Adult Stroke

Stroke (2010 Guideline for CPR & ECC)

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Adult Strok
2010 AHA Guidelines for CPR and ECC 
Circulation. 2010;122:S818-S828 

The “D's of Stroke Care”

1. Detection: Rapid recognition of stroke symptoms
2. Dispatch: Early activation and dispatch of EMS system by calling 911
3. Delivery: Rapid EMS identification, management, and transport
4. Door: Appropriate triage to stroke center
5. Data: Rapid triage, evaluation, and management within the ED
6. Decision: Stroke expertise and therapy selection
7. Drug: Fibrinolytic therapy, intra-arterial strategies
8. Disposition: Rapid admission to stroke unit or ICU

Management Goals

• Time is Brain
• Minimize acute brain injury and maximize patient recovery
• Stroke Chain of Survival

EMS Stroke Recognition

• Cincinnati Prehospital Stroke Scale (CPSS)

Sensitivity: 59%; Specificity: 89%

• Los Angeles Prehospital Stroke Screen (LAPSS)

Sensitivity: 93%; Specificity: 97%

In-Hospital Care

• Protocols should be used in the ED to minimize delay to definitive diagnosis and therapy.
• ED personnel should assess the patient with suspected stroke within 10 minutes of arrival in the ED.
• The EP should perform a neurologic screening assessment, order emergent CT, and activate the stroke team.

Approach To Arterial Hypertension In Acute Ischemic Stroke For Patients Potentially Eligible for Acute Reperfusion Therapy

• Patient eligible for acute reperfusion therapy except that BP >185/110 mmHg
• Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat ×1
• If BP does not below 185/110 mmHg, do not administer rtPA

Management of BP During and After rtPA or Other Acute Reperfusion Therapy

• If SBP 180–230 mmHg or DBP 105–120 mmHg
• Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min
• If BP not controlled or diastolic BP >140 mmHg, consider sodium nitroprusside

For Patients Not Potential Candidates for Acute Reperfusion Therapy

• Consider lowering BP in acute ischemic stroke if BP >220/120 mmHg
• A reasonable target is to lower BP by 15% to 25% within the first day

CT should be completed within 25 minutes and should be interpreted within 45 minutes of the patient's arrival in the ED.


Inclusion and Exclusion Characteristics of Patients with Ischemic Stroke Who Could Be Treated with rtPA within 3 Hours from Symptom Onset
Inclusion Criteria

1. Diagnosis of ischemic stroke causing measurable neurologic deficit
2. Onset of symptoms <3 hours before beginning treatment 
3. Age >18 years

Exclusion Criteria

• Head trauma or prior stroke in previous 3 months
• Symptoms suggest SAH
• Arterial puncture at non-compressible site in previous 7 days
• History of previous ICH
• Elevated BP (systolic >185 mmHg or diastolic >110 mmHg)
• Evidence of active bleeding on examination
• Acute bleeding diathesis, including but not limited to

• Platelet count <100,000/mm3
• Heparin received within 48 hours, resulting in aPTT >upper limit of normal
• Current use of anticoagulant with INR >1.7 or PT >15 seconds 

• Blood glucose <50 mg/dl
• CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Relative Exclusion Criteria

• Only minor or rapidly improving stroke symptoms (clearing spontaneously)
• Seizure at onset with postictal residual neurologic impairments
• Major surgery or serious trauma within previous 14 days
• Recent GI or urinary tract hemorrhage (within previous 21 days)
• Recent AMI (within previous 3 months)

Additional Inclusion and Exclusion Characteristics of Patients with Ischemic Stroke Who Could Be Treated with rtPA from 3 to 4.5 Hours from Symptom Onset
Inclusion Criteria

• Diagnosis of ischemic stroke causing measurable neurologic deficit
• Onset of symptoms 3 to 4.5 hours before beginning treatment

Exclusion Criteria

1. Age >80 years
2. Severe stroke (NIHSS >25)
3. Taking an oral anticoagulant regardless of INR
4. History of both DM and prior ischemic stroke

At present, use of IV rtPA within 3 to 4.5 hour has not yet been FDA approved, although it is recommended by current AHA/ASA science advisory

General Stroke Care

• BP Management
• Glycemic Control: hyperglycemia should be treated with insulin when glucose >185 mg/dL
• Temperature Control: treat fever >37.5°C
• Dysphagia Screening
• Observe for signs of IICP: severe stroke, posterior circulation, stroke younger patient

Treatment of Acute Ischemic Stroke: IV rtPA

• Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 minutes with 10% of the dose given as a bolus over 1 minute. 

延伸閱讀：AHA/ASA 2007 Guidelines for Ischemic Stroke