DIAGNOSIS AND INITIAL TREATMENT OF ISCHEMIC STROKE
MAJOR RECOMMENDATIONS
Note from the National Guideline Clearinghouse (NGC) and the Institute for
Clinical Systems Improvement (ICSI): In addition to updating their clinical guidance,
ICSI has developed a new format for all guidelines. Key additions and changes include:
combination of the annotation and discussion section; the addition of "Key Points" at the
beginning of most annotations; the inclusion of references supporting the
recommendations; and a complete list of references in the Supporting Evidence section of
the guideline. For a description of what has changed since the previous version of this
guidance, refer to "Summary of Changes -- February - 2006."
The recommendations for the diagnosis and initial treatment of ischemic stroke are
presented in the form of four algorithms with 40 components, accompanied by detailed
annotations. Algorithms are provided for: Screening (Ambulatory), Emergency
Department Treatment, Stroke Code, and Ischemic Stroke Emergency Department
Management (not a thrombolysis candidate); clinical highlights and selected annotations
(numbered to correspond with the algorithm) follow.
Class of evidence (A-D, M, R, X) and conclusion grade (I-III, Not Assignable)
definitions are repeated at the end of the "Major Recommendations" field.
Clinical Highlights and Recommendations
1. Patients who present in time to be candidates for treatment with tissue
plasminogen activator (tPA) should be evaluated by a physician within 10
minutes, undergo a computed tomography (CT) scan within 25 minutes of arrival
in the emergency department (ED), and have CT interpreted within 20 minutes of
test completion. (Annotations #20, 25)
2. Intravenous (IV) tPA, if given, should be administered within 3 hours of stroke
onset and less than 60 minutes of arrival at the ED. (Annotations #20, 21, 23, 25,
26)
3. Patients presenting with stroke onset who are not candidates for IV tPA should
promptly be given aspirin, after exclusion of hemorrhage on CT scan. (Annotation
# 31)
4. Education regarding early stroke symptoms, risk factors, diagnostic procedures,
and treatment options should be offered to the patient and family. This should be
documented in the patient chart. (Annotation #27)
5. Medical management for prevention of complications; within the initial 24 to 48
hours of diagnosis and initial treatment of ischemic stroke include:
continue appropriate blood pressure management
continue to treat hyperthermia
continue to treat hypo or hyperglycemia
, continue IV fluids
initiate deep vein thrombosis prophylaxis
perform swallow evaluation
initiate early rehabilitation
perform nutritional status assessment
Screening (Ambulatory) Algorithm Annotations
1. Initial Contact with Patient and Complaint of Neurological Symptoms
This contact may occur with one of several medical system personnel, including
primary care physicians, other medical specialty physicians, emergency medical
personnel, nursing staff in a clinic or urgent care setting or even non-medical
triage personnel. This does not refer to the ED evaluation. This contact may be by
phone or in person. Potential staff contacts should be educated in the importance
of stroke symptom recognition and the appropriate triage measures that should be
taken.
2. Immediate Screening for Ischemic Stroke
This should include detail as to the location, severity, duration of symptoms, and
any aggravating or relieving factors. Symptoms that are commonly associated
with ischemic stroke or transient ischemic attack (TIA) diagnoses include:*
Sudden numbness or weakness of the face, arm, or leg--especially on one
side of the body
Sudden mental confusion, trouble speaking or understanding
Sudden trouble walking, dizziness, loss of balance or coordination
Sudden trouble seeing in one or both eyes
Sudden severe headache with no known cause
* List from American Stroke Association for public education
Less common symptoms that may represent ischemic stroke or TIA include
sudden onset vertigo, double vision, nausea or vomiting, stupor or coma,
difficulty swallowing, a hoarse voice, and/or shaking of a limb.
Clinical diagnoses with neurologic symptoms that may imitate or superficially
resemble ischemic stroke or TIA include:
Migraine
Neurologic symptoms experienced with migraine tend to have a more
gradual onset and slower development. However, the two problems may
be indistinguishable.
, Seizures
Although seizures typically consist of a "positive" phenomenon (jerking of
a limb) rather than loss of neurologic function (weakness or paralysis of a
limb), symptoms and signs during the ictus or in the postictal state may be
similar to ischemic stroke (e.g., confusion or speech arrest during the ictus
as in complex partial seizure, postictal confusion, postictal paralysis, and
other sensory or visual phenomenon.)
Syncope
Transient global amnesia
This is characterized by a sudden onset antegrade and retrograde memory
disturbance without other focal neurologic symptoms. If the patient
experiences symptoms of transient global amnesia it would be
inappropriate to assume the diagnosis without a complete neurologic
exam.
Peripheral nerve disorders
Mononeuropathy and radiculopathy can be distinguished from ischemic
stroke by the anatomic distribution of the symptoms and in the case of
radiculopathy by the associated painful symptoms. Bell's palsy, vestibular
neuritis and extraocular muscle imbalance due to cranial neuropathy may
also imitate ischemic stroke and require a complete history and neurologic
examination to accurately differentiate from ischemic stroke.
Intracranial hemorrhage
Other intracranial masses (e.g., tumor, abscess [often differentiated by
CT])
The mode of onset and early course tend to be more gradual in
development.
Neuroses
Neuroses such as anxiety or panic disorder may need to be considered in
some cases.
Metabolic disorders
Hypoglycemia is the most common metabolic disorder producing
neurologic symptoms that imitate stroke. A patient with known diabetes or
liver disease should be screened for hypoglycemia.
MAJOR RECOMMENDATIONS
Note from the National Guideline Clearinghouse (NGC) and the Institute for
Clinical Systems Improvement (ICSI): In addition to updating their clinical guidance,
ICSI has developed a new format for all guidelines. Key additions and changes include:
combination of the annotation and discussion section; the addition of "Key Points" at the
beginning of most annotations; the inclusion of references supporting the
recommendations; and a complete list of references in the Supporting Evidence section of
the guideline. For a description of what has changed since the previous version of this
guidance, refer to "Summary of Changes -- February - 2006."
The recommendations for the diagnosis and initial treatment of ischemic stroke are
presented in the form of four algorithms with 40 components, accompanied by detailed
annotations. Algorithms are provided for: Screening (Ambulatory), Emergency
Department Treatment, Stroke Code, and Ischemic Stroke Emergency Department
Management (not a thrombolysis candidate); clinical highlights and selected annotations
(numbered to correspond with the algorithm) follow.
Class of evidence (A-D, M, R, X) and conclusion grade (I-III, Not Assignable)
definitions are repeated at the end of the "Major Recommendations" field.
Clinical Highlights and Recommendations
1. Patients who present in time to be candidates for treatment with tissue
plasminogen activator (tPA) should be evaluated by a physician within 10
minutes, undergo a computed tomography (CT) scan within 25 minutes of arrival
in the emergency department (ED), and have CT interpreted within 20 minutes of
test completion. (Annotations #20, 25)
2. Intravenous (IV) tPA, if given, should be administered within 3 hours of stroke
onset and less than 60 minutes of arrival at the ED. (Annotations #20, 21, 23, 25,
26)
3. Patients presenting with stroke onset who are not candidates for IV tPA should
promptly be given aspirin, after exclusion of hemorrhage on CT scan. (Annotation
# 31)
4. Education regarding early stroke symptoms, risk factors, diagnostic procedures,
and treatment options should be offered to the patient and family. This should be
documented in the patient chart. (Annotation #27)
5. Medical management for prevention of complications; within the initial 24 to 48
hours of diagnosis and initial treatment of ischemic stroke include:
continue appropriate blood pressure management
continue to treat hyperthermia
continue to treat hypo or hyperglycemia
, continue IV fluids
initiate deep vein thrombosis prophylaxis
perform swallow evaluation
initiate early rehabilitation
perform nutritional status assessment
Screening (Ambulatory) Algorithm Annotations
1. Initial Contact with Patient and Complaint of Neurological Symptoms
This contact may occur with one of several medical system personnel, including
primary care physicians, other medical specialty physicians, emergency medical
personnel, nursing staff in a clinic or urgent care setting or even non-medical
triage personnel. This does not refer to the ED evaluation. This contact may be by
phone or in person. Potential staff contacts should be educated in the importance
of stroke symptom recognition and the appropriate triage measures that should be
taken.
2. Immediate Screening for Ischemic Stroke
This should include detail as to the location, severity, duration of symptoms, and
any aggravating or relieving factors. Symptoms that are commonly associated
with ischemic stroke or transient ischemic attack (TIA) diagnoses include:*
Sudden numbness or weakness of the face, arm, or leg--especially on one
side of the body
Sudden mental confusion, trouble speaking or understanding
Sudden trouble walking, dizziness, loss of balance or coordination
Sudden trouble seeing in one or both eyes
Sudden severe headache with no known cause
* List from American Stroke Association for public education
Less common symptoms that may represent ischemic stroke or TIA include
sudden onset vertigo, double vision, nausea or vomiting, stupor or coma,
difficulty swallowing, a hoarse voice, and/or shaking of a limb.
Clinical diagnoses with neurologic symptoms that may imitate or superficially
resemble ischemic stroke or TIA include:
Migraine
Neurologic symptoms experienced with migraine tend to have a more
gradual onset and slower development. However, the two problems may
be indistinguishable.
, Seizures
Although seizures typically consist of a "positive" phenomenon (jerking of
a limb) rather than loss of neurologic function (weakness or paralysis of a
limb), symptoms and signs during the ictus or in the postictal state may be
similar to ischemic stroke (e.g., confusion or speech arrest during the ictus
as in complex partial seizure, postictal confusion, postictal paralysis, and
other sensory or visual phenomenon.)
Syncope
Transient global amnesia
This is characterized by a sudden onset antegrade and retrograde memory
disturbance without other focal neurologic symptoms. If the patient
experiences symptoms of transient global amnesia it would be
inappropriate to assume the diagnosis without a complete neurologic
exam.
Peripheral nerve disorders
Mononeuropathy and radiculopathy can be distinguished from ischemic
stroke by the anatomic distribution of the symptoms and in the case of
radiculopathy by the associated painful symptoms. Bell's palsy, vestibular
neuritis and extraocular muscle imbalance due to cranial neuropathy may
also imitate ischemic stroke and require a complete history and neurologic
examination to accurately differentiate from ischemic stroke.
Intracranial hemorrhage
Other intracranial masses (e.g., tumor, abscess [often differentiated by
CT])
The mode of onset and early course tend to be more gradual in
development.
Neuroses
Neuroses such as anxiety or panic disorder may need to be considered in
some cases.
Metabolic disorders
Hypoglycemia is the most common metabolic disorder producing
neurologic symptoms that imitate stroke. A patient with known diabetes or
liver disease should be screened for hypoglycemia.
