Henry Ford Health Stroke Guideline PDF

## Henry Ford Health Stroke Guideline ### 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...

## Henry Ford Health Stroke Guideline ### 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 ### Guideline The Henry Ford Health Stroke Council has approved this guideline to delineate a consistent, evidenced-based approach to treating patients who present with signs and symptoms consistent with acute ischemic stroke across our Henry Ford Health locations. ### Goals With stroke, every minute matters and the goal is to evaluate and treat patients as quickly as possible. With this in mind, the following time targets are suggested: | Action | Time | |---|---| | Door to physician | < 5 minutes | | Stroke team page to call back | < 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 if direct arrivals < 60 minutes if transfer | ### Emergency Evaluation of Patients with Suspected Acute Ischemic Stroke - Patients arriving to the ED with symptoms of acute stroke < 24 hours from last known normal will receive emergent evaluation according to hospitals' workflow. Patients arriving after 24 hours from symptom onset will be triaged for evaluation. - The ED physician and charge nurse will be notified immediately of a potential stroke patient. The goal for door-to-physician evaluation time will be < 5 min. - The initial evaluation will begin with immediate stabilization of the airway, breathing, and circulation followed by obtaining a history and neurologic exam including NIHSS, time of symptom onset if witnessed (or last known normal if not witnessed or wake-up), medical history, and a current list of medications. - The RN will ensure completion of: - Continuous cardiac monitoring - Insertion of two peripheral IVs - Preferably in different extremities, with IV in the left being at least 20-gauge and IV in the right being an 18-gauge placed in the upper forearm/AC for CTA/ perfusion studies - If peripheral IV access cannot be established within 5 minutes and the patient is a candidate for IV thrombolysis or mechanical thrombectomy, do not delay CT. After CT, alternative venous access should be considered in a compressible site. - Lab draws (CBC, platelets, electrolytes, PT/INR/PTT) - Point of care glucose - Vital signs and neuro assessments every 15 minutes until treatment decision made - Assessment of need for supplemental oxygen to maintain SpO2 > 94% - Patient remains NPO and no food or medication are given by mouth until a dysphagia screen is completed - The ED physician/designee will utilize the Stroke (Acute) Quick List in the EHR to order: - Standard laboratory tests will include a STAT serum glucose (finger stick is acceptable), coagulation studies (PT, PTT, INR), pregnancy test (as appropriate), serum electrolytes, renal function tests, troponin, and a complete blood count - A STAT non-contrast CT head & CTA of the head and neck immediately. Additional imaging studies may be requested as outlined below: - Emergency imaging of the brain is required before any specific treatment for acute stroke is initiated. - If endovascular therapy (EVT) is contemplated, a noninvasive intracranial vascular study (CTA or MRA) is recommended during the initial imaging evaluation of the acute stroke patient but should not delay intravenous thrombolytics if indicated. - For patients who qualify for IV thrombolytics according to guidelines from professional medical societies, initiating IV thrombolytics before noninvasive vascular imaging is recommended for patients who have not had noninvasive vascular imaging as part of their initial imaging assessment for stroke. Noninvasive intracranial vascular imaging should then be obtained as quickly as possible. - For patients who otherwise meet criteria for EVT, it is reasonable to proceed with CTA if indicated in patients with suspected intracranial large vessel occlusion (LVO) before obtaining a serum creatinine concentration in patients without a history of renal impairment. - In patients who are potential candidates for mechanical thrombectomy, imaging of the extracranial carotid and vertebral arteries, in addition to the intracranial circulation, is recommended to provide useful information on patient eligibility and endovascular procedural planning. - For patients who have a known allergy to contrast media, or who experience one for the first time, see Related Documents below for management guidelines. - In selected patients with AIS within 4.5 - 24 hours of last known well who have LVO in the anterior circulation, obtaining CTP (without Diamox), DW-MRI or MRI perfusion is recommended to aid in patient selection for mechanical thrombectomy, but only when imaging and other eligibility criteria showing benefit are being strictly applied in selecting patients for mechanical thrombectomy. It may be reasonable to incorporate collateral flow status into clinical decision making to determine eligibility for mechanical thrombectomy. - If available, it may be reasonable to add CTP along with initial order for CT & CTA if LVO is suspected (NIHSS ≥ 6) and patient was last known to be well > 4.5 hours ago (i.e. outside IV thrombolytic window), so as to expedite determination for endovascular treatment. - In select patients with acute ischemic stroke who awake with stroke symptoms or have unclear time of onset > 4.5 hours, but are less than 4.5 hours from symptom discovery, an MRI with DWI and FLAIR sequences may help select patients for treatment with IV thrombolytics. - Stroke patients will be triaged to receive priority for CT scanning. - If acute stroke is still suspected, the ED provider will notify the stroke specialist and if LVO suspected (NIHSS ≥ 6) at a site not offering thrombectomy, ED provider should place EMS on standby for possible transfer. - The stroke specialist will coordinate patient care with the treatment team. - Optimize cerebral perfusion - Intravenous saline will be promptly administered to all patients unless contraindicated, e.g. severe CHF - Place head of bed flat. Patients at risk for airway obstruction or aspiration and those with suspected elevated Intracranial Pressure (ICP) will have the head of the bed elevated 15° to 30°. - If necessary, a 12-lead EKG and a chest X-ray may be ordered but will be completed after the CT scan. Transport to CT will not be delayed for these tests. These tests should be completed within 45 minutes of patient presentation. - A neurological examination and NIHSS score will be determined and documented by the treating provider in a timely manner so as to not delay the administration of IV thrombolytics. - Based on the history, laboratory and neuroimaging information, the ED provider in consultation with the stroke specialist will determine eligibility for IV thrombolysis (see section, "Evaluation for IV Thrombolytic") or EVT (see section, “Evaluation for Endovascular Therapy"). - Ischemic stroke patients will be admitted to either an acute stroke unit or ICU; admission to any other unit will be at the discretion of the stroke team. ### Evaluation for IV Thrombolytic - **Indications for IV Thrombolytic** - Clinical diagnosis of ischemic stroke causing a measurable neurological deficit. - Time of symptom onset established to be within three hours of IV thrombolytic administration. - Select patients may be eligible to receive IV thrombolytics between 3 and 4.5 hours from symptom onset or last known well. These patients must satisfy additional criteria outlined below. - Select patients with acute ischemic stroke, who awake with stroke symptoms, or have unclear time of onset > 4.5 hours, may be eligible to receive IV thrombolytic within 4.5 hours of stroke symptom recognition, if DWI-MRI lesion is smaller than 1/3 of the MCA territory and there is not visible signal change on FLAIR. - Age ≥ 18 - Patients below the age of 18 may be treated at the discretion of the primary team physician and stroke specialist. - **Contraindications to IV Thrombolytic** - **Exclusion Criteria** - Evidence of intracranial hemorrhage on baseline computed tomography (CT) scan - Ischemic stroke within previous three months - Signs and symptoms consistent with subarachnoid hemorrhage - History of intracranial hemorrhage - Uncontrolled hypertension at time of treatment (blood pressure >185/110 mmHg - two readings 5 minutes apart) - IV antihypertensive agents may be used to lower blood pressure to an acceptable level prior to administration of IV thrombolytic. - IV Labetalol 10-20 mg will be administered to a maximum cumulative dose of 50 mg. - Alternatively, IV Nicardipine may be administered as a continuous infusion with a starting dose of 5 mg/hour, and then increased by 2.5 mg/hour every 15 minutes as needed, up to a maximum of 15 mg/hour. - Active internal bleeding - Any intracranial or spinal surgery, severe head trauma within the past three months - Intra-axial neoplasms - Known aortic dissection - Patients with known infective endocarditis - Acute bleeding diathesis, including but not limited to: - Current use of Warfarin with INR >1.7 - Systemic medical conditions resulting in INR > 1.7 - Patients taking oral direct thrombin inhibitors and oral direct Factor Xa inhibitors unless aPTT, INR, platelet count, ecarin clotting time, thrombin time, or appropriate direct factor Xa activity assays are normal or the patient has not received a dose of these agents for >48 h (assuming normal renal metabolizing function). - Administration of unfractionated Heparin with an elevated PTT (above the upper limit of reported normal) or anti-Xa level or low molecular weight heparin within 24 hours (therapeutic dose) - Platelet count <100,000/mm3 - CT demonstrates extensive regions of clear hypoattenuation suggestive of irreversible ischemia - **Relative Exclusion Criteria** - The risk of intracranial hemorrhage may be increased, or the risk/benefit ratio may not be as favorable as usual in the conditions listed below. In these situations, anticipated benefits for each individual case will be weighed against the potential risks. - Patients with minor or rapidly improving stroke symptoms at the discretion of the physician (treatment should not be delayed to monitor for further improvement) - Blood glucose concentration < 50 mg/dL and >400 mg/dL: Note: An attempt should be made to correct the blood glucose and the patient should be reassessed for ongoing neurologic deficits. If the glucose is corrected and disabling neurologic symptoms persist, IV thrombolytic treatment will be considered. - 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 - Additional absolute and relative exclusion criteria for treating patients between 3 and 4.5 hours from symptom onset: - National Institutes of Health Stroke Scale (NIHSS) score >25 (Absolute) - Age >80 (Relative) - Use of oral warfarin regardless of the INR (Relative) - Diabetic patients with previous stroke (Relative) - **Additional Considerations** - For patients with mild and non-disabling stroke symptoms per patient perspective (NIHSS 0-3), IV thrombolytic treatment is not recommended. - Intravenous thrombolytics may be a reasonable treatment for patients with CRAO after a discussion of the benefits and risks with the patient or surrogate. - **Sequence of events for IV Thrombolytic Administration** - The stroke specialist will respond to a stroke page within 5 minutes. - The following components of the acute stroke evaluation must be ordered/ completed STAT and are used in the IV thrombolytic decision making process. - Establish time of symptom onset or last known well - NIHSS - Lab tests: INR, blood glucose (finger stick is acceptable) and pregnancy test (as appropriate) - A STAT non-contrast CT and CTA of the head and neck will be done immediately. CT technicians will receive a call in order to immediately prepare an open scanner. - Stroke patients will be triaged to receive priority for CT scanning. - IV thrombolytic administration should not be delayed for completion of CTA or CT-Perfusion scan or other studies if all inclusion criteria for IV thrombolysis are met. - Blood pressure management goal < 185/110 mm Hg. Labetalol or Nicardipine or other agents (hydralazine, enalaprilat) may be considered when appropriate; refer to IV Thrombolytic order set for administration parameters. Clevidipine may be considered for patients undergoing neuro interventional procedure and is only available in the neuro interventional radiology area. - Primary team should discuss with the stroke specialist - Discussion with patient and/or family - Additional Laboratory Tests: These tests will be sent but the results are not required prior to administration of IV thrombolytic: - Platelet count - Serum electrolytes - Renal function tests - Markers of cardiac ischemia - Complete blood count - Additional laboratory tests in selected patients - Liver function tests - Toxicology screen and blood alcohol level - 12-lead ECG and chest x-ray: - Transportation to CT will not be delayed to obtain an EKG or chest x-ray unless there is high clinical suspicion for aortic dissection or other life-threatening condition that mandates an ECG or chest x-ray. - Placement of indicated invasive lines, nasogastric tube or urinary catheter should not delay administration of IV thrombolytics. Completion of invasive procedures prior to administration of IV thrombolytic does not decrease the risk of local bleeding from subsequent IV thrombolytic administration - Ensure that no food or medication is given by mouth until a dysphagia screen is completed. - If IV thrombolytic is administered > 45 minutes from hospital arrival, document a reason for delay. ### Intravenous Thrombolytic Consent, Dosing and Administration Refer to Tier 1: Preparation and Administration of Tenecteplase (TNK) for Treatment of Acute Ischemic Stroke Guideline - As soon as the decision is made to proceed with IV thrombolytic treatment, verbal informed consent will be obtained from the patient or their representative. Informed consent is not neccessary, i.e. may be waived if patient is unable to consent and surrogate not available. - Informed consent will include a discussion of the potential benefits, risks, side effects, likelihood of the patient achieving his or her goals, and any other potential problems that might occur as the result of treatment. The discussion will also include benefits and risks of alternative treatments. - If the patient develops severe headache, acute hypertension, nausea, vomiting, depressed level of consciousness, or has a worsening neurological examination, obtain emergency head CT scan. - From the time of administration, monitor vital signs and neurological assessments every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then every hour for 16 hours. - Maintain BP <180/105 mm Hg. Increase the frequency of BP monitoring if BP is elevated above these parameters. - Administer antihypertensive medications to maintain BP < 180/105 mm Hg. Patients eligible for intravenous thrombolytic treatment should receive IV thrombolytic even if endovascular treatments are being considered. Observation of patients after IV thrombolytic to assess for clinical response before pursuing endovascular therapy should not be performed. ### Evaluation for Endovascular Therapy (EVT) The decision to offer endovascular treatment is made between the stroke specialist and the neuro-interventional specialist on call based on the criteria below. - **Indications for Endovascular Therapy (EVT):** The decision to offer endovascular treatment is made between the stroke specialist and the neuro-interventional specialist on call based on the criteria below: - Acute ischemic stroke causing a measurable neurological deficit. - Patients who are aged 18 years or older (no upper age limit), with good functional capacity prior to the current stroke (modified Rankin score 0-1) - Pediatric patients will be stabilized and transferred. - Causative occlusion of the internal carotid artery or MCA segment 1 (M1) - NIHSS score ≥ 6 - ASPECTS of ≥ 6 - Although its benefits are uncertain, the use of mechanical 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 with additional perfusion imaging and who have pre-stroke mRS score > 1, ASPECTS < 6, or NIHSS score < 6 and causative occlusion of the ICA or proximal MCA (M1). - **Additional Considerations (0-24 hours):** Patients will be treated based on clinical and imaging characteristics, on a case-by-case basis, and after agreement between the stroke specialist and the neuro-interventional specialist. - Although the benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients when treatment can be initiated (groin puncture) within 24 hours of symptom onset with appropriate perfusion imaging or for patients who have causative occlusion of the MCA segment (M2) or MCA segment 3 (M3) portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries. - Although its benefits are uncertain, the use of mechanical therapy with stent retrievers may be reasonable for patients with acute ischemic stroke in whom treatment can be initiated (groin puncture) within 24 hours of symptom onset with additional perfusion imaging and who have pre-stroke mRS score > 1, ASPECTS < 6, or NIHSS score < 6 and causative occlusion of the ICA or proximal MCA (M1). - **Contraindications to Endovascular Therapy** - **Exclusion Criteria** - Intracranial hemorrhage by imaging - Suspected aneurysmal subarachnoid hemorrhage - Well-established acute infarct on CT/MR in the affected brain region with mass effect - Substantial volume of irreversible infarction and/or limited salvageable tissue based on perfusion imaging according to clinical judgment of neuro-interventional specialist taking the DAWN and DEFUSE 3 criteria into account - If intra-arterial infusion of thrombolytic medication is anticipated and - History of intracranial lesions with a high likelihood of hemorrhage (e.g., brain tumor, abscess, vascular malformation, aneurysm > 10 mm, or contusion) or - Recent surgery or trauma (<15 days) or - Recent intracranial or spinal surgery, head injury, or stroke or - Recent active internal bleeding or arterial puncture at a non-compressible site. - **Relative Exclusion Criteria** - These factors may increase the chance of an unfavorable outcome but are not absolute contraindications for endovascular treatment. - Severe comorbid states with life expectancy < 1 year - Baseline Modified Rankin ≥ 2 - Bleeding diatheses - No established time of onset of stroke - **Informed Consent** - All patients undergoing endovascular therapy must be appropriately consented with a surgical/procedural consent form (in addition to IV thrombolytic consent, if relevant). - Preferably the patient undergoing the procedure will provide written or verbal consent. A witness must be present if a verbal consent is given. - If the patient is not able to provide consent due to his/her medical state, then consent will be obtained from a family member, next of kin, or a LAR (legally authorized representative). - Emergency implied consent may be considered if no one can provide consent on the patient's behalf. - Refer to Tier 1 Informed Consent policy - **Sequence of Events for Suspected or Confirmed LVO** - Due to the importance of onset to treatment time on outcome, if a patient is not eligible for EVT at a Henry Ford Health facility due to a prolonged time of transport, sending facility will contact closer alternative eligible site. For EVT at a Henry Ford Health facility: - The neuro-interventional specialist will be contacted when the CTA of the head and neck reveals a large vessel occlusion (LVO), or sooner if clinical presentation is suggestive of possible LVO. Images may be reviewed by Radiology, FAST physician and neuro-interventional specialist. The decision to proceed will be made based on imaging and once contraindications have been ruled out. This decision will be made by the on-call FAST physician and neuro-interventional specialist. - The neuro-interventional team will be mobilized as soon as the patient is deemed to be a suitable candidate for endovascular treatment. The neuro-interventional team and the Anesthesia team will be activated by the neuro-interventional specialist. - Upon arrival to Henry Ford Hospital ER, the patient needs to be "arrived" and "roomed" in the EHR. Refer to Transfer of the Acute Stroke Patient policy. - Utilize the order for "HFHS stroke endovascular therapy and ADT orders," or if patient has not yet arrived, an orders-only encounter can be placed utilizing the "HFHS Stroke TRANSFER endovascular therapy and admission order." - After business hours, the neuro-interventionalist will be available in house within 30 minutes of activation, 24/7. - If a patient is receiving IV thrombolytic, the patient will be transported to the angio suite with appropriate monitoring as soon as IV thrombolytic has been administered. - Anesthesia support will be used in all cases. - The Anesthesia team will be available as an emergency case. The Anesthesia team will be available with equipment in the room within 15 minutes of notification and assume care of the patient as soon as patient enters the angio suite. - A target time of less than 15 minutes from the time patient enters the angio suite to induction of general anesthesia if being used. - All efforts will be made to perform interventional treatment with monitored anesthesia care, avoiding intubation, if the patient can tolerate it. The decision to put the patient under general anesthesia will be made by the Anesthesia staff together with the neuro-interventional specialist. - It is reasonable to favor conscious sedation over general anesthesia during endovascular therapy for acute ischemic stroke. However, the ultimate selection of anesthetic technique during endovascular therapy for acute ischemic stroke should be individualized on the basis of patient risk factors, tolerance of the procedure, and other clinical characteristics. Randomized trial data are needed. ### Related documents * 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 ### Related EHR Impact * 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.