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Treating Ischemic Stroke As an Emergency

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Treating Ischemic Stroke As an Emergency NEUROLOGICAL REVIEW Treating Ischemic Stroke as an Emergency Harold P. Adams, Jr, MD he success of treatment with tissue plasminogen activator serves as an impetus to ap- proach stroke as a medical emergency; diagnosis and treatment must be accurate and prompt. The initial evaluation should be straightforward and aimed at confirming is- chemic stroke as the cause of the patient’s acute neurologic impairments. Until the Tusefulness of diagnostic tests to demonstrate an arterial occlusion is established in emergent man- agement, their application before treatment should not be mandated. Most individuals with acute ischemic stroke will receive their initial, key treatment in a community setting. Thus, strategies for emergent treatment should aim at management of patients whose strokes are diagnosed and first treated by emergency treatment and primary care physicians with the collaboration of neu- rologists. Arch Neurol. 1998;55:457-461 Ischemic stroke is the most common acute ment also is influenced by the patient’s neurologic illness and a leading cause of condition and his/her wishes. Most pa- death, disability, and human suffering. Fi- tients with acute ischemic stroke will not nancially, it also is an expensive disease. be treated initially by neurologists or stroke Stroke costs the US economy more than care specialists. Because of limited avail- $40 billion per year.1 Thus, successful ability of acute stroke care units, most pa- management of ischemic stroke has vast tients are admitted to community hospi- public health implications. In the past, is- tals that do not have special expertise in chemic stroke was approached with ni- the treatment of cerebrovascular disease. hilism by both the public and health care The primary goal of modern treat- providers.2 This negative attitude is be- ment of acute ischemic stroke is to limit ing abandoned in response to a revolu- or reverse the brain injury so that the pa- tion in the management of stroke. Stroke tient can recover as much as possible. A now is being treated as the life-threat- sustained improvement in neurologic out- ening disease it is. Several factors under- come is the measure to judge responses to pin modern management. The interval treatment.3 Ischemic stroke is a complex from onset until treatment is critical. Is- vascular and metabolic process that evolves chemic stroke usually is caused by throm- over minutes to hours. The concept of the boembolic occlusion of an artery supply- ischemic penumbra emphasizes that al- ing a portion of the brain, and improving though a core of infarcted tissue might not perfusion will be fundamental for suc- be salvageable with any intervention, an cess. The spectrums of neurologic impair- area of dysfunctional, ischemic brain might ments and causes of stroke are broad; as be rescued if a therapy is prescribed a result, the prognosis of patients varies promptly. Experimental studies4-6 amply considerably. Besides treating the stroke demonstrate that the interval from onset itself, management includes measures to of ischemia until initiation of treatment is prevent or control medical or neurologic critical for success for any therapy. The complications, rehabilitation, and thera- window for effective treatment may be only pies to prevent recurrent stroke. Manage- a few hours. The maximum interval is not known but an intervention prescribed From the Division of Cerebrovascular Diseases, Department of Neurology, University more than 24 hours after onset of symp- of Iowa College of Medicine, Iowa City. toms is not likely to be of much benefit. ARCH NEUROL / VOL 55, APR 1998 457 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Starting treatment as soon as possible is and will con- chemistry studies, including serum electrolytes and blood tinue to be a driving force in emergent stroke care. glucose level; arterial blood gases, if hypoxia is sus- The push to start treatment quickly is the basis of ef- pected clinically; and cervical spine x-ray films, if the pa- forts to increase public and professional awareness of stroke, tient is unconscious and no medical history is available which is summarized in the term brain attack.7-15 Delays about the onset of neurologic impairments. In addition, in recognition, transport, evaluation, and treatment must the protocol should include components for general emer- be overcome to meet the short time windows required for gent management and the initiation of treatments of the current emergent care. The public’s knowledge about the stroke, including deciding whether a patient might be presentations of stroke and the best responses to their ap- treated with tissue plasminogen activator (Table). The pearance is limited.16-18 A concerted public education cam- published guidelines7-12 for care of acute stroke can be paign is needed; in particular, high-risk patients and their used as the templates for writing these protocols. family members, neighbors, friends, and coworkers should Intravenous administration of tissue plasminogen be instructed on the common symptoms of stroke. The mes- activator has engendered controversy.20-24 Intravenous sage to the public also should emphasize that stroke is treat- thrombolysis is not a cure-all but, at present, it is the only able but that time is critical. The educational program for therapy of proven efficacy for management of individu- acute ischemic stroke (brain attack) can be modeled on that als with acute ischemic stroke. While intra-arterial ad- used for acute myocardial ischemia (heart attack). Neu- ministration of thrombolytic drugs has hypothetical ad- rologists should lead these educational efforts in their com- vantages, its superiority over intravenous thrombolysis munities. is not proved.11,12,25 Although the results of some stud- Emergency medical services (EMS) should give acute ies26-30 are promising, neither antithrombotic drugs nor stroke the same priority as acute heart disease. Educa- neuroprotective agents are established as effective in im- tional programs on the importance of stroke care are proving outcomes after stroke. Until other therapies or needed for all components of EMS systems, including dis- treatment strategies are of proven value in improving neu- patchers and rescue squads. Evaluation in the field by rologic outcome after ischemic stroke, the goal of emer- EMS personnel should be prompt and transportation to gent management should be aimed at treatment with in- a hospital should be speedy. The first assessments should travenous tissue plasminogen activator. include relevant medical history, measurement of vital The short time window for effective and safe treat- signs, and a brief neurologic examination. If a para- ment with tissue plasminogen activator has implica- medic is in attendance, blood work and an electrocar- tions for all physicians, including neurologists. Initial man- diogram can be obtained and an intravenous line can be agement likely will occur in an emergency department. placed. A protocol that coordinates care between the EMS Most emergency departments are staffed by emergency and hospital can expedite transfer. The rescue squad medicine specialists or primary care physicians and in should inform the hospital that a patient with a possible many hospitals neurologists are not readily available. Many stroke is being transported to the emergency depart- patients cannot reach large tertiary medical centers with ment. The patient should go to a hospital that has the stroke specialists within 3 hours; in particular, patients ability to emergently perform computed tomography on in rural areas likely cannot be transported to a major hos- a 24-hour per day and a 7-day per week basis. Such a re- pital quickly enough to be treated with tissue plasmino- quirement might mean bypassing the closest hospital be- gen activator. Thus, a strategy to provide emergent care, cause it does not have imaging facilities. including the use of tissue plasminogen activator, must In turn, the hospital should have an acute stroke care be developed for a community setting. Hachinski31 ad- protocol to meet ambitious but feasible goals to rapidly vised that 3 criteria must be in place for the successful assess and treat patients.15 The availability of a treat- use of thrombolytic drugs: (1) availability of a physician ment of proven efficacy for improving outcomes of in- with expertise in the diagnosis and management of stroke, dividuals with ischemic stroke (tissue plasminogen ac- (2) accessibility to modern brain imaging studies, and tivator) but which must be given within 3 hours of onset (3) capability to handle potential complications of treat- of stroke highlights the importance of these ef- ment, especially brain hemorrhage. One could argue that forts.11,12,19 The protocol should include a list of physi- these requirements are needed for treatment of individu- cians, nurses, laboratory and radiology personnel, and als with stroke, regardless of the use of tissue plasmino- pharmacists who will be members of an acute stroke care gen activator. To expedite care of individuals with stroke, team. In institutions that do not have continuous cov- neurologists should be readily available for consulta- erage by stroke specialists or neurologists, primary care tions in emergency departments. Pending increased in- or emergency medicine physicians likely will be the lead- volvement of neurologists in emergency management, ers of this team. The protocol should outline steps in emer-
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