe, > 20 Severe

Critical Care Medicine

The primary goal of advanced stroke management is revascularization and limitation of secondary neuronal injury. IV thrombolysis and EVT are now available for selected patients.

CDEM

The single most important component of the history is the exact time of onset of symptoms. This is defined as the time when the patient was last known to be symptom-free, commonly referred to as the “last known well”.

Update on Management of Acute Ischemic Stroke in The Emergency Department

In patients who are not candidate for reperfusion therapy, the blood pressure should not be treated acutely unless the hypertension is extreme (SBP>220 or DBP>120 mmHg), or the patient has active ischemic coronary disease, heart failure, aortic dissection, hypertensive encephalopathy, or pre-eclampsia/eclampsia. When treatment is indicated, cautious lowering of blood pressure by approximately 15% during the first 24 hours after stroke onset is suggested.