Acute Ischemic Stroke Pathway
Acute Ischemic Stroke Pathway
Acute Ischemic Stroke Pathway
Neurosciences
Acute Ischemic
Stroke
ACUTE ISCHEMIC STROKE MAY 10, 2016
INTRODUCTION
Stroke is a major cause of death and disability worldwide, with approximately
795,000 people experiencing an acute stroke annually. In the United States
stroke is the fifth leading cause of death and the leading cause of preventable
disability. Incidence of stroke and overall stroke-related mortality has dropped
dramatically over the last 40 years related to both improved preventive care
and innovations in acute therapies.
Pathway Contacts
The content of this pathway is developed and maintained by the Neurosciences
service line of Christiana Care Health System. Questions or feedback about the
content may be directed to:
Evidence Definitions
Class I: Conditions for which there is evidence, general agreement, or both
that a given procedure or treatment is useful and effective.
Pre-Hospital Management
Activation of the 9-1-1 system by patients or other members of the public is
strongly recommended (Class I; Level of Evidence B). 9-1-1 Dispatchers
should make stroke a priority dispatch and transport.
Prehospital care providers should use prehospital stroke assessment tools,
such as the Los Angeles Prehospital Stroke Screen or Cincinnati Prehospital
Stroke Scale (Class I; Level of Evidence B).
EMS personnel should begin the initial management of stroke in the field, as
outlined in Table 4 (Class I; Level of Evidence B). Development of a stroke
protocol to be used by EMS personnel is strongly encouraged.
Patients should be transported rapidly to the closest available certified PSC or
CSC or, if no such centers exist, the most appropriate institution that provides
emergency stroke care as described in the statement (Class I; Level of
Evidence A).
reperfusion therapy who are within six hours of symptom onset and have an
ASPECTS <6. Further randomized, controlled trials should be done to
determine whether advanced imaging paradigms using CT perfusion and MRI
perfusion, CTA, and diffusion imaging, including measures of infarct core,
collateral flow status, and penumbra, are beneficial for selecting patients for
acute reperfusion therapy who are beyond 6 hours from symptom onset.
Frank hypodensity on non-contrast CT of the head may increase the risk of
hemorrhage with fibrinolysis and should be considered in treatment decisions.
If frank hypodensity involves more than one third of the MCA territory,
intravenous alteplase (rtPA) treatment should be withheld (Class III; Level of
Evidence A).
Recommendations for patients with cerebral ischemic symptoms that
have resolved:
Noninvasive imaging of the cervical vessels should be performed routinely as
part of the evaluation of patients with suspected TIAs (Class I; Level of
Evidence A).
Noninvasive imaging by means of CTA or MRA of the intracranial vasculature
is recommended to exclude the presence of proximal intracranial stenosis or
occlusion (Class I; Level of Evidence A) and should be obtained when
knowledge of intracranial steno-occlusive disease will alter management.
Patients with transient ischemic neurological symptoms should undergo
neuroimaging evaluation within 24 hours of symptom onset or as soon as
possible in patients with delayed presentations. MRI, including DWI, is the
preferred brain diagnostic imaging modality. If MRI is not available, head CT
should be performed (Class I; Level of Evidence B).
Intravenous Fibrinolysis
Intravenous alteplase (rtPA) (0.9 mg/kg, maximum dose 90 mg) is
recommended for selected patients who may be treated within 3 hours of
onset of ischemic stroke (Class I; Level of Evidence A).
Intravenous alteplase (rtPA) (0.9 mg/kg, maximum dose 90 mg) is
recommended for administration to eligible patients who can be treated in the
time period of 3 to 4.5 hours after stroke onset with some additional eligibility
criteria (Class I; Level of Evidence B).
In patients eligible for intravenous alteplase (rtPA), benefit of therapy is time
dependent, and treatment should be initiated as quickly as possible. The door-
to-needle time (time of bolus administration) should be within 60 minutes
from hospital arrival (Class I; Level of Evidence A).
In patients undergoing fibrinolytic therapy, physicians should be aware of and
prepared to emergently treat potential side effects, including bleeding
complications and angioedema that may cause partial airway obstruction
(Class I; Level of Evidence B).
Intravenous alteplase (rtPA) is reasonable in patients with a seizure at the
time of onset of stroke if evidence suggests that residual impairments are
secondary to stroke and not a postictal phenomenon (Class IIa; Lev-el of
Evidence C).
The usefulness of intravenous administration of tenecteplase, reteplase,
desmoteplase, urokinase, or other fibrinolytic agents and the intravenous
administration of ancrod or other defibrinogenating agents is not well
established, and they should only be used in the setting of a clinical trial
(Class IIb; Level of Evidence B). The use of IV streptokinase for treatment of
stoke is not recommended (Class III, Level A).
Use of intravenous fibrinolysis in patients with conditions of mild stroke
deficits, rapidly improving stroke symptoms, major surgery in the preceding 3
months, and recent myocardial infarction may be considered, and potential
increased risk should be weighed against the anticipated benefits (Class IIb;
Level of Evidence C).
The use of intravenous alteplase (rtPA) in patients taking direct thrombin
inhibitors or direct factor Xa inhibitors may be harmful and is not
recommended unless sensitive laboratory tests such as aPTT, INR, platelet
count, and ECT, TT, or appropriate direct factor Xa activity assays are normal,
or the patient has not received a dose of these agents for >2 days (assuming
normal renal metabolizing function). Similar consideration should be given to
patients being considered for intra-arterial alteplase (rtPA) (Class III; Level of
Evidence C).
Endovascular Interventions
Patients eligible for intravenous alteplase (rtPA) should receive intravenous
alteplase (rtPA) even if endovascular treatments are being considered (Class I;
Level of Evidence A).
Patients should receive endovascular therapy with a stent retriever if they
meet all the following criteria (Class I; Level of Evidence A):
Pre-stroke modified Rankin Scale (mRS) score 0 to 1.
Acute ischemic stroke receiving intravenous alteplase (rtPA) within 4.5
hours of onset according to guidelines from professional medical societies.
Causative occlusion of the internal carotid artery or proximal MCA (M1).
Age 18 years.
NIHSS score of 6.
ASPECTS of 6.
Treatment can be initiated (groin puncture) within 6 hours of symptom
onset.
Although the benefits are uncertain, use of endovascular therapy with stent
retrievers may be reasonable for patients with acute ischemic stroke in whom
treatment can be initiated (groin puncture) within 6 hours of symptom onset
and who have prestroke mRS score of >1, ASPECTS <6, or NIHSS score <6
and causative occlusion of the internal carotid artery or proximal MCA (M1)
(Class IIb; Lev-el of Evidence B-R).
Observing patients after intravenous alteplase (rtPA) to assess for clinical
response before pursuing endovascular therapy is not required to achieve
beneficial outcomes and is not recommended. (Class III; Level of Evidence B-
R). Use of stent retrievers is indicated in preference to the MERCI device.
(Class I; Level of Evidence A). The use of mechanical thrombectomy devices
other than stent retrievers may be reasonable in some circumstances (Class
IIb, Level B-NR).
The use of proximal balloon guide catheter or a large bore distal access
catheter rather than a cervical guide catheter alone in conjunction with stent
retrievers may be beneficial (Class IIa; Level of Evidence C).
The technical goal of the thrombectomy procedure should be a TICI 2b/3
angiographic result to maximize the probability of a good functional clinical
outcome (Class I; Level of Evidence A). Use of salvage technical adjuncts
including intra-arterial fibrinolysis may be reasonable to achieve these
angiographic results, if completed within 6 hours of symptom onset (Class IIb;
Level of Evidence B-R).
Angioplasty and stenting of proximal cervical atherosclerotic stenosis or
complete occlusion at the time of thrombectomy may be considered but the
usefulness is unknown (Class IIb; Level of Evidence C).
Initial treatment with intra-arterial fibrinolysis is beneficial for carefully
selected patients with major ischemic strokes of <6 hours duration caused by
occlusions of the MCA (Class I; Level of Evidence B-R). However, these data
derive from clinical trials that no longer reflect current practice, including use
of fibrinolytic drugs that are not available. A clinically beneficial dose of intra-
arterial alteplase (rtPA) is not established, and alteplase (rtPA) does not have
Anticoagulants
At present, the usefulness of argatroban or other thrombin inhibitors for
treatment of patients with acute ischemic stroke is not well established (Class
IIb; Level of Evidence B). These agents should be used in the setting of
clinical trials.
The usefulness of urgent anticoagulation in patients with severe stenosis of
an internal carotid artery ipsilateral to an ischemic stroke is not well
established (Class IIb; Level of Evidence B).
Urgent anticoagulation, with the goal of preventing early recurrent stroke,
halting neurological worsening, or improving outcomes after acute ischemic
stroke, is not recommended for treatment of patients with acute ischemic
stroke (Class III; Level of Evidence A).
Urgent anticoagulation for the management of noncerebrovascular conditions
is not recommended for patients with moderate-to-severe strokes because of
an increased risk of serious intracranial hemorrhagic complications (Class III;
Level of Evidence A).
Antiplatelet Agents
Oral administration of aspirin (initial dose is 325 mg) within 24 to 48 hours
after stroke onset is recommended for treatment of most patients (Class I;
Level of Evidence A).
The usefulness of clopidogrel for the treatment of acute ischemic stroke is not
well established (Class IIb; Level of Evidence C).
The efficacy of intravenous tirofiban and eptifibatide is not well established,
and these agents should be used only in the setting of clinical trials (Class IIb;
Level of Evidence C).
Aspirin is not recommended as a substitute for other acute interventions for
treatment of stroke, including intravenous alteplase (rtPA) (Class III; Level of
Evidence B).
The administration of other intravenous antiplatelet agents that inhibit the
glycoprotein IIb/IIIa receptor is not recommended (Class III; Level of
Evidence B).
The administration of aspirin (or other antiplatelet agents) as an adjunctive
therapy within 24 hours of intravenous fibrinolysis is not recommended
(Class III; Level of Evidence C).
Initiation of anticoagulant therapy within 24 hours of treatment with
intravenous alteplase (rtPA) is not recommended (Class III; Level of Evidence
B).
Surgical Interventions
The usefulness of emergent or urgent CEA when clinical indicators or brain
imaging suggests a small infarct core with large territory at risk
(e.g. penumbra), compromised by inadequate flow from a critical carotid
stenosis or occlusion, or in the case of acute neurological deficit after CEA, in
which acute thrombosis of the surgical site is suspected, is not well
established (Class IIb; Level of Evidence B).
The use of aspirin is reasonable for treatment of patients who cannot receive
anticoagulants for DVT prophylaxis (Class IIa; Level of Evidence A).
In selecting between NG and PEG tube routes of feeding in patients who
cannot take solid food or liquids orally, it is reasonable to prefer NG tube
feeding until 2 to 3 weeks after stroke onset (Class IIa; Level of Evidence B).
The use of intermittent external compression devices is reasonable for
treatment of patients who cannot receive anticoagulants (Class IIa; Level of
Evidence B).
Routine use of nutritional supplements has not been shown to be beneficial
(Class III; Level of Evidence B).
Routine use of prophylactic antibiotics has not been shown to be beneficial
(Class III; Level of Evidence B).
CLINICAL PATHWAY
1. Recognize signs and symptoms of acute stroke.
A. Sudden onset of the following symptoms should be recognized as
potential signs of acute stroke.
1. Weakness especially when unilateral.
2. Numbness especially when unilateral.
3. Inability to speak or understand speech.
4. Slurred speech.
5. Dizziness/vertigo.
6. Gait instability.
7. Acute Vision changes.
B. Posterior circulation ischemia should be considered in cases of
unexplained unresponsiveness with sudden onset.
2. EMS Initial Assessment and Transport.
A. Community is encouraged to activate 9-1-1 for stroke symptoms via
community education/outreach.
B. Stroke Scale, as determined by EMS standing orders and protocols,
completed for patients with symptoms of stroke.
C. Last known normal time documented.
D. Pre arrival call to emergency department base station with medical control
when initial screening consistent with stroke and last known normal time
less than 6 hours to request Stroke Alert activation.
E. IV, blood glucose and preliminary blood draw maybe completed during
transport when appropriate.
3. Emergent evaluation to determine potential candidacy for thrombolysis (Time
goal for ED physician evaluation is < 10 minutes from arrival).
A. Confirm time last seen normal (LSN) and presence of neurologic
signs/symptoms.
c. Upper blood pressure (BP) parameters for patient who did not
receive thrombolysis are typically 220/120 unless otherwise
contraindicated.
d. BP parameters for patients who received IV tPA are < 180/105 for
first 24 hours.
e. Restarting antihypertensive medications is reasonable after the first
24 hours for patients that are neurologically stable and do not have
significant vascular stenosis.
1. Utilize supplemental O2 as necessary to maintain O2 Sat of > 94%
f. Document stroke depression screen upon admission and discharge
and follow depression algorithm (Algorithm 3).
5. Document patients own goals daily.
C. Diagnostics: Goal is to determine associated risk factors and ideal choice
of long term prevention strategies.
1. Classify stroke etiology by modified TOAST criteria for all patients to
minimize variability in diagnostic testing.
2. MRI may be utilized to help define stroke etiology but is not necessary
for all patients with ischemic stroke. Refer to MRI algorithm for
suggested criteria to define patients who are most likely to benefit from
MRI (Algorithm 4).
3. Evaluate for cardioembolic source.
a. Obtain 12 lead EKG on all stroke patients.
b. Telemetry monitoring for at least 48 hours is recommended unless
patient has known history of atrial fibrillation. Monitoring for the first
five days of hospitalization is preferred for patients with cryptogenic
stroke.
c. Echocardiogram may be useful to further evaluate for cardioembolic
source of stroke but is not necessary for all patients with ischemic
stroke. Refer to Echocardiogram algorithm for suggested criteria to
define patients who are most likely to benefit from Echocardiogram
(Algorithm 5).
H. Peri-Discharge follow-up.
1. Follow up with Primary Care Provider is recommended upon discharge
2. Vascular neurologist follow- up per algorithm (Figure 2).
3. Provide prescriptions for outpatient physical, occupational and speech
therapy upon discharge if indicated.
4. Follow up phone calls will be made within 7 days post discharge to all
stroke patients who are discharged home.
5. Follow up phone calls within 75 to 105 days to complete the modified
Rankin scale for patients who received IV tPA or mechanical
thrombectomy.
DAY DAY 1, DAY 1 AFTER DAY 2 DAY 3 + INTERIM DISCHARGE POST D/C CARE
EMERGENCY ADMISSION DAYS
DEPARTMENT
Clinical Goals Recognition of Initiate evaluation for Ongoing testing Etiology of stroke Discharge to home Prevention of re-
stroke symptoms stroke etiology for etiology of and discharge or acute admission
Evaluation for Initial evaluation for stroke and planning rehabilitation
revascularization disposition needs discharge Complete
planning evaluation for
stroke etiology
Prepare for
discharge
Assessments Assess for Daily NIHSS ordered Daily NIHSS Daily NIHSS Documentation 7 day and 90 day
& Documentation Stroke Alert by and documented1 documented1 documented1 includes specifics follow-up phone
completing the Complete and Document Document of stroke type, calls completed1
revascularization document swallow patient's own patient's own location, 90 Day Modified
check list. screen prior to giving goals1 goals1 lateralization and Rankin Score
Include time last anything by mouth 1 etiology or completed and
seen normal Document documentation
Frequent assessment for documents for
(LSN) and any that these details patients who
exclusion for neurological cognitive decline are unknown8
assessments and per algorithm7 received IV tPA or
tPA/mechanical NIHSS at mechanical
thrombectomy 1 vital signs ordered no
less than Q4 hrs or discharge thrombectomy1
Obtain initial per post tPA or documented1
NIHSS <12 hour mechanical Depression screen
from arrival and thrombectomy documented at
prior to protocol when discharge1
revascularization applicable2
1 Document
Stroke Depression assessment for
Screen documented rehab services
and evaluate per prior to discharge
algorithm1 or documented
Document patient's none needed6
own goals1
Diagnostics Obtain CT head Stroke Power Plan or Goal MRI Evaluate long term
prior to Module initiated for complete cardiac monitoring
admission2 order entry1 < 48 hours from if appropriate per
Check Blood Obtain 12 lead EKG admission when algorithm7
Glucose and INR Initiate telemetry indicated5
if patient monitoring or Goal Echo
anticoagulated document exclusion2 complete
on warfarin2 < 48 hours from
Order MRI brain if admission when
indicated per protocol indicated5
or document
deviation from Goal vascular
protocol2 imaging complete
< 48 hours from
DAY DAY 1, DAY 1 AFTER DAY 2 DAY 3 + INTERIM DISCHARGE POST D/C CARE
EMERGENCY ADMISSION DAYS
DEPARTMENT
Order vascular admission when
imaging of neck indicated5
and/or head if Lipid profile and
indicated per protocol HgbA1C
or document completed if
deviation from indicated
protocol2
Order
echocardiogram if
indicated per protocol
or document
deviation from
protocol2
Order Lipid panel,
and HgbA1C or
documentation of
outpatient values2
Neurology consult
ordered if not
admitted to
neurointensivist2
Therapeutics Administer IV If patient received IV Initiate or modify Antiplatelets Carelink
tPA to eligible tPA maintain Blood statin therapy in prescribed at determines and
patients within Pressure < 180/105 accordance with discharge or documents if
60 minutes of for 24 hrs4 the AHA Cardiac contraindication patient is taking
arrival to ED or For patients who did risk guidelines or documented9 prescribed
document NOT receive IV tPA document Anticoagulation for medication.10
exclusions or no treatment for contraindications3 atrial fibrillation
reason for elevations in BP up Consult vascular prescribed at
increased time1 to 220/120 or surgery If discharge or
Provide documentation of symptomatic contraindication
Endovascular specific indications4 carotid artery documented9
treatment or Antiplatelet therapy stenosis > 50% Statin prescribed
document ordered with first identified or at discharge or
exclusions1 dose given prior to document contraindication
Administer first end of 2nd calendar exclusion documented9
dose of ASA day of admission if treatment2
325mg PO or not given in ED or
300mg PR if contraindication
patient does not documented3
receive IV tPA or VTE prophylaxis
document ordered and
exclusion.3 administered prior to
end of Day 2 or
contraindication
documented3
Initiate treatment for
hyperglycemia when
blood sugar > 1803
Nutrition Consult Speech Consult dietitian if Diet and regular
Therapy as needed PO diet activity
recommended on
DAY DAY 1, DAY 1 AFTER DAY 2 DAY 3 + INTERIM DISCHARGE POST D/C CARE
EMERGENCY ADMISSION DAYS
DEPARTMENT
for dysphagia2 inadequate2 discharge
Initiate cardiac diet if summary9
pt passes speech
evaluation2
Education Stroke education Patient own goals Patient own goals Patient own goals Perform 7 day
initiated and documented1 documented1 documented1 phone call and
documented1 Continue required All required stroke document if
Stroke education stroke education7 education patient is able to
materials provided to completed and express signs and
Tobacco symptoms of
patient or family and cessation documented prior
documented1 to d/c1 stroke, what to do
education if they have S&S
counseling of a stroke, and
initiated when the role of their
indicated1 medication in
preventing a
reoccurring stroke1
Transition Planning Admit to Daily Daily Stroke Clinic per CareLink follows
designated documentation of documentation of referral follow-up pt10
stroke unit7 assessment for assessment for algorithm9 If patient is d/c'd to
appropriateness appropriateness of home, PCP
of acute, referral for acute, appointment
subacute, home subacute, home scheduled within
health, or health, or 14 days10
outpatient therapy outpatient therapy
(Continued below) services6 services6
DAY DAY 1, DAY 1 AFTER DAY 2 DAY 3 + INTERIM DISCHARGE POST D/C CARE
EMERGENCY ADMISSION DAYS
DEPARTMENT
Family assessed
for skills, capacity,
and resources or
document not
relevant6
1Powerform 2Powerchart Order 3Powerchart EMAR 4Powerchart vital signs 5Powerchart test results 6Disc Spec Powerchart doc
7Unknown or paper 8ICCD-10coding 9D/C med reconciliation or instructions 10Aerial
Version 102915
No
Yes
Triage:
Go to Stroke Is pt a potential Initial ER eval
Alert / Code Yes candidate for No consistent with
Algorithm (IV) thrombolysis ischemic stroke (V)
(III)
Are symptoms
Yes
persistent
History of prior
Yes
stroke?
No
Go to low risk
TIA
observation
Disposition protocol
This algorithm serves as guideline for the inpatient evaluation of etiology of ischemic stroke, but does not
supersede clinical judgment accounting for individual patient characteristics. Documentation of the rationale
for variation in care from the algorithm is recommended.
Version 120315
Back to Table of Contents page 35
ACUTE ISCHEMIC STROKE MAY 10, 2016
Figure 3
STROKE DEPRESSION
ASSESSMENT
Yes
Provide patient or
caregiver stroke
education booklet that
includes a depression
section
Score 10 and/or
Score <10
suicidal thoughts No OR
Unable to
answer
This algorithm serves as a guideline for assessment of depression post stroke, but does not supersede clinical judgment accounting
for individual patient characteristics. Documentation of the rationale for variation in care from the algorithm is
recommended.Version 120315
No
Is acute cerebral
infarction clearly present
Yes
on Head CT? Yes
Is MRA head and/or MRA neck
recommended by vascular imaging
No algorithm?
Yes No
No
This algorithm serves as guideline for the inpatient evaluation of etiology of ischemic stroke, but does not supersede clinical
judgment accounting for individual patient characteristics. Documentation of the rationale for variation in care from the
algorithm is recommended.
Version 010716
No
No Yes
Defer TTE Consider TTE (2D echo) Defer TTE Order TTE (2D echo) *
*For young patients without vascular risk factors, or for patients with suspected endocarditis, TEE may be appropriate
initial study.
This algorithm serves as guideline for the inpatient evaluation of etiology of ischemic stroke, but does not supersede clinical
judgment accounting for individual patient characteristics. Documentation of the rationale for variation in care from the
algorithm is recommended.
Version 010716
DEFINITIONS
Cryptogenic stroke: cortical stroke, or subcortical stroke without features typical of a lacune without other
clear etiology (i.e. >1.5 cm OR not located in brainstem, cerebellum, basal ganglia, or periventricular
white matter).
Lacunar stroke: <1.5 cm linear or ovaloid infarct located in brainstem, cerebellum, basal ganglia, or
periventricular white matter.
ILD: Implantable loop device (cardiac monitor).
Yes
Yes
Yes
No
No/Unknown
* If a vascular abnormality is noted on initial study, additional imaging may be recommended by consultant
This algorithm serves as guideline for the inpatient evaluation of etiology of ischemic stroke, but does not supersede clinical
judgment accounting for individual patient characteristics. Documentation of the rationale for variation in care from the
algorithm is recommended. Version 010706
This document serves as a guideline for outpatient stroke clinic neurology follow-up; however it does not supersede clinical
judgment accounting for individual patient characteristics. Documentation of the rationale for variation in care from the
algorithm is recommended.
Version 040116
Unit or ED Clerk via Page Operator (911 on hospital phone): For all Stroke Alert Patients
Overhead page Physician:
Stroke Alert/Code Team Notified: Acute Stroke/TIA Treatment Evaluation Form
*Neurology Stroke Alert On-Call Neurologic assessment as outlined by NIHSS
[Response Time Goal 15 minutes from contact] Nurse:
*Neuroscience APN/PA 20 Gauge IV (2nd IV can be done after CT)
*CT Technologist Stroke Alert Labs (Stroke Alert Label)
[Lab Report Time Goal 45 minutes]
*ED Pharmacy
Vital signs, Bedside Glucose, Weight
*ICU Nursing Coordinator EKG (can be done after CT)
*Charge Nurse STAR, NCCU, SCCC, MICU Notify CT when patient ready
*RRT team CT Technologist:
Assessment
Inpatient Only: Phlebotomy, Vascular Access Nurse, Prepare CT Scanner for Stroke Alert
EKG tech, Patient Escort Imaging
Version 120315
ACKNOWLEDGEMENTS