Acute Ischemic Stroke Guidelines
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Acute Ischemic Stroke Guidelines

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Questions and Answers

What is the target time for induction of general anesthesia upon patient entry to the angio suite?

  • Less than 10 minutes
  • Less than 30 minutes
  • Less than 20 minutes
  • Less than 15 minutes (correct)

    • Which anesthetic technique is generally favored during endovascular therapy for acute ischemic stroke?

  • Conscious sedation (correct)
  • Sedative-hypnotic combination
  • General anesthesia
  • Spinal anesthesia

    • What should determine the selection of anesthetic technique for a patient undergoing endovascular therapy for an acute ischemic stroke?

  • Patient risk factors and clinical characteristics (correct)
  • Time available before surgery
  • Surgeon's preference only
  • Cost of the anesthetic agents

    • Which of the following is NOT a related document mentioned in the content?

    <p>Post-Anesthesia Care Unit Protocol</p> Signup and view all the answers

    What is the role of the anesthesia staff in the decision for general anesthesia during endovascular therapy?

    <p>The decision is made in consultation with the neuro-interventional specialist.</p> Signup and view all the answers

    What type of trial data is needed to further evaluate anesthetic techniques in endovascular therapy for acute ischemic stroke?

    <p>Randomized trial data</p> Signup and view all the answers

    Which order set is NOT associated with acute stroke treatment in the content provided?

    <p>Stroke Rehabilitation Order Set</p> Signup and view all the answers

    What is the main goal of performing interventional treatment with monitored anesthesia care?

    <p>To avoid intubation if possible</p> Signup and view all the answers

    What is the maximum time allowed for door-to-physician evaluation in suspected acute stroke cases?

    <p>5 minutes</p> Signup and view all the answers

    Which of the following is a recommended action that should take place within 15 minutes of patient arrival?

    <p>Door to CT initiation</p> Signup and view all the answers

    Which of the following actions should happen within 25 minutes of patient arrival?

    <p>Door to CT interpretation</p> Signup and view all the answers

    What is the NIHSS primarily used for in the evaluation of stroke patients?

    <p>Measuring neurologic deficits</p> Signup and view all the answers

    What is the recommended timeframe for door-to-needle administration of thrombolytics?

    <p>&lt;45 minutes</p> Signup and view all the answers

    What immediate action should be performed first when a stroke patient arrives?

    <p>Stabilize airway, breathing, and circulation</p> Signup and view all the answers

    Patients presenting with stroke symptoms more than 24 hours after their last known normal will be subject to which protocol?

    <p>Triage for evaluation</p> Signup and view all the answers

    What is the maximum time allowed for door-in door-out transfers to a Comprehensive Stroke Center (CSC) for patients needing possible EVT?

    <p>&lt;60 minutes</p> Signup and view all the answers

    What is one absolute contraindication for administering IV thrombolytics in stroke patients?

    <p>Recent anterior ST elevation myocardial infarction</p> Signup and view all the answers

    Which of the following patients would be excluded from receiving IV thrombolytics based on their NIHSS score?

    <p>Patient with NIHSS score of 25</p> Signup and view all the answers

    What should be done immediately after confirming a patient is a candidate for IV thrombolytics?

    <p>Perform a STAT non-contrast CT and CTA of the head and neck</p> Signup and view all the answers

    Which of the following is a relative exclusion criterion for IV thrombolytics?

    <p>Diabetic patient with a history of prior stroke</p> Signup and view all the answers

    What is the goal for blood pressure management before administering IV thrombolytics?

    <p>Below 185/110 mm Hg</p> Signup and view all the answers

    Which symptom onset timeline is critical for the administration of IV thrombolytics?

    <p>Within 4.5 hours post-symptom onset</p> Signup and view all the answers

    What is the first step to be taken when a stroke page is activated?

    <p>Establish time of symptom onset</p> Signup and view all the answers

    For patients with mild stroke symptoms, what is the recommendation regarding IV thrombolytic treatment?

    <p>IV thrombolytics are not recommended</p> Signup and view all the answers

    Study Notes

    Henry Ford Health Stroke Guideline

    • Henry Ford Health Stroke Council approved guideline to provide consistent evidenced-based care for acute ischemic stroke patients across all locations.
    • The goal is to treat patients as quickly as possible.
    • Time targets:
      • Door to physician evaluation: < 5 minutes
      • Door to CT initiation: < 15 minutes
      • Door to CT interpretation: < 25 minutes
      • Door to needle: < 45 minutes
      • Door-in door-out, if transfer to CSC for possible EVT: < 60 minutes
      • Door to device (1st pass): < 90 minutes (direct arrivals); < 60 minutes (if transfer)

    Emergency Evaluation

    • Patients with suspected acute stroke symptoms within 24 hours of onset will receive immediate evaluation.
    • Patients arriving after 24 hours will be triaged for evaluation.
    • The goal is to have a physician evaluation within 5 minutes of arrival
    • Immediate stabilization of airway, breathing, and circulation is essential.
    • Obtain a history and neurologic exam, including:
      • NIHSS
      • Time of symptom onset (or last known normal)
      • Medical history
      • Current medications

    Anesthesia for Endovascular Therapy

    • Target time: < 15 minutes from patient entry into the angio suite to induction of general anesthesia (if used)
    • Monitored anesthesia care is preferred to avoid intubation, if tolerated.
    • General anesthesia decision is made collaboratively by anesthesia staff and neuro-interventional specialist.
    • Conscious sedation may be favored over general anesthesia during endovascular therapy for acute ischemic stroke.
    • Selection of anesthesia technique should be individualized based on patient risk factors, procedure tolerance, and clinical characteristics.
    • Randomized trial data is needed.

    Exclusion Criteria for IV Thrombolytic Therapy

    • Absolute:
      • Pregnancy and early postpartum period (< 14 days after delivery)
      • Seizure at symptom onset
      • Patients with recent anterior ST elevation myocardial infarction (within 3 months) or evidence of acute pericarditis
      • Major surgery or serious trauma within 14 days
      • Arterial puncture at a non-compressible site in the previous 7 days
      • Lumbar puncture within previous 7 days
      • Recent gastrointestinal or urinary tract hemorrhage within 21 days
      • Known untreated extra-axial intracranial neoplasm
      • Known untreated and unsecured intracranial aneurysm (particularly if > 10 mm)
      • Known untreated intracranial vascular malformation
    • Relative:
      • NIHSS score >25 (for patients treated between 3 and 4.5 hours from symptom onset)
      • Age >80
      • Use of oral warfarin regardless of INR
      • Diabetic patients with previous stroke

    Additional Considerations

    • IV thrombolytic treatment is not recommended in patients with mild and non-disabling stroke symptoms (NIHSS 0-3).
    • IV thrombolytics may be reasonable for CRAO patients after a discussion of benefits and risks.

    Sequence of Events for IV Thrombolytic Administration

    • Stroke specialist responds to a stroke page within 5 minutes.
    • Complete the following STAT, used in the IV thrombolytic decision-making process:
      • Establish time of symptom onset or last known well
      • NIHSS
      • Labs: INR, blood glucose, and pregnancy test (if appropriate)
      • Non-contrast CT and CTA of the head and neck will be done immediately.
      • IV thrombolytic administration should not be delayed if all inclusion criteria are met.
      • Blood pressure management goal: < 185/110 mm Hg.

    Abbreviations

    • CRAO: central retinal artery occlusion
    • CSC: Comprehensive Stroke Center
    • CT: computer-tomography scan
    • CTA: CT angiography
    • CTP: CT perfusion
    • DW-MRI: diffusion-weighted magnetic resonance imaging
    • EHR: Electronic Health Record
    • EVT: Endovascular Therapy
    • FLAIR MRI: fluid-attenuated inversion recovery magnetic resonance imaging
    • LVO: Large vessel occlusion
    • MRA: Magnetic resonance angiogram imaging
    • MRP: Magnetic resonance perfusion imaging
    • NIHSS: National Institutes of Health Stroke Scale
    • Tier 1: Informed Consent Policy
    • HFH Tier 2: Transfer of the Acute Stroke Patient Policy
    • Tier 1: Contrast Media Allergy Management Guideline for Adult and Pediatric Patients
    • Tier 1: Preparation and Administration of IV Tenecteplase (TNK) for Acute Ischemic Stroke
    • Stroke Alert Order Set
    • Stroke Treatment IV Thrombolytic Order Set
    • Stroke Post IV Thrombolytic Order Set
    • HFHS Stroke endovascular therapy and ADT Order Set
    • HFHS Stroke TRANSFER endovascular therapy and admission Order Set
    • Stroke (Acute) Quick List

    References/External Regulations

    • Powers, WJ, Rabinstein, AA, Ackerson, T, et al. 2019 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.Stroke. 2019;50:e344-e418.DOI: 10.1161/STR.0000000000000211.
    • Demaerschalk, BM, Kleindorfer, DO, et al. 2015 Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke. 2016;47:581-641.DOI: 10.1161/STR.0000000000000086.

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    Related Documents

    Henry Ford Health Stroke Guideline PDF

    Description

    Test your knowledge on the Henry Ford Health Stroke Council's guidelines for acute ischemic stroke patients. This quiz covers time targets for evaluations and procedures, as well as emergency evaluation protocols. Ensure you understand the critical timelines to provide effective patient care.

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