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A stroke is an episode of acute neurological dysfunction persisting ≥ 24 hours with acute infarction or
hemorrhage.
Strokes are generally classified as ischemic or hemorrhagic.
Ischemic strokes (80-87% of strokes) are caused by large artery atherosclerosis (embolus or
thrombosis), small vessel occlusion (lacunar), or cardioembolism (often from atrial fibrillation).
Hemorrhagic strokes are typically due to intracerebral hemorrhage or subarachnoid hemorrhage.
The most common mechanism of intracerebral hemorrhage is hypertensive small-vessel disease,
causing small lipohyalinotic aneurysms that rupture. Most subarachnoid hemorrhages are caused by
rupture of saccular aneurysms.
The estimated global incidence of stroke is 2-3 per 1,000 person-years, with older patients and patients
with carotid artery stenosis or atrial fibrillation most often affected.
Risk factors for stroke include history of transient ischemic attack, hypertension, myocardial infarction,
atrial fibrillation, left atrial enlargement, smoking, heavy alcohol use, diabetes, obesity, high cholesterol,
and carotid artery stenosis.
Evaluation
The most common presenting symptoms of ischemic stroke are speech difficulty and hemiparesis. Other
common symptoms of ischemic stroke include extremity or facial weakness, arm or leg numbness,
confusion, headache, and nonorthostatic dizziness.
Severe headache is the most common presenting symptom of subarachnoid hemorrhage. Symptoms of
intracerebral hemorrhage can include neurological deterioration and reduced consciousness, vomiting, and
hemiparesis and hemisensory symptoms that develop gradually.
Determine the precise time of symptom onset (when patient was last asymptomatic and at neurological
baseline) if assessing eligibility for thrombolytic therapy and other emergency interventions.
Neurologic exam may reveal change in mental status, focal weakness affecting the arm, leg, and/or face,
aphasia or dysarthria, hemiparetic or ataxic gait, eye movement abnormalities, spatial neglect, and visual
field defects.
Initial assessment should include calculation of a formal stroke score, such as National Institutes of
Health Stroke Scale (NIHSS), for diagnostic and prognostic classification of stroke severity (Strong
Recommendation).
Deterioration of neurologic exam or mental status after initial stroke assessment may occur in 25%
of patients, attributable to stroke progression, brain edema (can be life threatening with peak risk 3-
4 days after stroke), recurrent ischemia, or hemorrhage.
Emergent studies to evaluate suspected acute stroke and differentiate stroke from other conditions include
(Strong Recommendation)
Noncontrast brain computed tomography (CT) or magnetic resonance imaging (MRI)
Noncontrast head CT is appropriate to diagnose stroke, rule out intracranial hemorrhage
(absolute contraindication to thrombolytic therapy), and is the test of choice for diagnosing
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Management
Rapid evaluation and initial management of stroke patients is important to facilitate timely intervention
which may preserve neurologic function and decrease mortality.
Admit patient to acute stroke unit care if available for neurologic and cardiac monitoring, as associated
with deceased mortality (Strong Recommendation).
Thrombolytics
Thrombolytics (tissue-type plasminogen activator [t-PA], recombinant tissue-type plasminogen
activator [rt-PA], Activase) are recommended for patients with an acute ischemic stroke who have a
measurable neurologic deficit if treatment can be started quickly enough and the patient has no
contraindications (Strong Recommendation)
Contraindications vary across guidelines and drug marketing authorization but usually include
Any evidence of intracranial hemorrhage on neuroimaging, or symptoms suggestive of
subarachnoid hemorrhage
Severe stroke, based on National Institutes of Health Stroke Scale (NIHSS) score ≥ 26 or
ischemic signs involving > one-third of middle cerebral artery territory on neuroimaging
Minor stroke - only minor symptoms or stroke is rapidly improving
Seizure at stroke onset
Platelet count < 100,000/mm3 or abnormal coagulation tests including INR > 1.7 or PT > 15
sec
Blood glucose level < 50 mg/dL (2.8 mmol/L) or > 400 mg/dL (22.2 mmol/L)
Recent procedures or surgery - arterial or venous puncture at noncompressible site in past 7
days, major surgery in past 2 weeks (or past 3 months)
Recent trauma or cardiovascular event - prior stroke or myocardial infarction in past 3
months, serious trauma in past 2 weeks (or past 3 months), significant head trauma in past 3
months
Selected comorbidities - blood pressure ≥ 185/110 mm Hg, neoplasm, acute pancreatitis,
endocarditis, pericarditis, severe liver disease, ulcerative gastrointestinal disease,
arteriovenous malformation, aneurysm, diabetes in patients with prior stroke
History of or current bleeding - active bleeding, gastrointestinal tract or urinary tract bleeding
in prior 3 weeks, known hemorrhagic diathesis, history of intracranial hemorrhage
Most guidelines (especially guidelines from neurologists and stroke specialists) recommend
alteplase for carefully selected patients within 3 hours of acute ischemic stroke and also 3-4.5 hours
after stroke onset, while multiple emergency medicine associations state use of t-PA is not supported
by the evidence and should not be considered standard of care.
t-PA within three hours has evidence for improved functional outcomes but increases risk of
intracranial hemorrhage and does not appear to affect mortality.
t-PA given 3-4.5 hours after stroke onset increases risk of symptomatic intracranial
hemorrhage and risk of fatal intracranial hemorrhage within 7 days and might increase 90-day
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Related Summaries
Stroke (list of topics)
Neuroimaging for acute stroke
Intracerebral hemorrhage
Subarachnoid hemorrhage
Transient ischemic attack (TIA)
Thrombolytics for acute stroke
Endovascular therapy for acute stroke
Long-term management of stroke
Stroke rehabilitation in adults
General Information
Description
episode of acute neurological dysfunction caused by ischemia or hemorrhage, persisting ≥ 24 hours or
until death (Stroke 2013 Jul;44(7):2064)
classification includes(2, 3)
ischemic (80%-87% of strokes)
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Also called
cerebrovascular accident (CVA)
cerebral infarct
"brain attack"
shock (term often used by patients and family members)
Definitions
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meets older time-based definitions for TIA but infarction seen on imaging
higher risk for stroke at 7 days and at 90 days than TIA without infarction
Reference - Neurology 2011 Sep 27;77(13):1222, Stroke 2011 Aug;42(8):2186
reversible ischemic neurologic deficit (event > 24 hours but < 7 days) considered obsolete term (Stroke
2009 Jun;40(6):2276 full-text)
Types
classification includes(2, 3)
ischemic (80%-87% of strokes)
large artery occlusion
small vessel occlusion (lacunar)
cardioembolic
other or undetermined cause
hemorrhagic (13%-20% of strokes)
intracerebral hemorrhage
subarachnoid hemorrhage
Oxfordshire Community Stroke Project clinically identifiable subtypes of cerebral infarction
lacunar infarct (LACI)
small infarcts confined to the territory of the deep perforating arteries (basal ganglia or the
pons)
pure motor stroke, pure sensory stroke, sensorimotor stroke, or ataxic hemiparesis
includes face-arm and arm-leg syndromes, but not more restricted deficits
total anterior circulation infarct (TACI) - combination of 3 new deficits
higher cerebral dysfunction (such as dysphasia, dyscalculia, visual-spatial disorder)
homonymous visual field defect
ipsilateral motor and/or sensory defect involving 2 areas of face, arm, and leg
partial anterior circulation infarct - only 2 of 3 TACI components, with higher cerebral dysfunction
alone, or with motor/sensory deficit more restricted than those classified as LACI (such as confined
to one limb or to face and hand, but not whole arm)
posterior circulation infarct - any one of
ipsilateral cranial nerve palsy with contralateral motor and/or sensory deficit
bilateral motor and/or sensory deficit
disorder of conjugate gaze
cerebellar dysfunction without ataxic hemiparesis
isolated homonymous visual field defect
Reference - Lancet 1991 Jun 22;337(8756):1521
left hemispheric strokes diagnosed more commonly than right hemispheric strokes
based on German hospital-based stroke registry with 20,097 patients
56% left hemispheric vs. 44% right hemispheric
Reference - Lancet 2005 Jul 30;366(9483):392, editorial can be found in Lancet 2005 Jul 30-Aug
5;366(9483):349
Epidemiology
Who is most affected
older patients
patients with
carotid artery stenosis
atrial fibrillation
in United States (based on telephone survey of 109,629 adults in 2003)
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Incidence/Prevalence
global incidence of stroke and geographic variation
global stroke incidence and mortality between 1990 and 2010
based on systematic review of observational studies
systematic review of 119 studies assessing worldwide stroke incidence, prevalence, and
mortality between 1990 and 2010
2010 incidence and prevalence
high-income countries (all ages)
incidence 217 per 100,000 person-years
prevalence 715 per 100,000 people
mortality 61 per 100,000 person-years
low- and middle-income countries (all ages)
incidence 281 per 100,000 person-years
prevalence 393 per 100,000 people
mortality 105 per 100,000 person-years
during 30 year period from 1990 to 2010
age-standardized incidence of stroke decreased by 12% in high income countries and
increased by 12% (not significant) in low- and middle-income countries
mortality significantly decreased in high-income and in low- and middle-income
countries
Reference - Lancet 2014 Jan 18;383(9913):245, correction can be found in Lancet. 2014 Jan
18;383(9913):218, editorial can be found in Lancet 2014 Jan 18;383(9913):195
geographic variation in incidence of stroke
Geographic Variations:
Annual Incidence per Fatality Rate at 28-30
Location Reference
100,000 Days
Lancet 2005 Jun
Iquique, Chile* 140 23.3%
25;365(9478):2206
Stroke 2008
Puglia, Italy 160 18.1%
Nov;39(11):2923
Stroke 2010
Grodno, Belarus* 222 26.1%
Dec;41(12):2726
Stroke 2010
Maputo, Mozambique 260.1 49.6%
Nov;41(11):2463
* First-ever stroke.
incidence and prevalence of stroke in United States
incidence of stroke 3.73 per 1,000 person-years in United States between 1987 and 2011
based on prospective cohort study of 14,357 adults aged 45-64 years without stroke at
baseline in Atherosclerosis Risk in Communities study and followed for up to 25 years
(median 22.5 years)
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1,051 persons (7%) had incident stroke (929 had ischemic stroke, 140 had hemorrhagic
stroke) over 282,097 person-years of follow-up
crude incidence rates per 1,000 person-years by type of stroke
3.73 for total stroke
3.29 for ischemic stroke
0.49 for hemorrhagic stroke
age-adjusted stroke incidence decreased over time in adults ≥ 65 years old (incidence rate
ratio per 10-year period 0.69, 95% CI 0.59-0.81), but no significant difference in adults < 65
years old
Reference - JAMA 2014 Jul 16;312(3):259, editorial can be found in JAMA 2014 Jul
16;312(3):237
incidence of stroke in United States decreased from 1950 to 2004
based on prospective study of 9,512 men and women > 55 years old without stroke at baseline
in Framingham original and offspring cohorts and followed for up to 50 years (mean 18.4
years)
1,030 (10.8%) had incident stroke over 174,917 person-years of follow-up
age-adjusted incidence of first stroke per 1,000 person-years
in 1950-1977 was 7.6 in men and 6.2 in women
in 1978-1989 was 6.2 in men and 5.8 in women
in 1990-2004 was 5.3 in men and 5.1 in women
in men
lifetime risk of stroke at age 65 years decreased from 19.5% to 14.5% (not significant)
30-day stroke mortality decreased from 23% to 14% (p = 0.01)
in women
lifetime risk of stroke at age 65 years decreased from 18% to 16.1% (not significant)
30-day stroke mortality decreased from 21% to 20% (not significant)
Reference - JAMA 2006 Dec 27;296(24):2939
incidence of ischemic stroke in United States decreased from 1992 to 2007 among older
patients with atrial fibrillation
based on review of database of Medicare enrollees (≥ 65 years old) with prevalent atrial
fibrillation from 1992 to 2007
ischemic stroke rate in patients with prevalent atrial fibrillation
48 per 1,000 patient-years in 1992
17 per 1,000 patient-years in 2006-2007
warfarin use among patients with prevalent atrial fibrillation increased from 26.7% in 1992 to
63.1% in 2007
hemorrhagic stroke rate nearly constant at approximately 2 per 1,000 patient-years from 1992
to 2007
Reference - JAMA Intern Med 2013 Jan 28;173(2):159
prevalence of self-reported stroke in United States 2005
based on telephone survey of noninstitutionalized United States civilian persons > 18 years
old
2.6% had history of stroke based on positive answer to "Has a doctor or other health
professional ever told you that you had a stroke?"
prevalence increased with age from 0.8% at ages 18-44 years to 8.1% at > 65 years old
prevalence 2.7% men and 2.5% women
Reference - MMWR Morb Mortal Wkly Rep 2007 May 18;56(19):469 full-text
high incidence in older Americans
prospective cohort study of 3,393 women and 2,495 men > 65 years old followed for 10 years
incidence of stroke per 1,000 person-years was 14.7 in men and 13.7 in women
Reference - J Am Geriatr Soc 2005 Feb;53(2):211
16.3 per 1,000 United States adults > 65 years old were hospitalized for stroke in 2000, based
on Medicare enrollees (MMWR Morb Mortal Wkly Rep 2003 Jun 27;52(25):586 full-text)
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see Risk factors for stroke or transient ischemic attack for details
Associated conditions
hyperglycemia detected on admission in > 40% patients with acute ischemic stroke, most commonly
among patients with diabetes mellitus(6)
new-onset constipation common in patients with acute stroke
based on prospective cohort of 154 patients admitted to hospital with first acute stroke
55.2% patients developed new-onset constipation within 4 weeks of stroke
constipation associated with
dependence (p < 0.01) (as measured by the Barthel Index, a measure of disability)
bedpan for defecation (p < 0.05)
Reference - Stroke 2009 Apr;40(4):1304
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persistent chest pain in women without obstructive coronary artery disease might be associated with
higher rate of stroke
based on cohort study
673 women with chest pain had coronary angiography for suspected myocardial ischemia and at
least 1 year of follow-up
median age 58 years, median follow-up 5.2 years
45% had persistent chest pain defined as self-reported continuing chest pain at 1 year
among 39% women who had obstructive coronary artery disease, no association of persistent chest
pain with composite cardiovascular events (myocardial infarction, stroke, heart failure,
cardiovascular death)
among 61% women without obstructive coronary artery disease, persistent chest pain associated
with
higher risk of stroke (p = 0.03)
no significant association with other cardiovascular events
Reference - Eur Heart J 2006 Jun;27(12):1408
sleep apnea is common in patients with stroke or transient ischemic attack (TIA)
based on systematic review
systematic review and meta-analysis of 29 studies evaluating 2,343 stroke and TIA patients with
auto continuous positive airway pressure (CPAP), limited-channel sleep study, or full
polysomnography
72% had sleep-disordered breathing with apnea-hypopnea index (AHI) > 5
38% had sleep-disordered breathing with AHI > 20
only 7% of sleep-disordered breathing was primarily central apnea
Reference - J Clin Sleep Med 2010 Apr 15;6(2):131 full-text
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SSS-TOAST had high inter-rater agreement (kappa 0.9) in study of 2 neurologists rating 50
patients from medical record reviews (Ann Neurol 2005 Nov;58(5):688)
computerized SSS-TOAST algorithm (Causative Classification System for Ischemic Stroke
[CCS]) had high inter-rater agreement (kappa 0.86) for 5 neurologists rating 50 patients
(Stroke 2007 Nov;38(11):2979), but software has not been approved for clinical use
approximate distribution of causes of ischemic stroke
15% large-vessel atherothrombotic (9% due to internal carotid artery stenosis)
25% small-vessel (lacunar)
60% embolic (15% due to atrial fibrillation)
3% due to dissection or other causes
Reference - N Engl J Med 2000 Jun 8;342(23):1743
about half of ischemic strokes in younger adults have cardioembolic etiology
based on retrospective review of data from Get with the Guidelines-Stroke database (2005-
2010)
215 patients aged 18-45 years with ischemic stroke (94%) or transient ischemic attack (6%)
were evaluated
most frequent etiologies were
cardioembolic in 100 patients (47%)
patent foramen ovale (PFO)-associated in 76 patients (35.3%)
isolated PFO in 36 patients (16.7%)
PFO with predisposing risk factor for clot formation in 29 patients (13.5%)
PFO with atrial septal aneurysm in 11 patients (5.1%)
cardiomyopathy in 10 patients (4.7%)
valvular heart disease in 7 patients (3.3%)
small vessel disease in 14 patients (7%)
large vessel atherosclerosis in 4 patients (2%)
other determined causes in 74 patients (34%)
carotid dissection in 20 patients (9.3%)
reversible cerebral vasoconstriction syndromes in 11 patients (5.1%)
vertebral/basilar artery dissection in 9 patients (4.2%)
Moyamoya disease in 7 patients (3.3%)
hypercoagulable state in 6 patients (2.8%)
primary angiitis of central nervous system in 5 patients (2.3%)
drug-induced stroke in 5 patients (2.3%)
multiple etiologies in 4 patients (2%)
undetermined cause in 19 patients (9%)
Reference - JAMA Neurol 2013 Jan;70(1):51 full-text
spontaneous dissection of cervical carotid artery may be cause of stroke in younger adults
based on cohort study
retrospective study of 298 patients (mean age 46 years) with spontaneous dissection of
cervical carotid artery
admission diagnosis
ischemic stroke in 55.4%
transient ischemic attack (TIA) in 12.4%
retinal ischemia in 2.7%
local symptoms and signs (headache, neck pain, Horner syndrome, cranial nerve palsy)
in 26.9%
no symptoms in 2.7%
during 3-month follow-up, new cerebral ischemic events included
ischemic stroke in 0.3%
TIA in 3.4%
retinal ischemia in 1%
frequency of new ischemic events was significantly higher in patients with vs. without
ischemic events at onset (6.2% vs. 1.1%) but did not differ significantly for patients treated
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Medication history
ask about current use of antiplatelet agent or anticoagulantion as may be contraindication to thrombolytic
therapy
ask about any other medication usage(4)
if suspected intracerebral hemorrhage, ask about anticoagulant therapy (CSBPR Evidence Level A)(4)
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interruption of aspirin therapy may be associated with increased risk of ischemic stroke or transient
ischemic attack
based on case-control study
309 patients with ischemic stroke or TIA while on long-term aspirin therapy compared with 309
matched controls with similar antiplatelet therapy but no ischemic stroke in previous 6 months
aspirin therapy discontinuation in 4 weeks preceding ischemic cerebral event (cases) or interview
(controls) reported in 13 cases (4.2%) vs. 4 controls (1.3%)
Reference - Arch Neurol 2005 Aug;62(8):1217 full-text, commentary can be found in Arch Neurol
2006 Feb;63(2):300
Physical
General physical
conduct clinical assessment immediately to establish diagnosis, rule out stroke mimics, determine
eligibility for thrombolytic or endovascular therapy, and develop plans for further care (CSBPR Evidence
Level B)(4)
initial assessment including at emergency department should include(1, 4)
vital signs (CSBPR Evidence Level B)
heart rate and rhythm
blood pressure
temperature
oxygen saturation
hydration status
neurological examination to determine focal neurological deficits and assess severity CSBPR
Evidence Level B)
use standardized scale such as National Institutes of Health Stroke Scale (NIHSS)
(AHA/ASA Class I, Level B-NR ) or Canadian Neurological Scale (CNS)
assessment for presence of seizure activity (CSBPR Evidence Level B)
if suspected intracerebral hemorrhage, assess for clinical signs of elevated intracranial pressure (CSBPR
Evidence Level B)(4)
clinical presentation of elevated intracranial pressure include nausea and vomiting, altered level of
consciousness, and papilledema
assess nutritional and hydration status as early as possible, ideally on same day as admission (CSBPR
Evidence Level B)(5)
some bedside findings may help distinguish hemorrhagic from ischemic stroke, though diagnostic
certainty requires neuroimaging
based on systematic review
systematic review of 19 prospective studies of accuracy of clinical exam compared with accepted
diagnostic standards (computed tomography or autopsy) for distinguishing hemorrhagic and
ischemic stroke in 6,438 adults
24% had hemorrhagic stroke
findings significantly associated with probability of hemorrhagic stroke
coma (likelihood ratio [LR] 6.2, 95% CI 3.2-12)
neck stiffness (LR 5, 95% CI 1.9-12.8)
seizures accompanying neurologic deficit (LR 4.7, 95% CI 1.6-14)
diastolic blood pressure > 110 mm Hg (LR 4.3, 95% CI 1.4-14)
vomiting (LR 3, 95% CI 1.7-5.5)
headache (LR 2.9, 95% CI 1.7-4.8)
Siriraj score > 1 (LR 5.7, 95% CI 4.4-7.4)
findings significantly associated with decreased probability of hemorrhagic stroke
cervical bruit (LR 0.12, 95% CI 0.03-0.47)
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Skin
HEENT
look for signs of trauma or seizure activity, such as contusions or tongue lacerations(6)
Neck
71% sensitivity
81% specificity
positive likelihood ratio 3.65
negative likelihood 0.36
Reference - BMC Neurol 2008 Jun 24;8:23 full-text
DynaMed Commentary -- diagnostic performance of carotid bruits on auscultation
reported by authors based on "per side" analysis, patient-level analysis not reported
jugular venous distention may suggest heart failure
Cardiac
Neuro
neurologic exam should use formal stroke scale (AHA/ASA Class I, Level B-NR ; CSBPR Evidence
Level B) to determine focal neurological deficits and for diagnostic and prognostic classification of stroke
severity(1, 4)
National Institutes of Health Stroke Scale (NIHSS)
Canadian Neurological Scale (CNS)
most common physical findings(2)
focal weakness
arm weakness
leg weakness
facial weakness
dysphasia or dysarthria
hemiparetic or ataxic gait
eye movement abnormality
visual field defect
speech disturbance
factors that make clinical evaluation less reliable(2)
confusion
aphasia (word-finding difficulties nonspecific finding and often caused by metabolic or infectious
processes)
presentation > 48 hours after event
assess withh Glasgow Coma Scale (GCS) if patient obtunded or comatose
best possible score 15 points
eye opening
spontaneously - 4 points
to verbal commands - 3 points
to pain - 2 points
none - 1 point
best motor response
follows verbal command - 6 points
localizes painful stimuli - 5 points
normal flexion to painful stimuli - 4 points
abnormal flexion to painful stimuli - 3 points
decerebrate posturing to painful stimuli - 2 points
none - 1 point
best verbal response
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Diagnosis
Making the diagnosis
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American Heart Association / American Stroke association recommends the National Institutes of
Health Stroke Scale (NIHSS) (AHA/ASA Class I, Level B-NR)(1)
see Prognostic tools section for additional information
noncontrast computed tomography (CT) or other neuroimaging needed to confirm diagnosis, distinguish
between hemorrhagic and ischemic stroke, and determine eligibility for endovascular therapy
obtain blood glucose before starting IV alteplase if indicated
other tests can be conducted after starting IV alteplase if indicated
Differential diagnosis
Testing overview
pregnancy test
hepatic function tests
toxicology screen
blood alcohol level
arterial blood gas (if hypoxemia suspected)
lumbar puncture (if subarachnoid hemorrhage suspected and head CT negative for blood)
electroencephalography (if seizure suspected)
Prehospital prediction
emergency medical services personnel should use standardized acute stroke out-of-hospital screening tool
(AHA/ASA Class I, Level B-NR ; CSBPR Evidence Level B)(1, 4)
examples include
Los Angeles Prehospital Stroke Screen PDF (LAPSS)
Cincinnati Prehospital Stroke Scale PDF (CPSS)
FAST (described in Chief Concern section)
if positive
direct all actions toward moving to ambulance and beginning transport
any treatments not immediately required, such as IVs, should be performed en route to
hospital
LAPSS stroke scale appears to have moderate sensitivity and high specificity for stroke diagnosis in
prehospital setting (level 2 [mid-level] evidence)
based on systematic review of diagnostic studies with clinical heterogeneity
systematic review of 8 diagnostic cohort studies evaluating performance of prehospital stroke scales
conducted by emergency responders for out-of-hospital stroke diagnosis in 14,847 patients
Reference standard in all studies was inpatient diagnosis or discharge diagnosis of stroke or
transient ischemic attack (TIA)
prehospital stroke scales included
Cincinnati Prehospital Stroke Scale (CPSS)
Los Angeles Prehospital Stroke Screen (LAPSS)
Melbourne Ambulance Stroke Screen (MASS)
Medic Prehospital Assessment for Code Stroke (Med PACS)
Ontario Prehospital Stroke Screening Tool (OPSS)
Recognition of Stroke in the Emergency Room (ROSIER)
Face Arm Speech Test (FAST)
all screening tests considered positive if any of the abnormal physical findings are present after
eligibility criteria are met (ROSIER is exception where score ≥ 1 is considered positive)
meta-analyses not performed due to clinical heterogeneity in study population and stroke prevalence
performance of prehospital stroke scales for out-of-hospital stroke diagnosis
CPSS had sensitivity 79%-95% and specificity 24%-99% in 3 studies with 1,366 patients
LAPSS had sensitivity 78%-91% and specificity 85%-99% in 4 studies with 12,732 patients
MASS had sensitivity 83%-90% and specificity 74%-86% in 2 studies with 950 patients
Med PACS had sensitivity 74% and specificity 33% in 1 study with 416 patients
OPSS had sensitivity 92% and specificity 86% in 1 study with 554 patients
ROSIER had sensitivity 97% and specificity 18% in 1 study with 295 patients
FAST had sensitivity 97% and specificity 13% in 1 study with 295 patients
Reference - Neurology 2014 Jun 17;82
CPSS and LAPSS appear to have moderate sensitivity and low specificity for prehospital detection
of stroke or transient ischemic attack (level 2 [mid-level] evidence)
based on retrospective cohort study using electronic records
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prehospital stroke evaluations for 2,442 patients in North Carolina were obtained from PreMIS, a
statewide emergency medical services database
1,217 patients had Cincinnati Prehospital Stroke Scale (CPSS) data
1,225 patients had Los Angeles Prehospital Stroke Screen (LAPSS) data
54% of patients with CPSS data and 66% of patients with LAPSS data had confirmed stroke or
transient ischemic attack (based on records from NC DETECT, a real-time surveillance database of
emergency department visits across North Carolina)
for out-of-hospital detection of stroke or transient ischemic attack
CPSS had
sensitivity 80%
specificity 48%
positive predictive value 66%
negative predictive value 33%
LAPSS had
sensitivity 74%
specificity 48%
positive predictive value 73%
negative predictive value 51%
Reference - Ann Emerg Med 2014 Nov;64(5):509
RACE score may help predict large vessel occlusion in patients with clinical suspicion of acute
stroke (level 2 [mid-level] evidence)
based on diagnostic cohort study with inadequate validation
derivation cohort included 654 patients with acute ischemic stroke having transcranial duplex
ultrasound for detection of large vessel occlusion (LVO)
validation cohort included 357 of 885 eligible patients (mean age 73 years) with clinical suspicion
of acute stroke within 6 hours of symptom onset assessed by emergency medical services
528 patients excluded from validation cohort for unspecified reasons
LVO diagnosed on hospital admission in validation cohort by computed tomography angiography,
magnetic resonance angiography, arteriography, or transcranial duplex ultrasound
prevalence of LVO was 27% in derivation cohort and 21% in validation cohort
Rapid Arterial Occlusion Evaluation (RACE) scale based on factors from National Institutes of
Health Stroke Scale (NIHSS) associated with LVO in derivation cohort (total score 0-9 points)
facial palsy = 0 points if absent, 1 point if mild, 2 points if moderate or severe
arm motor function = 0 points if normal or mild, 1 point if moderate, 2 points if severe
leg motor function = 0 points if normal or mild, 1 point if moderate, 2 points if severe
head and gaze deviation = 0 points if absent, 1 point if present
aphasia (if right hemiparesis) = 0 points if normal, 1 point if moderate, 2 points if severe
agnosia (if left hemiparesis) = 0 points if normal, 1 point if moderate, 2 points if severe
optimal cutoff ≥ 5 points for detection of LVO
for detection of LVO in validation cohort with cutoff ≥ 5 points, RACE score had
sensitivity 85%
specificity 68%
positive predictive value 42%
negative predictive value 94%
Reference - Stroke 2014 Jan;45(1):87
Cincinnati Prehospital Stroke Severity Scale has high sensitivity but low specificity for
distinguishing severe from moderate ischemic stroke (level 1 [likely reliable] evidence)
based on retrospective cohort study with independent derivation and validation cohorts
derivation cohort included 624 patients from NINDS trial with mild-to-severe acute ischemic stroke
(pretreatment National Institutes of Health Stroke Scale [NIHSS] score 1-37)
Cincinnati Prehospital Stroke Severity Scale (CPSSS) developed using NIHSS items associated
with greatest risk of severe stroke in derivation cohort (range 0-4 points)
2 points for conjugate gaze deviation
1 point each for
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arm weakness defined as inability to hold up 1 or both arms for 10 seconds before arm
falls to bed
abnormal consciousness defined as incorrectly answering ≥ 1 of 2 questions (age,
current month) and not following ≥ 1 of 2 commands (close eyes, open and close hand)
validation cohort included 650 patients from IMS III trial with moderate-to-severe acute ischemic
stroke (pretreatment NIHSS score 8-40)
60% had severe stroke (NIHSS ≥ 15)
for prediction of severe stroke, CPSSS score ≥ 2 had
sensitivity 89% and specificity 73% in derivation cohort
sensitivity 92% and specificity 51% in validation cohort
303 patients in validation cohort had imaging data to assess large vessel occlusion (LVO),
prevalence of LVO 73%
for prediction of LVO, CPSSS score ≥ 2 had sensitivity 83% and specificity 40%
Reference - Stroke 2015 Jun;46(6):1508
correct prehospital identification of stroke reduced in Hispanic and Asian adults compared to non-
Hispanic whites or men (level 2 [mid-level] evidence)
based on cohort analysis
10,719 adults ≥ 18 years old discharged with primary diagnosis of stroke evaluated
35% werer transported by emergency medical service providers
32%, of those diagnosed with stroke, were identified in prehospital setting
compared to non-Hispanic whites, correct prehospital identification of stroke reduced if
Hispanic (odds ratio [OR] 0.77, 95% CI 0.61-0.96)
Asian (OR 0.66 95% CI 0.55-0.8)
others (OR 0.71, 95% CI 0.53-0.94)
compared to men, correct prehospital identification of stroke reduced in women (OR 0.82, 95%
CI0.71-0.94)
Reference - Acad Emerg Med 2015 Mar;22(3):264 full-text
Recognition of Stroke in the Emergency Room scale helps identify acute stroke in patients
presenting to emergency department (level 1 [likely reliable] evidence)
based on diagnostic study with independent derivation and validation cohorts
derivation cohort included 343 adults (mean age 71 years) presenting to emergency department with
suspected stroke and admitted to hospital
51.3% had stroke or transient ischemic attack
7-item Recognition of Stroke in the Emergency Room (ROSIER) scale (range -2 to 5) developed
using common clinical features of stroke in derivation cohort
-1 point for
loss of consciousness or syncope
seizure activity
1 point for new acute onset (or on awakening from sleep) of
asymmetrical facial weakness
asymmetrical arm weakness
asymmetrical leg weakness
speech disturbance
visual field defect
validation cohort included 160 patients (mean age 71 years) presenting to emergency department
with suspected stroke
63.1% had stroke or transient ischemic attack
performance of ROSIER scale at cutoff score > 0 for diagnosis of acute stroke in validation cohort
sensitivity 93%
specificity 83%
positive predictive value 90%
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Siriraj, Guy's Hospital, and Greek stroke scores may not accurately distinguish ischemic from
hemorrhagic strokes (level 2 [mid-level] evidence)
based on systematic review of diagnostic cohort studies with poor reporting of blinding of index test
from reference test and with studies with significant heterogeneity
systemic review of 20 studies including 3,638 patients being evaluated for type of stroke with a
clinical stroke scores proposed to distinguish stroke type
computerized tomography used as reference test
Siriraj stroke score uses 5 variables to determine score (< -1 infarction, > +1 hemorrhagic, -1 to +1
equivocal)
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Guy's hospital score uses 13 variables to determine score (< 4 infarction, > 24 hemorrhagic, 4-24
equivocal)
Greek stroke score uses 4 variables to determine score (< 3 infarction, > 11 hemorrhagic, 3-11
equivocal)
prevalence of hemorrhagic stroke ranged from 17.3% to 68.9% and prevalence of ischemic stroke
ranged from 31% to 82.7%
Siriraj stroke score in 18 studies
for ischemic stroke, sensitivity ranged from 0.3 to 0.85 and specificity ranged from 0.36 to
0.97
for hemorrhagic stroke, sensitivity ranged from 0.33 to 0.87 and specificity ranged from 0.65
to 0.99
Guy's hospital score in 11 studies
for ischemic stroke, sensitivity ranged from 0.25 to 0.93 and specificity ranged from 0.5 to
0.83
for hemorrhagic stroke, sensitivity ranged from 0.2 to 0.84 and specificity ranged from 0.48
to 1
Greek stroke score in 3 studies
for ischemic stroke, sensitivity ranged from 0.39 to 0.64 and specificity ranged from 0.63 to
0.88
for hemorrhagic stroke, sensitivity ranged from 0.11 to 0.44 and specificity ranged from 0.63
to 0.96
J Neurosci Rural Pract 2014 Oct;5(4):330
Blood tests
recommendations for all patients from professional organizations
American Heart Association/American Stroke Association (ASA/AHA)
before starting IV alteplase (AHA/ASA Class I, Level B-R )(1)
blood glucose
if suspected coagulopathy, international normalized ratio (INR), activated partial
thromboplastin time (aPTT), and platelet count
order other blood tests, but they should not delay IV alteplase(6)
baseline troponin (AHA/ASA Class I, Level B-NR )(1)
serum electrolytes/renal function tests(6)
complete blood count (CBC), including platelet count(6)
prothrombin time, INR, and aPTT if not already assessed(6)
Canadian Stroke Best Practice Recommendations (CSBPR) recommends ordering blood work for
(CSBPR Evidence Level B)(4)
electrolytes
glucose
hematology / CBC
coagulation (INR / aPTT)
renal function (creatinine level / estimated glomerular filtration rate [eGFR])
troponin
in selected patients, consider(6)
pregnancy test
hepatic function tests
thrombin time and/or ecarin clotting time, factor Xa activity assays (if patient taking direct thrombin
inhibitor or direct factor Xa inhibitor)
toxicology screen
blood alcohol level
arterial blood gas (if hypoxiemia suspected)
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52% specificity
Reference - Cerebrovasc Dis 2010;29(1):82
Imaging studies
Neuroimaging
conduct brain noncontrast CT or other imaging for any patient with suspected acute stroke at hospital
arrival (AHA/ASA Class I, Level B-NR; CSBPR Evidence Level A)
neuroimaging needed for determining eligibility for thrombolytic or endovascular therapy
if noncontrast CT reveals acute intracranial hemorrhage, do not give IV alteplase (AHA/ASA Class
III Harm, Level C-EO)
early ischemic changes or severity no longer considered a clear contraindication to thrombolytics
eligibility for mechanical thrombectomy in patients with stroke onset ≤ 6 hours previously is based
on clinical characteristics and imaging characteristics including
causative occlusion of the internal carotid artery or middle cerebral artery (MCA) segment 1
(M1)
causative occlusion of the MCA segment 2 (M2) or MCA segment 3 (M3) portion of the
MCAs
causative occlusion of the anterior cerebral arteries, vertebral arteries, basilar artery, or
posterior cerebral arteries
see Endovascular therapy for acute stroke topic for additional information and full criteria
conduct CT perfusion, diffusion-weighted MRI, or MRI perfusion to aid patient selection for
mechanical thrombectomy if (AHA/ASA Class I, Level A)
acute ischemic stroke occurrence within 6-24 hours since time last known well
large vessel occlusion in anterior circulation
imaging and other eligibility criteria from trials showing benefit are being strictly applied in
selecting patients for mechanical thrombectomy
see Endovascular therapy for acute stroke topic for additional information on eligibility
criteria from trials
additional imaging can be considered to help guide treatment
conduct vascular imaging / collateral flow status at time of brain CT if possible to help determine
eligibility for endovascular therapy, but do not delay IV alteplase to do so
additional imaging including specialized studies can also be considered
Echocardiography
baseline electrocardiogram recommended, but do not delay IV alteplase if indicated (AHA/ASA Class I,
Level B-NR )(1)
consider 2D or transesophageal echocardiography if(5)
suspected embolic stroke and normal neurovascular imaging (CSBPR Evidence Level B)
no contraindications for anticoagulant therapy, especially if patient younger or suspected transient
ischemic attack with unknown etiology
no current consensus on indications for and optimal echocardiographic approach for cardiac workup of
ischemic stroke
insufficient evidence to determine if transthoracic or transesophageal echocardiography is best
approach
Reference - Curr Cardiol Rev 2010 Aug;6(3):175 full-text
high-risk patients identified by transesophageal echocardiography associated with increased
mortality in patients with acute ischemic stroke
based on cohort study
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38 patients with ischemic stroke and without risk factors for cardiac source of stroke had
transesophageal echocardiography and were followed for mean 14 months
23 patients defined as high-risk by presence of ≥ 1 of left heart thrombus, vegetation, mass or
spontaneous echo contrast, mobile ascending aortic or arch debris, patent foramen ovale, atrial
septal defect or aneurysm, mitral annular calcification, mitral valve thickening, prolapse or mitral
valve strands
cardiovascular survival in 92% of 15 low risk patients vs. 63% of 23 high risk patients at 24 months
(p = 0.036)
Reference - Am J Cardiol 1998 May 1;81(9):1144, commentary can be found Am Fam Physician
1998 Oct 15;58(6):1420
Chest x-ray
professional organizations recommend chest x-rays, but they should not delay urgent treatments and
assessments
American Heart Association/American Stroke Association (AHA/ASA)
chest x-ray (AHA/ASA Class IIb, Level B-NR)(1)
has unclear usefulness in hyperacute setting if no evidence of acute pulmonary, cardiac,
or pulmonary vascular disease; if obtained they should not unnecessarily delay
administration of IV alteplase
should not unnecessarily delay IV alteplase
Canadian Stroke Best Practice Recommendations (CSBPR)(4)
take chest x-ray if evidence of acute heart disease or pulmonary disease (CSBPR Evidence
Level B)
if hemodynamically stable, defer until after deciding on acute treatment (CSBPR Evidence
Level C); it should not delay assessment for thrombolysis and endovascular therapy
Electrocardiography (ECG)
obtain electrocardiogram, but if hemodynamically stable, defer until after determination of acute therapy
including assessment for thrombolytic or endovascular therapy (CSBPR Evidence Level B; (AHA/ASA
Class I, Level B-NR)(1, 4)
if ischemic stroke or transient ischemic attack, also assess (with additional ECG after initial assessment if
appropriate), baseline cardiac rhythm or evidence of structural heart disease such as previous myocardial
infarction or left ventricular hypertrophy (CSBPR Evidence Level C)
baseline ECG assessment is recommended in patients presenting with acute ischemic stroke but should not
delay initiation of IV alteplase(1)
monitor cardiac rhythm for at least first 24 hours to screen for arrhythmias (AHA/ASA Class I, Level B)
(6)
prolonged cardiac monitoring (up to 30 days) is recommended to assess for paroxysmal atrial fibrillation if
cardioembolic mechanism suspected and no evidence of atrial fibrillation on 24-48 hour ECG monitoring
(CSBPR Evidence Level B)(4, 5)
100 patients with ischemic stroke in previous 7 days were randomized to noninvasive
cardiac event monitoring plus standard investigations vs. standard investigations alone
and followed to 90 days
noninvasive cardiac monitoring used light-weight (50 g) device to capture 30-
second cardiac rhythm data over 7 days
cardiac rhythm data transferred to central electrocardiogram (ECG) laboratory for
analysis, and recordings with suspected atrial fibrillation were reviewed by
experienced electrocardiologist
standard investigations were consistent with guidelines and may have included
12-lead ECG after hospitalization, 24-hour Holter monitoring, and
echocardiography with ECG
all patients presented in sinus rhythm and had no history of atrial fibrillation
sustained paroxysms of atrial fibrillation defined as duration ≥ 20 seconds and
nonsustained paroxysms of atrial defibrillation defined as ≥ 6 conducted ventricular
complexes with duration < 20 seconds
comparing noninvasive cardiac event monitoring vs. standard investigations at 14 days
sustained or nonsustained paroxysms of atrial fibrillation detected in 44% vs. 4%
(p < 0.001, number needed to screen 3)
anticoagulation treatment for atrial fibrillation thromboembolism prophylaxis in
16% vs. 0% (p < 0.01, number needed to screen 7)
consistent results at 90 days
noninvasive cardiac event monitoring associated with significantly increased detection
of sustained paroxysms of atrial fibrillation at 14 days but difference was no longer
significant at 90 days
Reference - Stroke 2013 Sep;44(9):2525 full-text , commentary can be found in Evid
Based Med 2014 Aug;19(4):152
monitoring with insertable cardiac monitor may increase detection of atrial fibrillation
compared to conventional follow-up in patients with cryptogenic stroke or TIA (level 2
[mid-level] evidence)
based on randomized trial with allocation concealment not stated
441 patients ≥ 40 years old with cryptogenic stroke or TIA (91% with nonlacunar
stroke) within past 90 days were randomized to 1 of 2 ECG monitoring interventions
implantation of cardiac monitor for ECG monitoring within 10 days
conventional follow-up with ECG monitoring performed at discretion of site
investigator
all patients had no history of atrial fibrillation or atrial flutter and cause of stroke or
TIA was unknown following standard tests, including ECG monitoring for ≥ 24-hour
5% of patients with implantable cardiac monitor crossed over to conventional ECG
monitoring and 2.7% of patients with conventional ECG monitoring crossed over to
implantable cardiac monitor (no p value reported)
comparing insertable cardiac monitor vs. conventional follow-up
atrial fibrillation > 30 seconds at 6 months in 8.9% vs. 1.4% (p < 0.001)
atrial fibrillation > 30 seconds at 1 year in 12.4% vs. 2% (p < 0.001)
insertable cardiac monitor was removed in 2.4% due to infection at insertion site or
pocket erosion
Reference - CRYSTAL AF trial (N Engl J Med 2014 Jun 26;370(26):2478 full-text ),
editorial can be found in N Engl J Med 2014 Jun 26;370(26):2532
DynaMed Commentary --trial sponsor (Medtronic) had nonvoting membership on
steering committee and assisted in study design, data collection, data analysis, and
manuscript technical content and review
consistent findings at 3 years
based on follow-up of CRYSTAL AF trial
11% of patients had follow-up data available at 3 years
comparing insertable cardiac monitor vs. conventional follow-up
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24% diagnosed with atrial fibrillation during monitoring with implantable loop recorder in
patients with embolic stroke of undermined origin
based on prospective cohort study
123 patients with embolic stroke of undetermined origin received implantable loop recorder
(ILR) with daily remote monitoring and were followed every 6 months
ILR was implanted mean 20 days after stroke
atrial fibrillation was documented on ILR and manually confirmed in 24% of patients during
mean follow-up of 12.7 months
first atrial fibrillation detection occurred after mean 3.6 months of monitoring
Reference - Thromb Haemost 2017 Oct 5;117(10):1962
in patients at increased risk for stroke-related seizures such as those with otherwise unexplained reduced
consciousness, consider enhanced and increased seizure monitoring, such as with electroencephalogram
(EEG) (CSBPR Evidence Level C)(4, 5)
swallowing evaluation
conduct as early as possible and before any oral intake, but dot not delay assessment for
thrombolytic or endovascular therapy(1, 4)
see Swallowing dysfunction after stroke topic for additional information
language evaluation
Language Screening Test (LAST) is simple test for identifying aphasia in patients with stroke
LAST is bedside test derived from expert consensus and includes 15 items to evaluate speech
expression and reception (total points 1-15)
median time for test administration 124 seconds, based on sample of 50 patients with acute
stroke
LAST score < 15 had 98% sensitivity and 100% specificity for aphasia in 102 stabilized
stroke patients, of whom 54 had aphasia on Boston Diagnostic Aphasia Evaluation
Reference - Stroke 2011 May;42(5):1224
Treatment
Treatment overview
initial management
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all patients with disabling acute ischemic stroke must be assessed immediately by physician with
stroke expertise (on-site or through telemedicine consult) to determine eligibility for thrombolytic or
endovascular therapy
treat in stroke unit as soon as possible, ideally within 6 hours of hospital arrival
assess swallowing function before any oral intake, including medications
supportive measures include
airway support and ventilatory assistance if decreased consciousness and bulbar dysfunction
compromising airway
oxygen for hypoxemic patients (maintain oxygen saturation > 92%-94%)
monitoring for neurologic deterioration, cardiac arrhythmias, and elevated temperature
assessing fluid status and urinary retention
correcting hypotension and hypovolemia
supportive medications (for both ischemic and hemorrhagic stroke)
medications to control hypoglycemia
short-acting anticonvulsants (such as IV lorazepam 4 mg bolus) if new-onset seizure ≤
24 hours after stroke onset and seizure isn't self-limited
antipyretics to control elevated temperature
antibiotics if elevated temperature and infection
for ischemic stroke
additional medications for ischemic stroke
thrombolytics
standard dose: IV alteplase 0.9 mg/kg (maximum dose 90 mg) over 60 minutes
with initial 10% of dose given as bolus over 1 minute
some contraindications include stroke onset > 4.5 hours previous, intracranial
hemorrhage, severe stroke, seizure at stroke onset, and blood glucose < 50 mg/dL
or > 400 mg/dL
see Thrombolytics for acute stroke topic for details
antiplatelets
usually aspirin within 24-48 hours of stroke, but consider waiting > 24 hours
after IV alteplase if given
contraindications may include primary intracerebral hemorrhage, aspirin allergy,
and gastrointestinal bleeding
see Antiplatelet therapy for acute stroke topic for details
anticoagulants
generally not recommended for non-cardioembolic acute ischemic stroke
anticoagulants may be considered for acute cardioembolic stroke, acute stroke
secondary to arterial dissection, cerebral venous sinus thrombosis, or
symptomatic deep vein thrombosis or pulmonary embolism
see Anticoagulation therapy for acute stroke topic for details
antihypertensives in some patients with elevated blood pressure (such as > 185/110 mm
Hg)
lower blood pressure (15% reduction is reasonable) if indicated by comorbidities
(such as concomitant acute coronary event, symptomatic intracerebral
hemorrhage, or eclampsia)
in patients eligible for IV alteplase, lower BP to < 185/110 mm Hg before
starting alteplase
if no thrombolytics or no comorbidities requiring antihypertensive therapy,
lowering BP has uncertain benefits
see Blood pressure management in acute ischemic stroke topic for details
surgical options for ischemic stroke
endovascular therapy
mechanical thrombectomy with stent retriever recommended for adults with
occlusion and who are expected to have favorable outcome after reperfusion
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Treatment setting
Prehospital management
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minimize on-scene time, ideally ≤ 20 minutes for patients who present with 4.5-hour
treatment time window (CSBPR Evidence Level C)
measure blood glucose as part of initial care (CSBPR Evidence Level B)
provide instructions to patient's family prior to transport, including recommending that
family/decision-maker accompany patient to hospital or be accessible by phone
(CSBPR Evidence Level C)
for decision-making
to confirm time that patient was last known to be well
to provide required information about existing health conditions, medications,
and other information as needed
transport of suspected patients with stroke
follow direct transport protocols that facilitate transfer of patients who may be eligible for
thrombolytic or endovascular therapy to appropriate acute care hospital (CSBPR Evidence
Level C)
triage by EMS personnel according to Canadian Triage Acuity Scale (CTAS)
triage most patients as CTAS Level 2 (CSBPR Evidence Level B)
if compromised airway, breathing, or cardiovascular function, triage as CTAS Level 1
(CSBPR Evidence Level B)
additional information on CTAS can be found at Canadian Association of Emergency
Physicians
while en route, provide emergency department with enough information to activate "Code
Stroke" including (CSBPR Evidence Level B)
time of stroke onset, symptom recognition, or last time known well (as accurate as
possible)
total duration of symptoms at anticipated arrival time
presenting signs and symptoms
Glasgow Coma Scale (GCS) score
CTAS score
patient age
expected time of arrival
even if patient not eligible for time-sensitive thrombolytic or endovascular therapy, transport
patient urgently to closest hospital able to diagnose and treat stroke (emergency department,
neurovascular imaging capability, stroke unit, and stroke expertise available on site or through
Telestroke modalities (CSBPR Evidence Level C)
for arrival at hospital
transfer of care from EMS to receiving hospital personnel should occur with minimal delay;
give highest priority in emergency department triage queue to patients with suspected
hyperacute stroke who are potentially eligible for thrombolytic or endovascular therapy
(CSBPR Evidence Level B)
EMS personnel should provide hospital personnel with the following information (CSBPR
Evidence Level C) and ensure this information is documented on EMS record (CSBPR
Evidence Level B)
time of stroke onset, symptom recognition, or last time known well (as accurate as
possible)
total duration of symptoms
GCS score
CTAS triage score
patient age
comorbidities
current medications and medication allergies
vital signs including capillary glucose
if capillary glucose assessed by EMS personnel, emergency department team should review to
determine immediate management (CSBPR Evidence Level B)
Reference - Int J Stroke 2015 Aug;10(6):924
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use of comprehensive specialized stroke care (stroke units) incorporating rehabilitation recommended
(AHA/ASA Class I, Level A , CSBPR Evidence Level A )(1, 5)
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use an organized protocol for the emergency evaluation of patients with suspected stroke (AHA/ASA
Class I, Level B-NR)(1)
treat in stroke unit as soon as possible, ideally within 6 hours of hospital arrival (CSBPR Evidence Level
C)(5)
use standardized stroke care order sets (AHA/ASA Class I, Level B-NR )(1)
organized inpatient stroke unit care associated with decreased mortality compared to general
medical wards (level 2 [mid-level] evidence)
based on Cochrane review limited by heterogeneity
systematic review of 28 randomized trials evaluating organized inpatient stroke unit care in 5,855
patients with any stroke type
organized inpatient stroke unit care associated with decreased mortality compared to general
medical wards in analysis of 23 trials with 4,591 patients
odds ratio 0.81 (95% CI 0.69-0.94)
NNT 17-93 with 23% mortality in general medical wards group
results limited by significant heterogeneity
mortality at end of follow-up in single trials
8.6% with stroke ward vs. 22.4% with mobile stroke team (p < 0.0001, NNT 8) in 1 trial with
304 patients
3.7% with semi-intensive stroke unit vs. 25.9% with conventional stroke unit (p = 0.023,
NNT 5) in 1 trial with 54 patients
Reference - Cochrane Database Syst Rev 2013 Sep 11;(9):CD000197, commentary on earlier
version can be found in ACP J Club 2008 Jun 17;148(4):3
stroke unit care associated with reduction in stroke progression or recurrence, chest and other
infections, and pressure sores in this systematic review (Stroke 2007 Sep;38(9):2536)
stroke unit care may reduce mortality compared to general ward care in patients with hemorrhagic
stroke but may not reduce mortality in patients with ischemic stroke (level 2 [mid-level] evidence)
based on systematic review with subgroup analysis and limited by heterogeneity
systematic review of 13 randomized trials comparing stroke unit care to general ward care with
3,570 patients with intracerebral hemorrhage or ischemic stroke
stroke unit care associated with reduced mortality (risk ratio [RR] 0.79, 95% CI 0.64-0.97) in
overall analysis of 8 trials with 2,657 patients, results limited by significant heterogeneity
stroke unit care associated with reduced mortality (RR 0.73, 95% CI 0.54-0.97) in subgroup
analysis of 483 patients with hemorrhagic stroke from 8 trials
no significant difference in mortality (RR 0.82, 95% CI 0.61-1.09) in subgroup analysis of
2,174 patients with ischemic stroke from 8 trials, results limited by significant heterogeneity
Reference - Stroke 2013 Nov;44(11):3044
continuous physiological monitoring in acute stroke unit associated with reduced risk of death or
dependency compared to intermittent monitoring (level 2 [mid-level] evidence)
based on Cochrane review of trials with methodologic limitations
systematic review of 2 randomized trials and 1 quasi-randomized trial comparing continuous vs.
intermittent physiologic monitoring in 354 patients with stroke onset within 3 days
all trials had ≥ 1 limitation including
unclear or inadequate allocation concealment
small sample size
physiologic monitoring included ≥ 1 of the following measures: blood pressure, pulse rate,
respiration rate, oxygenation, heart rhythm, or body temperature
continuous monitoring associated with
decreased death or dependency in analysis of all trials
odds ratio (OR) 0.27 (95% CI 0.13-0.56)
NNT 3-8 with death or dependency in 47% in intermittent monitoring group
increased detection of cardiac complications in analysis of 2 trials with 332 patients
OR 8.65 (95% CI 2.52-29.66)
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centralization of acute stroke services might be associated with decreased mortality at 90 days (level
2 [mid-level] evidence)
based on retrospective cohort study
258,915 patients with stroke living in urban areas in London or Manchester, England were analyzed
acute specialist stroke services were centralized across both metropolitan areas in 2010
all patients with stroke in London received care in hyperacute stroke unit, but only patients
presenting within 4 hours of stroke onset received care in hyperacute stroke unit in Manchester
outcomes were assessed over 21-30 month periods before and after hospital reconfiguration in each
metropolitan area
following hospital reconfiguration (in adjusted analyses)
90-day mortality decreased in London (mean difference -1.1%, 95% CI -2.1% to -0.1%), but
not in Manchester
length of hospital stay decreased in London (mean difference -1.4 days, 95% CI -2.3 to -0.5
days) and Manchester (mean difference -2 days, 95% CI -2.8 to -1.2 days)
Reference - BMJ 2014 Aug 5;349:g4757 full-text
Home hospitalization
home care to avoid hospital admission may not increase mortality compared to acute hospital
inpatient care in patients with stroke (level 2 [mid-level] evidence)
based on Cochrane review with wide confidence intervals
systematic review of 16 randomized trials comparing home care to avoid hospital admission vs.
acute hospital inpatient care in 1,814 adults
2 trials enrolled patients recovering from moderately severe stroke
hospital at home is hospital outreach admission avoidance multidisciplinary with joint care from
community services
comparing hospital at home vs. stroke unit care in 1 trial with 305 patients
mortality at 6 months 10.6% vs. 16.1% (risk ratio [RR] 0.66, 95% CI 0.36-1.21), not
significant but confidence interval includes possibility of benefit or harm
living in residential care at 6 months in 10.4% vs. 8.1% (not significant)
no significant difference in functional status (Modified Rankin Scale and Barthel Index) at 3
and 12 months
comparing hospital outreach admission avoidance (24-hour multidisciplinary team) vs. hospital
inpatient care at 6 months in 1 trial with 120 patients
mortality 30% vs. 40% (RR 0.75, 95% CI 0.46-1.23), not significant but confidence interval
includes possibility of benefit or harm
living in residential care in 5% vs. 27% (p < 0.05, NNT 5)
no significant difference in activities of daily living or functional impairment
Reference - Cochrane Database Syst Rev 2016 Sep 1;(9):CD007491
if not admitting patient to hospital, same-day evaluation for transient ischemic attack or minor
stroke associated with reduced risk of recurrent stroke at 90 days (level 2 [mid-level] evidence)
based on before-and-after study
591 patients not admitted to hospital for transient ischemic attack (TIA) or minor stroke were
evaluated before and after government policy change
before April 2002 patients seen in outpatient clinic (including scheduling delays in obtaining
appointments and referrals)
between 2002 and 2004 patients were seen mostly on same day and had neuroimaging same
day or soon afterward
median delay to assessment in study clinic decreased from 3 days to < 1 day (p < 0.0001)
median delay to first prescription of treatment decreased from 20 days to 1 day (p < 0.0001)
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90-day risk of recurrent stroke was 10.3% before vs. 2.1% after policy change (p = 0.0001, NNT
13)
Reference - EXPRESS study (Lancet 2007 Oct 20;370(9596):1432), editorial can be found in
Lancet 2007 Oct 20;370(9596):1398
policy change associated with reduced fatal or disabling stroke (p = 0.0005), hospital bed-days (p =
0.017), and acute costs (p = 0.028) in subsequent multivariate analysis (Lancet Neurol 2009
Mar;8(3):235), editorial can be found in Lancet Neurol 2009 Mar;8(3):218
see Transient ischemic attack (TIA) for evaluation of patients presenting with TIA or transient symptoms
with infarction
Diet
first assess swallowing function
avoid any oral intake until after swallowing screen (CSBPR Evidence Level B)(4)
impaired swallowing common after stroke (especially brainstem stroke)
see Swallowing dysfunction after stroke for additional information
start enteral diet within 7 days of admission and consider supplements for patients who are malnourished
or at risk of malnourishment (see Nutrition section of Long-term management of stroke topic for
additional information)
oral nutritional supplementation does not appear to reduce mortality in patients with acute or
subacute stroke (level 2 [mid-level] evidence)
based on Cochrane review of trials with methodologic limitations
systematic review of 33 randomized trials evaluating interventions for dysphagia or nutritional
support in 6,779 patients with acute or subacute stroke
all trials had ≥ 1 limitation including
unclear allocation concealment
lack of or unclear blinding
high dropout rate
lack of intention-to-treat analysis
small sample size
5 trials (7 comparisons) compared nutritional supplementation to usual diet in 4,343 patients with
acute or subacute stroke and without dysphagia
no significant difference in mortality at end of trial (odds ratio 0.58, 95% CI 0.28-1.21) in analysis
of 5 trials
Reference - Cochrane Database Syst Rev 2012 Oct 17;(10):CD000323
routine oral nutritional supplements during hospitalization for acute stroke may not substantially
affect death or dependency (level 2 [mid-level] evidence)
based on randomized trial without blinding of patients or caregivers
in 125 hospitals in 15 countries, 4,023 patients admitted within 7 days of stroke (and enrolled in trial
within 30 days of hospital admission) and able to swallow were randomized to normal hospital diet
vs. normal hospital diet plus oral protein energy supplements until hospital discharge
only 314 patients (8%) were undernourished at baseline
modified Rankin scale known for 4,004 patients (99.5%) at end of trial
trial had allocation concealment, intent-to-treat analysis and near-complete follow-up
outcome assessors (but not patients or clinicians) were blinded
normal diet vs. supplement group had similar outcomes at 6 months
12.6% vs. 12% mortality (95% CI for absolute difference -1.4% to +2.7%)
58.3% vs. 59.2% rate of death or poor outcome defined as modified Rankin Scale score 3-5
(95% CI for absolute difference -3.8% to +2.3%)
Reference - FOOD trials (Lancet 2005 Feb 26-Mar 4;365(9461):755), editorial can be found in
Lancet 2005 Feb 26-Mar 4;365(9461):729, commentary can be found in Lancet 2005 Jun 11-
17;365(9476):2005, ACP J Club 2005 Sep-Oct;143(2):36, Ann Intern Med 2006 Jan 3;144(1):59
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adequate fluids and nutrition plus antiplatelet therapy in first 72 hours associated with reduced 30-
day mortality in patients with acute stroke (level 2 [mid-level] evidence)
based on prospective cohort study
36,197 patients (median age 77 years) with acute stroke in 106 hospitals in England were followed
for 30 days
associations between 6 processes of care and 30-day all-cause mortality were evaluated
evaluated processes included
adequate fluids and nutrition plus antiplatelet therapy where appropriate for first 72 hours
enteral or IV fluids ≥ 1 L/day
“adequate” nutrition (oral, nasogastric, or parenteral) was subjectively assessed
nutrition screening and formal swallow assessment within 72 hours where appropriate
evaluation by stroke consultant or associate specialist within 24 hours of admission
brain scan within 24 hours of admission
evaluation by nurse and 1 therapist within 24 hours and all relevant therapists within 72 hours
initial admission to stroke unit and admission within 4 hours of presentation
processes associated with reduced 30-day mortality included
adequate fluids and nutrition plus antiplatelet therapy where appropriate for first 72 hours
(adjusted odds ratio [OR] 0.55, 95% CI 0.49-0.61)
nutrition screening and formal swallow assessment within 72 hours (adjusted OR 0.83, 95%
CI 0.72-0.96)
review by a stroke consultant within 24 hours of admission (adjusted OR 0.86, 95% CI 0.78-
0.96)
receipt of 5-6 care processes associated with reduced mortality compared with receipt of 0-4
(adjusted OR 0.74, 95% CI 0.66-0.83)
Reference - BMJ 2013 May 10;346:f2827 full-text
Activity
mobilization refers to having patient move in bed, sit up, stand, and eventually walk(5)
professional organizations recommend starting rehabilitation as early as possible, but no "high-dose"
mobilization within 24 hours of stroke onset
do not start high-dose mobilization within 24 hours of stroke onset because it can reduce the odds of
a favorable outcome at 3 months (AHA/ASA Class III Harm, Level B-R)(1)
mobilization should be started 24-48 hours after stroke onset if no contraindications (CSBPR
Evidence Level B)(5)
contraindications include
arterial puncture
unstable medical condition
low oxygen saturation
lower limb injury
mobilization within 24 hours of stroke onset may be reasonable for some patients; use clinical
judgement (CSBPR Evidence Level C)(5)
Mobilization within 24 hours of stroke onset can be considered, but use caution and consider avoiding
long (> 17 minutes) out-of-bed sessions. In the AVERT trial (2,104 patients), intensive mobilization within
24 hours of stroke might reduce the likelihood of a favorable outcome at 3 months. However, the effect is
modest and, due in part to methodologic limitations, it is unclear if the effect is due to timing or intensity
of activities. A dose-response cohort analysis of it suggests that frequent (> 5 daily) but short (< 17.5
minutes) out-of-bed activity sessions within 20 hours may have benefits. Smaller trials have inconsistent
results.
intensive mobilization within 24 hours of stroke might reduce likelihood of favorable outcomes
at 3 months (level 2 [mid-level] evidence)
based on randomized trial with changes in usual care during trial in the control group
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2,104 adults admitted to acute stroke unit with stroke onset within previous 24 hours were
randomized to usual care with vs. without very early mobilization (VEM) until discharge or ≤
14 days and followed for 12 months
usual care consisted of nursing and physiotherapy activities targeting recovery of
standing and walking for about 2 sessions every 1-2 days for patients with low arousal
and total dependence and more intensive and frequent activities for patients with
greater arousal and less dependence
VEM consisted of sitting, standing, and walking activities starting within 24 hours of
stroke onset (or as soon as possible) for ≥ 3 sessions per day, with nursing and
physiotherapy activities titrated according to patient function
exclusion criteria included inability to react to verbal commands, significant
deterioration after admission, unstable physiological variables, and inability to
participate in mobilization therapies (lower-limb injury or administration of
thrombolysis with restricted mobilization)
treating nurses and physiotherapists not blinded to treatment allocation but followed protocols
to conceal allocation from patient, family, and outcome assessors
possible changes in usual care during trial in the control group
over the course of the trial, median time to first mobilization decreased among patients
with usual care alone by 28 minutes/year (p = 0.001) but not among patients with VEM
no significant changes in median frequency of activities or total time of out-of-bed
activities during trial among patients with usual care alone (change over time not
reported for patients with VEM)
comparing VEM vs. no VEM
median time to first mobilization 18.5 vs. 22.4 hours (p < 0.0001)
median frequency of mobilization sessions 6.5 vs. 3 sessions/day (p < 0.0001)
at 3 months
death in 8% vs. 7% (not significant)
favorable outcome (mRS 0-2 points) in 46% vs. 50% (adjusted odds ratio 0.73,
95% CI 0.59-0.9) (NNH 25)
able to walk unassisted in 75% vs. 76% (not significant)
at 12 months, no significant differences between groups in quality of life or walking ability,
but VEM had a nonsignificant reduced likelihood of favorable outcome (adjusted odds ratio
0.84, 95% CI 0.68-1.03, absolute rates not reported)
Reference - AVERT trial (Health Technol Assess 2017 Sep;21(54):1 full-text), results also
reported in Lancet 2015 Jul 4;386(9988):46
more frequent (> 5 daily) and shorter-duration (< 17.5 minutes) out-of-bed activity
sessions within 20 hours of stroke might be associated with increased likelihood of
favorable outcomes at 3 months (level 2 [mid-level] evidence)
based on cohort analysis of AVERT trial
dose-response analysis conducted on 2,083 patients with acute stroke (99% of
randomized) evaluated effects of time to first mobilization, frequency (median number
of daily out-of-bed activity sessions), and duration (median minutes of daily out-of-bed
activity sessions)
analyses were controlled for age and stroke severity
frequency based on nurse- and physiotherapist-derived data, but duration based
only on physiotherapist-derived data
for entire cohort, median time to first mobilization was 20.2 hours, median number of
daily out-of-bed sessions was 5, and median duration of daily out-of-bed sessions was
17.5 minutes
for likelihood of favorable outcome (mRS 0-2 points) at 3 months
increased time to first mobilization associated with nonsignificant reduced
likelihood (odds ratio [OR] for each additional hour 0.99, 95% CI 0.98-1)
increased daily frequency of sessions associated with increased likelihood (OR
for each additional session 1.13, 95% CI 1.09-1.18)
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increased duration of sessions associated with reduced likelihood (OR for each
additional 5 minutes 0.94, 95% CI 0.91-0.97)
Reference - Neurology 2016 Jun 7;86(23):2138 full-text
smaller trials with methodologic limitations have inconsistent results for effects of mobilization
within 24 hours of stroke
mobilization within 24 hours of stroke might improve functional status (level 2 [mid-
level] evidence)
based on randomized trial without intention to treat analysis
86 patients aged 30-80 years (mean age 59 years) with acute stroke were randomized to
early mobilization vs. no early mobilization for 7 days or until discharge and followed
for 3 months
early mobilization included out of bed activities for 5-30 minutes ≥ twice daily
starting within 24 hours of stroke
all patients had standard care including passive and active mobilization, correct
positioning in bed, mobilization in bed, sitting balance activities, facilitation of
limb and trunk control activities, and education 45 minutes once daily
functional status assessed using Barthel Activities of Daily Living (ADL) Index (range
0-100 points, with higher score indicating better function)
93% completed trial and included in analysis
median improvement in Barthel ADL index comparing early mobilization vs. no early
mobilization
35 points vs. 17.5 points (p < 0.001) at discharge
42.5 points vs. 30 points (p < 0.001) at 3 months
Reference - Clin Rehabil 2016 Jul;30(7):669
mobilization within 24-36 hours of stroke might reduce risk of complications and
increase independence at 3 months (level 2 [mid-level] evidence)
based on pooled analysis of 2 small phase II trials
meta-analysis of 2 randomized trials evaluating very early mobilization (getting out of
bed, standing, walking early after stroke, and continuing at frequent intervals) vs.
standard care in 103 patients with acute stroke
comparing very early mobilization vs. standard care in analyses of 2 trials (p < 0.05 for
both)
median time to first mobilization from symptom onset 21 hours vs. 31 hours
≥ 1 complication in 35.2% vs. 51%
very early mobilization associated with fewer immobilization-related complications in
analysis of 2 trials
odds ratio 0.2 (95% CI 0.1-0.7)
NNT 4-14 assuming immobilization-related complications in 35% standard care
group
very early mobilization associated with greater independence at 3 months (adjusted
odds ratio 3.11, 95% CI 1.03-9.33) in analysis of 2 trials
Reference - Stroke 2010 Nov;41(11):2632 full-text
mobilization within 24 hours of stroke might increase mortality and reduce function
compared to mobilization at 24-48 hours (level 2 [mid-level] evidence)
based on small randomized trial
56 patients (mean age 77 years) with stroke randomized to mobilization out of bed
within 24 hours vs. at 24-48 hours and followed for 3 months
comparing mobilization within 24 hours vs. at 24-48 hours
initial mean stroke scale 7.5 vs. 9.2 (not significant)
death in 25.9% vs. 6.9% (p = 0.08)
2 or 3 complications in 44% vs. 16% (p = 0.08)
poor global function (modified Rankin Scale score 3-6) in 60% vs. 39% (not
significant)
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Medications
Thrombolytics
IV alteplase (tissue plasminogen activator [t-PA], recombinant tissue plasminogen activator [rt-PA],
Activase, Actilyse) may improve outcomes when given within 4.5 hours of acute ischemic stroke
standard dose: 0.9 mg/kg (maximum dose 90 mg) over 60 minutes with initial 10% of dose given as
bolus over 1 minute
given < 3 hours after symptom onset (AHA/ASA Class I, Level A)
given 3-4.5 hours after symptom onset (AHA/ASA Class I, Level B-R)
dose 0.6 mg/kg used in Japan
most guideline organizations do not have recommendations for use > 4.5 hours after stroke onset
assess blood glucose levels before starting IV alteplase (AHA/ASA Class I, Level B-R ); administer
IV alteplase if initial blood glucose > 50 mg/dL and patient meets other criteria (AHA/ASA Class I,
Level A)
other non-imaging laboratory tests should not delay IV alteplase in otherwise eligible patients
contraindications include intracranial hemorrhage; infective endocarditis; aortic arch dissection;
intra-axial intracranial neoplasm; laboratory indications of coagulopathy; low molecular weight
heparin within past 24 hours; structural gastrointestinal malignancy; gastrointestinal bleed within
previous 21 days; and recent (within past 3 months) ischemic stroke, severe head trauma, or
intracranial/intraspinal surgery;
if elevated blood pressure, lower to < 185/110 mm Hg before administering alteplase (AHA/ASA
Class I, Level B-NR), and maintain at < 180/105 mm Hg for at least the first 24 hours (AHA/ASA
Class IIa, Level B-NR)
discontinue infusion and obtain emergency computed tomography (CT) if patient develops severe
headache, acute hypertension, nausea, vomiting, or has worsening neurological examination
post-stroke antiplatelet therapy within 24 hours of starting IV alteplase is generally avoided, but can
be considered in some cases
tenecteplase 0.4 mg/kg IV single bolus might be considered as an alternative to alteplase in patients with
minor neurological impairment and no major intracranial occlusion (AHA/ASA Class IIb, Level B-R)
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Antiplatelet therapy
give aspirin within 24-48 hours of acute ischemic stroke (AHA/ASA Class I, Level A; AAN/AHA Grade
A)
for patients given IV alteplase, aspirin generally delayed for > 24 hours after alteplase
administration, but might be considered if concomitant conditions such that aspirin would be
beneficial if alteplase not given
sample dose: 160-325 mg/day (ACCP Grade 1A; AAN/AHA Grade A), then 75-100 mg/day after 1-2
weeks of acute treatment
contraindications may include primary intracerebral hemorrhage, aspirin allergy, and gastrointestinal
bleeding
consider clopidogrel monotherapy as alternative antiplatelet agent if aspirin allergy/intolerance of patient
already taking aspirin
for patients with minor stroke within past 24 hours, consider clopidogrel plus aspirin for 21 days for early
secondary prevention of stroke
see Antiplatelet therapy for acute stroke topic for additional information
Anticoagulation
anticoagulants are generally not recommended for treating or reducing recurrence of non-cardioembolic
acute ischemic stroke (AHA/ASA Class III No Benefit, Level A)
anticoagulants may be considered in some cases
acute cardioembolic stroke
anticoagulants may not reduce death or disability, but may reduce risk of recurrence
if high risk of hemorrhagic conversion, consider delaying administration for > 14 days
symptomatic deep vein thrombosis or pulmonary embolism
acute stroke secondary to arterial dissection
cerebral venous sinus thrombosis
prophylactic-dose heparin has not been shown to reduce risk of deep vein thrombosis in immobile patiehts
with acute ischemic stroke(AHA/ASA Class IIb, Level A)
see Anticoagulation therapy for acute stroke topic for additional information
also see Venous thromboembolism prophylaxis section for anticoagulation therapy for venous
thromboembolism prophylaxis
Antihypertensives
very high and very low blood pressure (BP) at admission each associated with poor outcomes in patients
with acute ischemic stroke
hypotension and hypovolemia should be corrected to maintain systemic perfusion levels necessary to
support organ function (AHA/ASA Class I, Level C-EO)
if elevated blood pressure (BP)
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see Blood pressure management in acute ischemic stroke topic for additional information
Statins
statins have insufficient evidence to determine safety and efficacy within 2 weeks of acute ischemic
stroke or transient ischemic attack
based on Cochrane review
systematic review of 8 randomized trials comparing statins vs. placebo or no treatment, given to 625
adults within 2 weeks of onset of acute ischemic stroke or transient ischemic attack (TIA)
only 1 trial considered to have low risk of bias
no significant differences between groups in all-cause mortality (odds ratio 1.51, 95% CI 0.6-3.81)
in analysis of 7 trials with 431 patients
no cases of mortality from selected causes (ischemic stroke, adverse drug effects, bleeding, or
infections) reported in 6 trials with 444 patients
no cases of rhabdomyolysis in 3 trials with 274 patients
Reference - Cochrane Database Syst Rev 2011 Aug 10;(8):CD007551
statin use at time of ischemic stroke associated with increased likelihood of good functional outcome
at 90 days (level 2 [mid-level] evidence)
based on systematic review of mostly observational studies
systematic review of 27 studies (3 randomized trials, 24 cohort studies) comparing statin therapy at
time of ischemic stroke onset vs. no statin therapy before stroke in 113,148 patients
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decreased with statin withdrawal during hospitalization (OR 0.77 [95% CI 0.63-0.94] vs. no
withdrawal)
Reference - Neurology 2012 May 22;78(21):1678
for patients taking statins at time of onset of ischemic stroke, continuation of statin during acute period is
reasonable (AHA/ASA Class IIa, Level B)(6)
for patients taking statins before stroke, continuation of statin use without interruption
following acute stroke associated with decreased risk of death or dependency at 90 days (level
2 [mid-level] evidence)
based on randomized trial with allocation concealment not stated
89 patients on chronic statins treatment who had acute ischemic stroke within 24 hours
assigned by day of admission to withdrawal of statins for first 3 days after admission (then
starting atorvastatin 20 mg/day on day 4) vs. atorvastatin 20 mg/day without interruption of
statin therapy
median duration of statin treatment before stroke onset 8.7 months
comparing statin interruption for 3 days vs. continuous statin
60% vs. 39% died or were dependent at 90 days (p = 0.043, NNT 5 for statin
continuation)
60% vs. 39% had modified Rankin Scale score > 2 at 90 days (p = 0.043, NNT 5 for
statin continuation)
65.2% vs. 20.9% had early neurologic deterioration within 48 hours (p < 0.0001, NNT
3 for statin continuation)
Reference - Neurology 2007 Aug 28;69(9):904
Oxygen
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Antipyretics
most evidence in this section applicable to both ischemic and hemorrhagic stroke unless otherwise noted
if temperature > 37.5 degrees C, investigate for possible infection, such as pnenumonia or urinary tract
infection, and start antimicrobial therapy as required (CSBPR Evidence Level B)(5)
prophylactic antibiotics
prophylactic antibiotics not routinely recommended (AHA/ASA Class III No Benefit, Level B-R )
(1)
preventive antibiotics reduce risk urinary tract infections (level 1 [likely reliable] evidence)
and may reduce risk of overall infections (level 2 [mid-level] evidence), but may not affect
mortality or rate of poor functional outcome (level 2 [mid-level] evidence) in patients with
acute stroke
based on Cochrane review limited by heterogeneity (for infections overall and poor functional
outcome) and with confidence intervals that cannot exclude clinically important differences
(for mortality)
systematic review of 8 randomized and quasi-randomized trials comparing preventive
antibiotics vs. placebo or no intervention in 4,488 patients with acute stroke
trials differed in types of antibiotics, doses, and durations; follow-up varied from hospital
discharge to 90 days post-stroke
preventive antibiotics associated with
reduced risk of urinary tract infections at end of follow-up in analysis of 6 trials with
4,257 patients
risk ratio (RR) 0.4 (95% CI 0.32-0.51)
NNT 15-21 with urinary tract infections in 10% of control group
reduced risk of overall infections at end of follow-up in analysis of 7 trials with 4,317
patients, results limited by significant heterogeneity
RR 0.71 (95% CI 0.58-0.88)
NNT 10-32 with infections overall in 26% of control group
no significant differences in
mortality at end of follow-up (RR 1.03, 95% CI 0.87-1.21) in analysis of 8 trials with
4,422 patients
poor functional outcome (death or dependency) at end of follow-up in analysis of 7
trials with 4,332 patients
pneumonia at end of follow-up in analysis of 6 trials with 4,257 patients
Reference - Cochrane Database Syst Rev 2018 Jan 22;(1):CD008530
minocycline 6-24 hours after stroke onset may improve functional outcome (level 2 [mid-level]
evidence)
based on randomized trial without blinding
152 patients with acute stroke within 6-24 hours were randomized to minocycline 200 mg/day
vs. placebo orally for 5 days and followed for 90 days
1 patient excluded due to intracerebral hemorrhage before receiving treatment, 151 patients
analyzed
National Institutes of Health Stroke Scale (NIHSS) evaluated by blinded assessor and
findings categorized as
0-1 complete or nearly complete improvement
2-7 mild impairment
8-14 moderate impairment
≥ 15 severe impairment
comparing minocycline vs. placebo
mortality 6.8% vs. 11.7% (not significant)
mean NIHSS 7.5 vs. 7.6 on admission (not significant)
mean NIHSS 6.5 vs. 8.1 at day 7 (p < 0.0001)
mean NIHSS 1.8 vs. 7.1 at day 30 (p < 0.0001)
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Anticonvulsants
do not give prophylactic anti-seizure drugs if no evidence of seizure (AHA/ASA Class III, Level B-R;
CSBPR Evidence Level B)(1, 5)
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if not self-limited, treat with appropriate short-acting medication (CSBPR Evidence Level C)(4, 5)
IV lorazepam 4 mg bolus (may be repeated once after 5-10 minutes if needed)
also consider intramuscular midazolam or rectal diazepam
note that treatment for seizure may be necessary before completing imaging or other initial
assessments
treat recurrent seizures as one would when they occur in other neurologic conditions (AHA/ASA Class I,
Level C-LD; CSBPR Evidence Level C )(1, 4)
see Seizure in adults and Status epilepticus in adults topics for additional information
Insulin
reasonable to treat hyperglycemia to achieve serum glucose levels 140-180 mg/dL (7.8-10 mmol/L) and
closely monitor to prevent hypoglycemia (AHA/ASA Class IIa, Level C-LD )(1)
persistent hyperglycemia within first 24 hours after stroke associated with worse outcomes
closely monitor glucose levels with adjustment of insulin doses to avoid hypoglycemia
intensive glycemic control with continuous insulin IV infusion in adults with acute ischemic stroke
may not reduce mortality or dependency and may increase hypoglycemia (level 2 [mid-level]
evidence)
based on Cochrane review of trials without blinding
systematic review of 11 randomized trials comparing monitored insulin therapy vs. usual care in
1,583 adults presenting within 24 hours of acute ischemic stroke and with serum glucose levels >
110 mg/dL (6.1 mmol/L)
intervention consisted of continuous insulin IV infusion with goal to keep serum glucose level
between 75 and 135 mg/dL
no significant differences in
death or dependency at end of follow-up in analysis of 9 trials with 1,516 patients
mortality in analysis of 9 trials with 1,422 patients
independence in daily activities in analysis of 9 trials with 1,224 patients
for outcome of neurologic deficit
insulin therapy associated with small-to-moderate improvement in neurologic deficit at 30
days in analysis of 5 trials with 273 patients
no significant difference at 90 days in analysis of 3 trials with 1,159 patients
insulin therapy associated with
higher rate of overall hypoglycemia in analysis of 10 trials with 1,455 patients, results limited
by significant heterogeneity
higher rate of symptomatic hypoglycemia in analysis of 10 trials with 1,455 patients, results
limited by significant heterogeneity
Reference - Cochrane Database Syst Rev 2014 Jan 23;(1):CD005346
DynaMed commentary -- subgroup analyses by different cutoff levels for starting insulin therapy not
reported; subgroup analyses by presence or absence of diabetes did not find significant differences
consistent results in previous systematic review of 8 trials (J Adv Nurs 2013 Feb;69(2):263)
Antihypertensives
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blood pressure should be well controlled, particularly in patients with intracerebral hemorrhage
caused by hypertensive vasculopathy
for patients presenting with systolic blood pressure 150-220 mm Hg, acute lowering of systolic
blood pressure to target goal of 140 mm Hg is probably safe
see Intracerebral hemorrhage for additional information
in patients with subarachnoid hemorrhage
control blood pressure with titratable agent to balance risk of stroke, hypertension-related
rebleeding, and maintenance of cerebral perfusion pressure
decrease in systolic blood pressure to < 160 mm Hg is reasonable, though magnitude of blood
pressure control to reduce risk of rebleeding has not been established
see Subarachnoid hemorrhage for additional information
Statins
Oxygen
Antipyretics
antipyretic medications generally recommended to lower temperature in febrile patients (AHA/ASA Class
I, Level C) but effect on neurologic outcomes not established; seeking and treating source of fever also
suggested(1)
sources of hyperthermia (temperature > 38 degrees C) should be identified and treated, and antipyretic
medications should be administered to lower temperature in hyperthermic patients with stroke (AHA/ASA
Class I, Level C-EO)(1)
benefit of induced hypothermia for treating patients with acute ischemic stroke not well established and
should only be offered in context of ongoing clinical trials (AHA/ASA Class IIb, Level B-R)(1)
if temperature > 37.5 degrees C, increase frequency of monitoring and start temperature-reducing
measures (CSBPR Evidence Level B)(5)
see Antipyretics section under medications for ischemic stroke for additional evidence for antipyretics for
both ischemic and hemorrhagic stroke
Antibiotics
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if temperature > 37.5 degrees C, investigate for possible infection, such as phenumonia or urinary tract
infection, and start antimicrobial therapy as required (CSBPR Evidence Level B)(5)
see Antibiotics section under medications for ischemic stroke for additional evidence for antibiotics for
both ischemic and hemorrhagic stroke
Insulin
aggressive hyperglycemia management protocol may not reduce poor outcome in patients with
subarachnoid hemorrhage (level 2 [mid-level] evidence)
based on retrospective cohort study
332 patients admitted to intensive care unit with subarachnoid hemorrhage evaluated
166 patients treated with aggressive hyperglycemia management protocol upon admittance
166 patients treated with standard protocol upon admittance
modified Rankin scale ≥ 4 (poor outcome) at 3-6 months in 28.3% with aggressive hyperglycemia
management vs. 40.4% with standard protocol (not significant)
in aggressively managed patients, patients with good glucose control associated with reduced risk of
poor outcome (odds ratio 0.25, 95% CI 0.08-0.8)
Reference - Stroke 2009 May;40(5):1644 full-text
Anticonvulsants
if new-onset seizure ≤ 24 hours after stroke onset and seizure isn't self-limited, treat using appropriate
short-acting medication (CSBPR Evidence Level C)(4, 5)
reported regimens
lorazepam 0.07 mg/kg IV bolus (usually 4 mg) (may be repeated once)
other reported drugs include diazepam, clonazepam, and midazolam
see Seizure in adults or Seizure in children for additional information
see Anticonvulsants section for medications for ischemic stroke for additional evidence for
anticonvulsants for both ischemic and hemorrhagic stroke
neuroprotective agents
at present, no pharmacological or non-pharmacological treatments with putative neuroprotective
actions have demonstrated efficacy in improving outcomes after ischemic stroke, and therefore,
other neuroprotective agents are not recommended. (AHA/ASA Class III No Benefit, Level A )
many neuroprotective agents have not been shown to significantly reduce death or dependency in
acute stroke
examples include NXY-059, lubeluzole, gavestinel, aptiganel, calcium channel blockers,
magnesium sulfate, piracetam
few neuroprotective agents have evidence for benefit
edaravone (Radicut in Japan) 30 mg IV twice daily for 14 days associated with
neurological improvement in patients with acute ischemic stroke (level 2 [mid-level]
evidence)
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see Alternative and experimental therapies for acute stroke topic for additional information
see Intracerebral hemorrhage or Subarachnoid hemorrhage for additional information on therapies for
hemorrhagic stroke
Endovascular therapy
endovascular therapy is a treatment option used to achieve reperfusion in adults with functionally
disabling acute ischemic stroke
goal is to achieve reperfusion in ≥ 50% of downstream ischemic territory (modified Thrombolysis
in Cerebral Infarction grade 2b/3 [AHA/ASA Class I, Level A]) as soon as possible to ensure
benefit (AHA/ASA Class I, Level B-R)
endovascular therapeutic methods include
mechanical thrombectomy
with stent retrieval
stent is deployed within and integrated into the clot, and then the stent-clot
complex is removed
allows for rapid partial flow restoration before clot extraction
without stent retrieval (mechanical debulking and aspiration of clot)
intra-arterial thrombolysis
eligibility for endovascular therapy for acute stroke is determined based on neuroimaging findings and
time since symptom onset/patient was last known to be well
give mechanical thrombectomy with stent retriever to adults with
symptom onset ≤ 6 hours before groin puncture for treatment can be initiated and (AHA/ASA
Class I, Level A; CSBPR Evidence Level A)
causative occlusion of the internal carotid artery or middle cerebral artery segment 1
(M1)
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see Endovascular therapy for acute stroke topic for additional information
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if considering hemicraniectomy, consult with stroke specialist and neurosurgeon (CSBPR Evidence Level
C)(4)
indications / criteria for decompressive craniectomy
American Heart Association / American Stroke Association (AHA/ASA) recommendations
optimal indications for decompressive craniectomy not known, but a reasonable indication is
reduced consciousness attributable to brain swelling (AHA/ASA Class IIa, Level A)(1)
decompressive craniectomy with dural expansion can be considered in patients with unilateral
middle cerebral artery infarctions who deteriorate neurologically within 48 hours despite
medical therapy(1)
in patients ≤ 60 years, reported outcomes include mortality reduction by almost 50%,
with 55% of surgical survivors achieving moderate disability (mRS score 2-3) and 18%
achieving independence (mRS score 2) at 12 months (AHA/ASA Class IIa, Level A)
in patients > 60 years, reported outcomes include mortality reduction by almost 50%,
with 11% of surgical survivors achieving moderate disability (mRS score 3) but none
achieving independence (mRS score ≤ 2) at 12 months (AHA/ASA Class IIb, Level B-
R)
decompressive surgery for malignant edema of cerebral hemisphere is effective and
potentially lifesaving (AHA/ASA Class I, Level B)(6)
decompressive suboccipital craniectomy(1)
should be performed with dural expansion if cerebellar infarction causing neurological
deterioration from brainstem compression despite maximal medical therapy; treat
obstructive hydrocephalus with ventriculostomy where safe and indicated (AHA/ASA
Class I, Level B-NR)
may be necessary with or after ventriculostomy for obstructive hydrocephalus after
cerebellar infarct depending on infarct size, neurological condition, brainstem
compression, and effect of medical management (AHA/ASA Class I, Level C-LD)
Canadian Stroke Best Practice Recommendations (CSBPR)
criteria for hemicraniectomy for malignant hemispheric stroke include (CSBPR Evidence
Level A)(4)
age > 18 years
extensive (malignant) MCA territory ischemic stroke with signs of edema/mass effect
infarct ≥ 50% MCA territory on visual inspection or ischemic lesion volume > 150 cm3
worsening symptoms on NIHSS, CNS, or GCS; or worsening edema on imaging
consider hemicraniectomy in children if progressive extensive (malignant) MCA syndrome
(CSBPR Evidence Level C)
if patient not in comprehensive stroke center, expedite transfer to tertiary or quaternary center
with advnaced stroke care and neurological services (CSBPR Evidence Level C)
consider informing family that decompressive suboccipital craniectomy for cerebellar infarction may have
good outcomes (AHA/ASA Class IIb, Level C-LD)(1)
with large infarction of cerebellum, delayed swelling is common (6)
edema can cause brain stem compression and can progress very rapidly to a loss of brain stem
function
emergency posterior fossa decompression with partial removal of the infarcted tissue may be
lifesaving and can result in clinical outcomes with a reasonable quality of life
in patients with large territorial supratentorial infarctions, discuss options and possible outcomes quickly
with patients (if possible) and caregivers (AHA/ASA Class I, Level C-EO)(1)
assess and include patient-centered preferences in shared decision making, especially during
prognosis formation and considering interventions or limitations
consider individual preexisting decisions about end-of-life and degree of treatment performed in
face of severe neurological injury
these infarctions have high risk of complicating brain edema and increased intracranial pressure
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medical management is option for less severe edema, but surgical treatment may be only effective
option in very severe cases
timely decompressive surgery may reduce mortality, but persistent morbidity may be common
considerations for management prior to hemicraniectomy(4)
discuss with patient, family members, and legal decision-maker (CSBPR Evidence Level C)
stroke diagnosis
prognosis if untreated
risks and possible outcomes of surgery
patient's previously expressed wishes regarding treatment after catastrophic event
perform hemicraniectomy
within 48 hours of initial presentation (CSBPR Evidence Level A)
before major midline shift (CSBPR Evidence Level C)
transfer patient to intensive care unit or neuro step-down unit to closely monitor neurological status
(CSBPR Evidence Level B)
monitor at least hourly (more frequently if necessary) (CSBPR Evidence Level C)
consciousness (such as with CNS score)
symptom severity
blood pressure
if change in status, immediately inform stroke team and neurosurgeon for reevaluation
(CSBPR Evidence Level C)
example changes in status include
increasing drowsiness or consciousness
decrease in Canadian Neurological Scale score by 1 point
increase in National Institutes of Health Stroke Scale score by 4 points
if deterioration in neurological status, repeat CT scan (CSBPR Evidence Level C)
determine if treatment necessary for high blood pressure (CSBPR Evidence Level B)
if necessary, use hyperosmotic therapy (20% mannitol or 3% hypertonic saline) during perioperative
period (CSBPR Evidence Level C)
elevate patient's head by 30 degrees, and educate patient and family members about proper head
positioning (CSBPR Evidence Level C)
in general, avoid hyperventilation before surgery (CSBPR Evidence Level C)
withhold all antiplatelets and anticoagulants before hemicraniectomy (CSBPR Evidence Level B)
if increased intracranial pressure present, corticosteroids are not recommended as part of
preoperative management (CSBPR Evidence Level A)
if hydrocephalus present, consider external ventricular drain place by neurosurgeon (CSBPR
Evidence Level C)
decompressive surgery within 48 hours of onset of massive acute ischemic stroke with cerebral
edema may reduce mortality (level 2 [mid-level] evidence)
based on 2 meta-analyses of 3 randomized trials with unclear allocation concealment
3 randomized trials (DECIMAL, DESTINY, HAMLET) used different neuroimaging criteria
diffusion-weighted magnetic resonance imaging (MRI) infarct volume > 145 cm3 in
DECIMAL trial
brain computed tomography (CT) ischemic changes in > two-thirds of middle cerebral artery
(MCA) territory plus basal ganglia in DESTINY trial
brain CT ischemic changes affecting ≥ two-thirds of MCA territory plus space-occupying
edema in HAMLET trial
Cochrane review of 3 randomized trials evaluating addition of surgical decompression to medical
treatment in 134 patients with massive acute ischemic stroke complicated by cerebral edema
in analyses of 3 trials with 134 patients, surgical decompression associated with reduced
mortality at end of follow-up
odds ratio (OR) 0.19 (95% CI 0.09-0.37)
NNT 2-5 with 75% mortality in medical treatment alone group
mortality or severe disability (modified Rankin Scale score > 4) at 12 months
OR 0.26 (95% CI 0.13-0.51)
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NNT 3-7 with 66% mortality or severe disability in medical treatment alone
group
Reference - Cochrane Database Syst Rev 2012 Jan 18;(1):CD003435
meta-analysis of these same 3 trials limited to 93 patients treated within 48 hours
93 patients aged 18-60 years with malignant MCA infarction were randomized (in 1 of 3
trials) to decompressive surgery within 48 hours after stroke onset vs. conservative medical
management
malignant MCA infarction defined as space-occupying MCA infarction
comparing surgery vs. conservative treatment
survival at 1 year 78% vs. 29% (NNT 2)
functional status by modified Rankin Scale (mRS) score ≤ 4 in 75% vs. 24%
favorable functional mRS score ≤ 3 in 43% vs. 21%
Reference - Lancet Neurol 2007 Mar;6(3):215, editorial can be found in Lancet Neurol 2007
Mar;6(3):200
in individual trials
comparing surgery vs. no surgery in trial with 38 patients
1 of 20 (5%) vs. 12 of 18 (67%) died within one week
3 of 16 (19%) vs. 2 of 6 (33%) died during weeks 1-4
Reference - DECIMAL trial (Stroke 2007 Sep;38(9):2506), editorial can be found in
Stroke 2007 Sep;38(9):2410
comparing surgery vs. no surgery in trial with 32 patients
15 of 17 (88%) vs. 7 of 15 (47%) survived to day 30 (p = 0.02)
Reference - DESTINY trial (Stroke 2007 Sep;38(9):2518), editorial can be found in
Stroke 2007 Sep;38(9):2410
comparing surgery vs. no surgery in trial with 64 patients at 1 year
death in 22% vs. 59% (p < 0.05)
modified Rankin Scale disability in 75% vs. 75% (not significant)
Reference - HAMLET trial (Lancet Neurol 2009 Apr;8(4):326)
decompressive surgery associated with reduced mortality at 3 years (level 2 [mid-level] evidence)
based on follow-up of HAMLET trial
64 patients were followed up to 3 years
comparing surgery vs. no surgery
death in 26% vs. 63% (p = 0.002, NNT 3)
modified Rankin Scale disability in 74% vs. 75% (not significant)
living at home in 52% vs. 25% (p = 0.05)
Reference - Stroke 2013 Sep;44(9):2506
hemicraniectomy improves survival without severe disability in older patients with malignant
middle-cerebral-artery infarction (level 1 [likely reliable] evidence)
based on randomized trial
112 patients ≥ 61 years old (median age 70 years) with malignant middle-cerebral-artery infarction
were randomized within 48 hours of symptom onset to hemicraniectomy vs. conservative medical
treatment in intensive care unit and followed for 1 year
trial terminated early using predefined sequential stopping rule
comparing hemicraniectomy vs. conservative medical treatment in intention-to-treat analyses
6-month survival without severe disability (modified Rankin Scale score 0-4) 38% vs. 18% (p
= 0.04, NNT 5)
1-year overall survival 57% vs. 24% (p < 0.05, NNT 3)
infection or infestation in 20% vs. 10% (no p value reported)
nervous system disorder in 15% vs. 42% (no p value reported)
no significant differences in disability, activities of daily living, mental or physical well-being,
depression, or quality of life in analyses of surviving patients at 1 year
no surviving patients had modified Rankin Scale score ≤ 2
Reference - DESTINY II trial (N Engl J Med 2014 Mar 20;370(12):1091), editorial can be found in
N Engl J Med 2014 Mar 20;370(12):1159
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favorable functional outcome reported in 41% after decompressive hemicraniectomy for malignant
middle cerebral artery territory infarction (level 3 [lacking direct] evidence)
based on systematic review of noncomparative data from observational studies and randomized
trials
systematic review of 16 studies reporting outcomes in 382 patients (mean age 50 years) who had
decompressive hemicraniectomy for malignant middle cerebral artery territory infarction
mortality 24%
mean follow-up in survivors was 19 months
among 156 survivors with reported modified Rankin Scale (mRS) scores
favorable functional outcome (mRS score ≤ 3) in 41%
moderately severe disability (mRS score 4) in 47%
depression in 56% and moderate-to-severe in depression in 25% of 114 survivors who were
screened
77% of 209 patients and caregivers were satisfied with procedure
Reference - J Neurosurg 2012 Oct;117(4):749, editorial can be found in J Neurosurg 2012
Oct;117(4):745
severe orthostatic headache common after hemicraniectomy
based on cohort of 27 patients who had hemicraniectomy for malignant middle cerebral artery
infarction
11% had severe orthostatic headache
Reference - Stroke 2010 Mar;41(3):560
perform ventriculostomy for obstructive hydrocephalus after cerebellar infarct; concomitant or subsequent
decompressive craniectomy may be necessary depending on infarct size, neurological condition, degree of
brainstem compression, and effect of medical management (AHA/ASA Class I, Level C-LD)(1)
Carotid endarterectomy
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perform surgical clipping or endovascular coiling as soon as possible to reduce the risk of
rebleeding
see Subarachnoid hemorrhage topic for additional information
Other management
have interprofessional team assess patient within 48 hours of admission to formulate management plan
(CSBPR Evidence Level B)(5)
observe for neurologic deterioration within first 24 hours(6)
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monitor cardiac rhythm for at least first 24 hours to screen for arrhythmias (AHA/ASA Class I, Level B)
(6)
cardiac arrhythmias that might be reducing cardiac output should be corrected (AHA/ASA Class I, Level
C)
oxygen for hypoxemic patients to maintain oxygen saturation > 94% (AHA/ASA Class I, Level C-LD)(1)
supplemental oxygen is not recommended for nonhypoxic patients hospitalized with acute ischemic stroke
(AHA/ASA Class III No Benefit, Level B-R)
ventilatory support
airway support and ventilatory assistance recommended for patients with (AHA/ASA Class I, Level
C-EO )(1)
decreased consciousness
bulbar dysfunction causing compromise of airway
continuous positive airway pressure ventilation associated with decrease in apnea-hypopnea
index in patients with acute ischemic stroke (level 3 [lacking direct] evidence)
based on nonclinical outcome in small randomized trial
50 patients with acute ischemic stroke within 1 day randomized to continuous positive airway
pressure ventilation for 3 nights vs. control
treatment continued for 4 additional nights if apnea-hypopnea index > 10/hour
continuous positive airway pressure ventilation associated with
decrease in apnea-hypopnea index from 32/hour to 10/hour (p = 0.0001)
trend toward improved National Institutes of Health Stroke Scale (NIHSS) score (p =
0.092)
Reference - Stroke 2012 Apr;43(4):1137
endotracheal intubation and mechanical ventilation may help in patients with elevated intracranial
pressure or malignant brain edema after stroke(6)
hypotension and hypovolemia should be corrected to maintain systemic perfusion levels necessary to
support organ function (AHA/ASA Class I, Level C-EO)(1)
hypoglycemia (blood glucose < 60 mg/dL [3.33 mmol/L]) should be corrected to achieve normoglycemia
(AHA/ASA Class I, Level C-LD , CSBPR Evidence Level C )(1, 4)
fever assessment and management
monitor temperature as part of vital sign assessments every 4 hours for first 48 hours, and then as
determined by ward routine or clincal judgement (CSBPR Evidence Level C)(5)
for elevated temperature
sources of fever should be identified and treated and antipyretic medications given to lower
temperature in hyperthermic patients (AHA/ASA Class I, Level C-LD )(1)
if temperature > 37.5 degrees C(5)
increase monitoring frequency
start temperature-reducing measures
assess for pneumonia, urinary tract infection, or other infection (CSBPR Evidence
Level C)
start antipyretic and antimicrobial therapy as required (CSBPR Evidence Level B)
assess fluid status and urinary retention as part of vital sign assessments (CSBPR Evidence Level C)(4)
bladder catheters
avoid placement of indwelling bladder catheters because of associated risk of urinary tract
infections (AHA/ASA Class III Harm, Level C-LD , CSBPR Evidence Level A )(1, 4, 5)
if used(4, 5)
assess daily and remove as soon as possible (CSBPR Evidence Level A)
use excellent pericare and infection prevention to minimize risk of infection (CSBPR
Evidence Level B)
bladder reconditioning prior to indwelling catheter removal may not improve urinary
function in patients with acute stroke (level 2 [mid-level] evidence)
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Patient education
all interprofessional team members should provide comprehensive information, education, and skills
training to patients, family members, and informal care-givers (CSBPR Evidence Level A)(5)
information may improve patient and caregiver knowledge of stroke, with active interventions
possibly more effective than passive interventions (level 2 [mid-level] evidence)
based on Cochrane review of trials with methodologic limitations
systematic review of 21 randomized trials evaluating provision of information on stroke in 2,289
patients with stroke and 1,290 caregivers
all trials had ≥ 1 limitation including
unclear allocation concealment
lack of or unclear blinding
high loss to follow-up and/or lack of intention-to-treat analysis
12 trials evaluated active information intervention (information plus follow-up/reinforcement), 9
trials evaluated passive information intervention (information provision without follow-up)
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intervention associated with significantly improved patient and caregiver knowledge, patient
satisfaction with information about causes and nature of stroke, and patient depression scores
compared to control
no significant difference between intervention and control in mortality, incidence of anxiety or
depression, satisfaction with information about allowances and services, or caregiver mood or
satisfaction
post hoc analysis suggested active information intervention improved mood but not other outcomes
compared to passive information intervention
Reference - Cochrane Database Syst Rev 2012 Nov 14;(11):CD001919, earlier version published in
Clin Rehabil 2009 Mar;23(3):195
Swallowing dysfunction
assess thromboembolism and bleeding risk in medical patients (including patients with stroke) prior to
starting prophylaxis of VTE (ACP Strong recommendation, Moderate-quality evidence)
insufficient evidence to recommend a specific validated risk-assessment tool
risk factors for VTE include inherited or acquired thrombophilia, surgery, immobilization, cancer,
heart failure, trauma, pregnancy, thrombogenic drugs, presence of central venous catheter, chronic
renal disease, obesity, tobacco use, history of VTE, older age
risk factors for bleeding include older age, female gender, diabetes, hypertension, cancer,
alcoholism, liver disease, severe chronic kidney disease, peptic ulcer disease, anemia, prior stroke or
intracerebral hemorrhage, active bleeding lesions, bleeding disorder, poor treatment adherence; and
use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelet medications, antibiotics,
statins, fibrates, and steroids
use pharmacologic prophylaxis for VTE with heparin or a related medication in medical patients
(including patients with stroke) unless risk for bleeding outweighs likely benefits (ACP Strong
recommendation, Moderate-quality evidence)
mechanical prophylaxis with graduated compression stockings for prevention of VTE not recommended
(ACP Strong recommendation, Moderate-quality evidence) but intermittent pneumatic compression may
be reasonable in patients at high risk of bleeding and in whom heparin is contraindicated
Reference - ACP guideline on VTE prophylaxis in hospitalized patients (Ann Intern Med 2011 Nov
1;155(9):625)
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Canadian Stroke Best Practice Recommendations (CSBPR)
anticoagulation for VTE prophylaxis may be warranted in patients where risk of thromboembolism is
greater than risk of hemorrhagic transformation of stroke including
complete paralysis of leg
previous history of VTE
dehydration
comorbid conditions including malignancy
current or recent smoker
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Reference - NICE 2008 Jul:CG68 PDF, summary can be found in BMJ 2008 Jul 24;337:a786,
commentary can be found in BMJ 2008 Jul 24;337:a833, BMJ 2008 Aug 18;337:a1339
heparin for venous thromboembolism prophylaxis in patients with acute stroke appears to increase
risk for major bleeding, might reduce risk for pulmonary embolism, and does not appear to affect
mortality (level 2 [mid-level] evidence)
based on systematic review of trials with methodologic limitations
systematic review of 40 randomized trials evaluating interventions for thromboembolism
prophylaxis in hospitalized adult medical patients and patients with stroke
14 trials evaluated pharmacologic prophylaxis in patients with acute stroke
8 trials compared heparin prophylaxis vs. no heparin
5 trials compared low-molecular-weight heparin (LMWH) vs. unfractionated heparin (UFH)
1 trial compared LMWH vs. calf compression leggings
all 14 trials lacked either adequate allocation concealment or intention-to-treat analysis
follow-up ranged from 9 days to 6 months
comparing heparin to no heparin in patients with acute stroke
no significant differences in
mortality (odds ratio [OR] 0.91, 95% CI 0.7-1.18) in analysis of 8 trials with 15,405
patients
symptomatic deep vein thrombosis (DVT) (0% vs. 0.95%) based on 1 event in 1 trial
with 206 patients
any bleeding (OR 0.95, 95% CI 0.55-1.63) in analysis of 6 trials with 9,266 patients
nonsignificant trend toward reduction in pulmonary embolism (OR 0.72, 95% CI 0.5-1.04, p
= 0.08) in analysis of 5 trials with 14,862 patients
heparin associated with increased risk of major bleeding events in analysis of 8 trials with
15,405 patients
OR 1.66 (95% CI 1.2-2.28)
NNT 90-575 with major bleeding event in 0.88% patients not receiving heparin
comparing LMWH vs. UFH in patients with acute stroke
no significant differences in
mortality in analysis of 5 trials with 2,785 patients
pulmonary embolism (OR 0.57, 95% CI 0.25-1.34) in analysis of 4 trials with 2,698
patients
any bleeding in analysis of 5 trials with 2,785 patients
major bleeding (OR 1.49, 95% CI 0.73-3.06) in analysis of 5 trials with 2,785 patients
LMWH associated with trend toward decreased risk of symptomatic DVT (OR 0.34, 95% CI
0.11-1) in analysis of 2 trials with 1,974 patients
Reference - Ann Intern Med 2011 Nov 1;155(9):602
LMWH in patients with acute stroke may reduce risk for DVT and pulmonary embolism (level 3
[lacking direct] evidence) but increase risk for extracranial bleeding (level 2 [mid-level] evidence)
based on systematic review with limited trial quality assessment and limited data on symptomatic
thromboembolism outcomes
systematic review of 10 randomized trials of LMWH vs. placebo or open control in adults within 7
days of stroke onset
trials with active comparators (such as UFH or aspirin) were excluded
LMWH associated with significant reduction in
DVT in analysis of 9 trials with 2,765 patients (OR 0.4, 95% CI 0.18-0.91)
pulmonary embolism in analysis of 9 trials with 2,528 patients (OR 0.34, 95% CI 0.17-0.69)
LMWH associated with significant increase in extracranial bleeding in analysis of 8 trials with
2,666 patients (OR 2.17, 95% CI 1.1-4.28)
no statistically significant differences in meta-analyses of
case fatality (9 trials)
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based on systematic review without assessment of trial allocation concealment or full intention-to-
treat analysis, and without reporting clinical outcomes specific to patients with stroke
systematic review of 4 randomized trials evaluating enoxaparin 4,000 units subcutaneously once
daily vs. UFH 5,000 units subcutaneously 2-3 times daily in 3,600 acutely ill medical patients
(median age 71 years)
2 trials included 1,974 patients within 48 hours of stroke onset, 2 trials included 1,626 patients of
mixed populations (only 71 with stroke)
although data combined in individual patient data meta-analysis and statistical heterogeneity not
apparent it appears that results are different in patients with stroke and patients without stroke
comparing enoxaparin vs. UFH
incidence of any VTE at 15 days 11.7% vs. 19.9% (p < 0.05, NNT 13) in 1 trial with 1,762
patients with stroke
incidence of any VTE at 15 days 19.5% vs. 33.3% (p < 0.05, NNT 8) in 1 trial with 212
patients with stroke
low incidence of VTE and no significant differences in 1,555 patients without stroke
in overall meta-analysis enoxaparin reported to be associated with reduced risks for
symptomatic VTE (risk ratio [RR] 0.38, 95% CI 0.17-0.85, NNT 143 [as reported by
authors])
symptomatic pulmonary embolism (RR 0.37, 95% CI 0.13-1.02)
proximal VTE (RR 0.53, 95% CI 0.36-0.78)
results not reported stratified by stroke for any of these analyses
no significant differences in all-cause mortality, major bleeding, or intracranial hemorrhage
Reference - J Thromb Haemost 2011 Mar;9(3):464
Mechanical compression
intermittent pneumatic compression may reduce risk for deep vein thrombosis (DVT) in acute
stroke (level 2 [mid-level] evidence)
based on randomized trial and Cochrane review of limited evidence
intermittent pneumatic compression appears to reduce risk of DVT after acute stroke (level 2
[mid-level] evidence)
based on randomized trial with incomplete blinding of outcome assessors
2,876 immobile patients (median age 76 years) with acute stroke within 3 days were
randomized to intermittent pneumatic compression (IPC) for ≥ 30 days vs. no IPC and
followed for 6 months
IPC applied continuously, except during washing, physical therapy, and compression duplex
ultrasound
IPC discontinued early if patient became independently mobile, was discharged from hospital,
declined to continue IPC, or had adverse effects
median duration of IPC use 9 days in IPC group (31% used IPC every day)
primary outcome was composite of DVT in proximal veins detected by ultrasound or
symptomatic DVT in proximal veins within 30 days
clinicians were instructed to ignore allocated treatment when making decisions about use of
antithrombotic drugs
blinding of ultrasound technicians was incomplete due to some patients wearing IPC when
attending ultrasound
comparing IPC vs. no IPC at 30 days
primary outcome in 8.5% vs. 12.1% (p < 0.05, NNT 28)
symptomatic proximal or calf DVT in 4.6% vs. 6.3% (p = 0.045, NNT 59)
asymptomatic proximal DVT in 5.8% vs. 8.7% (p = 0.003)
death in 10.8% vs. 13.1% (p = 0.057)
comparing IPC vs. no IPC at 6 months
any symptomatic DVT in 5.4% vs. 7% (p = 0.061)
any DVT in 16.7% vs. 25.1% (p = 0.001, NNT 12)
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DVT evaluated by compression Doppler ultrasound of both legs between day 7 and 10, and if
possible, at day 25-30 (conducted by blinded technician)
compliance was 79.4% at day 14 and 73.1% at day 30
comparing graduated compression stocking vs. control at 30 days
symptomatic DVT (proximal or distal) in 4.4% vs. 4.8% (not significant)
symptomatic proximal DVT in 2.9% vs. 3.4% (not significant)
asymptomatic proximal DVT in 7.2% vs. 7.1% (not significant)
any DVT (proximal or distal) in 16.3% vs. 17.7% (not significant)
any DVT or pulmonary embolism in 17% vs. 18.4% (not significant)
skin breaks, ulcers, blisters, and skin necrosis in 5.1% vs. 1.3% (p < 0.05, NNH 26)
Reference - CLOTS trial 1 (Lancet 2009 Jun 6;373(9679):1958 full-text), editorial can be
found in Lancet 2009 Jun 6;373(9679):1923, commentary can be found in Lancet 2009 Oct
3;374(9696):1143
DynaMed commentary -- adverse effect reporting not blinded to treatment allocation
thigh-length compression stockings may reduce risk of proximal DVT compared to below-knee
stockings in patients with stroke (level 3 [lacking direct] evidence)
based on randomized trial with incomplete blinding and without differences in symptomatic
outcomes
3,114 hospitalized, immobile patients with acute stroke were randomized to thigh-length vs. below-
knee compression stockings for up to 30 days
75% wore stockings for 30 days or until discharge, death, or regained mobility
2,812 patients (96% of survivors) had ultrasound at 7-10 days after enrollment, 1,282 patients (87%
of survivors) had ultrasound at 25-30 days
ultrasonographers were blinded
comparing thigh-length vs. below-knee stockings
proximal DVT in 6.3% vs. 8.8% (p = 0.008, NNT 40)
asymptomatic proximal DVT in 3.2% vs. 4.8% (p = 0.02, NNT 63)
symptomatic proximal DVT in 3.2% vs. 4% (not significant)
any DVT or pulmonary embolism in 12.1% vs. 14.1% (not significant)
Reference - CLOTS trial 2 (Ann Intern Med 2010 Nov 2;153(9):553), correction can be found in
Ann Intern Med 2010 Dec 20;153(12):851, editorial can be found in Ann Intern Med 2010 Nov
2;153(9):610
Cerebral edema
patients with major infarctions are at high risk for complicating brain edema (AHA/ASA Class I, Level C-
LD )(1)
take measures to reduce risk of edema and closely monitor for signs of neurologic worsening during
first days after stroke
if high risk of malignant brain edema, consider early transfer to institution with neurosurgical
expertise
consider
elevating head 20-30 degress to aid venous drainage(6)
brief moderate hyperventilation (PCO2 target 30-34 mm Hg) as bridge to more definitive therapy if
acute severe neurological decline from brain swelling (AHA/ASA Class IIa, Level C-EO)(1)
osmotic therapy if clinical decline from infarction-associated cerebral swelling (AHA/ASA Class
IIa, Level C-LD)(1)
correcting factors that may exacerbate edema such as hypoxemia, hypercarbia, and hyperthermia(6)
avoiding excess glucose administration(6)
avoiding antihypertensive agents that induce cerebral vasodilatation(6)
surgery for select patients (see Decompressive surgery section for additional information)
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aggressive medical measures have unclear usefulness for deteriorating patients with malignant brain
edema after large cerebral infarction (AHA/ASA Class IIb, Level C)(6)
theapies to avoid in patients with edema due to ischemic stroke
hypothermia due to limited evidence (AHA/ASA Class III: No benefit, Level B-R)(1)
barbiturates due to limited evidence (AHA/ASA Class III: No benefit, Level B-R)(1)
corticosteroids (conventional or large doses) due to increased risk of infection (AHA/ASA Class III:
Harm, Level A)(1)
also see Management of elevated intracranial pressure topic
give vasopressors to improve cerebral blood flow in exceptional cases with systemic hypotension
producing neurological sequelae; if used, close neurological and cardiac monitoring recommended
(AHA/ASA Class I, Level C)(6)
treatments which are not well established for patients with acute ischemic stroke
devices to augment cerebral blood flow (AHA/ASA Class IIb, Level B-R )(1)
drug-induced hypertension (AHA/ASA Class IIb, Level B)(6)
therapies to avoid in patients with ischemic stroke(1)
hemodilution by volume expansion (AHA/ASA Class III No Benefit, Level A )
vasodilatory agents such as pentoxifylline (AHA/ASA Class III No Benefit, Level A )
high dose albumin (AHA/ASA Class III No Benefit, Level A)
induced hypothermia has unclear benefit for ischemic stroke and should only be offered in the context of
ongoing clinical trials (AHA/ASA Class IIb, Level BR)(1)
transcranial near-infrared laser therapy is not recommended for acute ischemic stroke (AHA/ASA Class
III: No Benefit, Level B-R)(1)
acupuncture starting within 30 days of stroke onset might reduce risk of death or institutionalization (level
2 [mid-level] evidence)
external counterpulsation may improve neurological impairment in patients with acute ischemic stroke
(level 2 [mid-level] evidence)
hemodilution within 72 hours of onset of acute ischemic stroke may not reduce mortality (level 2 [mid-
level] evidence)
insufficient evidence to support use of hyperbaric oxygen therapy or stem cell transplantation
see Alternative and experimental therapies for acute stroke for additional information
Follow-up
before discharging patient from acute care, provide a formal assessment of activities of daily living and
instrumental activities of daily living, communication abilities, and functional mobility; the findings can
be incorporated into the care transition and the discharge planning process (AHA/ASA Class I, Level B-
NR)(1)
if residual functional deficits are present, an expert in rehabilitation should conduct a functional
assessment (AHA/ASA Class I, Level C-LD)(1)
also see topics
Stroke rehabilitation in adults
Long-term management of stroke
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upper limit of time to treatment ranged from 3 to 7 hours in 7 studies (not specified in 3
studies)
23.3% of patients had cerebral microbleeds before thrombolysis, and 5% had
symptomatic ICH after thrombolysis
compared to no cerebral microbleeds, presence of any cerebral microbleeds associated
with increased risk of symptomatic ICH
after any thrombolysis regimen (odds ratio 2.26, 95% CI 1.46-3.49) in analysis of
all studies
after IV tPA (odds ratio 2.87, 95% CI 1.76-4.69) in analysis of 8 studies with
1,704 patients
Reference - Neurology 2015 Sep 15;85(11):927 full-text, editorial can be found in
Neurology 2015 Sep 15;85(11):925
seizures reported in < 10% patients after ischemic infarction, but may have increased incidence after
hemorrhagic transformation(6)
pneumonia
leading complication of stroke and important cause of poststroke mortality(6)
most likely to occur in seriously ill patients
prevention of early aspiration and protection of airway may decrease risk
may include aspiration pneumonia and nosocomial pneumonia
2 2
A DS score predicts in-hospital pneumonia after acute ischemic stroke (level 1 [likely reliable]
evidence)
Pneumonia in Stroke Consensus Group recommendation on diagnosis of stroke-associated
pneumonia
stroke-associated pneumonia preferred term for spectrum of pneumonia complicating the first
7 days after stroke in non-ventilated patients
if patient on ventilator and develops pneumonia, it should be called ventilator-
associated pneumonia
if patient develops pneumonia > 7 days after stroke, it should be called hospital-
acquired pneumonia
criteria for pneumonia
≥ 1 of the following must be met
fever (> 38 °C) with no other recognized cause
leukopenia (< 4,000 white blood cells (WBC)/mm3 ) or leukocytosis (> 12,000
WBC/mm3)
for adults ≥ 70 years old, altered mental status with no other recognized cause
≥ 2 of the following must be met
new onset of purulent sputum, or change in character of sputum over a 24 hour
period, or increased respiratory secretions, or increased suctioning requirements
new onset or worsening cough, or dyspnea, or tachypnea (respiratory rate >
25/min)
rales, crackles, or bronchial breath sounds
worsening gas exchange (such as oxygen desaturation or increased oxygen
requirements)
probable stroke-associated pneumonia if criteria met but typical chest x-ray changes
absent even after repeat or serial chest x-rays
definite stroke-associated pneumonia if criteria met and typical chest x-ray changes
present
Reference - Stroke 2015 Aug;46(8):2335 full-text
cardiac complications
increased risk of cardiac complications with large deficits and infarctions of right hemisphere(6)
may include(6)
myocardial ischemia
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Prognosis
Mortality
mortality 58% in patients with stroke in United States between 1987 and 2011
based on prospective cohort study
14,357 adults aged 45-64 years without stroke at baseline in Atherosclerosis Risk in Communities
study were followed for up to 25 years (median 22.5 years)
1,051 persons (7%) had incident stroke (929 had ischemic stroke, 140 had hemorrhagic stroke) over
282,097 person-years of follow-up
mortality at end of follow-up by type of stroke
58% for total stroke
57% for ischemic stroke
68% for hemorrhagic stroke
age-adjusted mortality after stroke decreased over time in adults < 65 years old (adjusted hazard
ratio per 10-year period 0.65, 95% CI 0.46-0.93), but no significant difference in adults ≥ 65 years
old
Reference - JAMA 2014 Jul 16;312(3):259, editorial can be found in JAMA 2014 Jul 16;312(3):237
stroke-related mortality decreased in United States between 1972 and 2002
age-standardized death rate in United States from stroke was
151.9 per 100,000 in 1970
56.1 per 100,000 in 2002 (with stroke as third leading cause of death)
Reference - JAMA 2005 Sep 14;294(10):1255, commentary can be found in JAMA 2006 Jan
25;295(4):383
stroke became fourth leading cause of death in United States, based on final data from 2008, after
more than 50 years as the third leading cause of death (National Vital Statistics Report 2011 Dec 7
PDF)
cerebrovascular disease caused 134,148 deaths in United States in 2008, with death rate 44.1 per
100,000 population (National Vital Statistics Report 2011 Dec 7 PDF)
cerebrovascular disease caused 167,661 deaths in United States in 2000, with death rate 60.9 per
100,000 population (JAMA 2004 Mar 10;291(10):1238), correction can be found in JAMA 2005
Jan 19;293(3):293, JAMA 2005 Jan 19;293(3):298, editorial can be found in JAMA 2004 Mar
10;291(10):1263, commentary can be found in JAMA 2004 Jun 23;291(24):2941
in-hospital mortality
4.9% in-hospital mortality
based on cohort of 13,440 patients with ischemic stroke admitted to 104 hospitals in Germany
independent risk factors in men and women were older age, number of neurological deficits,
and atrial fibrillation
additional independent risk factors in men were diabetes and previous stroke
complications were associated with substantially higher in-hospital mortality including
increased intracranial pressure (53% mortality)
pulmonary embolism (47% mortality)
pneumonia (30% mortality)
seizure (19% mortality)
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Neurologic morbidity
deterioration after initial stroke assessment is common (occurring in 25% patients) and due to(6)
stroke progression in 33% cases
brain edema in 33% cases
recurrent ischemia in 11% cases
hemorrhage in 10% cases
ischemic brain edema may include(6)
cytotoxic edema which normally peaks 3-4 days after injury
accelerated edema (malignant edema) with early reperfusion to large volume of necrotic tissue - can
be life-threatening within first 24 hours
edema can produce clinically significant increased intracranial pressure
symptomatic hemorrhagic transformation of ischemic infarction occurs in 5%-6% patients after use of IV
recombinant tissue-type plasminogen activator (rt-PA), usually within first 24 hours(6)
seizures reported in < 10% patients after ischemic infarction, but may have increased incidence after
hemorrhagic transformation(6)
death, dependence or institutionalization 3 months after stroke in 41.3%
based on cohort study of 2,034 patients with first-ever-lifetime stroke from European Registers of
Stroke Collaboration
Reference - Neurology 2011 Jan 11;76(2):159
highest incidence of stroke recurrence may be in first year after first stroke
based on prospective cohort study
1,626 patients having first time stroke were followed for median 432 days
first stroke type
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chronic pain syndromes appear common following ischemic stroke and are associated with
increased functional dependence
based on cohort analysis of data from PRoFESS trial
15,754 patients with ischemic stroke without history of chronic pain prior to stroke were followed
for mean 2.5 years
new chronic pain syndromes reported in 10.6% overall
central pain in 2.7%
peripheral neuropathic pain in 1.5%
pain from spasticity in 1.3%
pain from shoulder subluxation in 0.9%
new chronic pain syndromes associated with increased functional dependence (odds ratio 2.16, 95%
CI 1.8-2.6)
neuropathic pain and shoulder pain each associated with increased incidence of cognitive decline
Reference - Stroke 2013 May;44(5):1238 full-text
spasticity 10 days after stroke may help predict spasticity at 1 year in adults having first stroke
(ischemic or hemorrhagic) (level 2 [mid-level] evidence)
based on cohort study
117 adults who had first stroke (ischemic or hemorrhagic) and documented arm paresis 3 days after
stroke were assessed for spasticity at baseline, days 3 and 10, week 4, and month 12
65% of patients were available for assessment at 12 months
spasticity assessed on modified Ashworth Scale (MAS) where MAS ≥ 1 was any spasticity and
MAS ≥ 2 was severe spasticity
poststroke spasticity
at 3 days, spasticity in 24%
at 10 days, spasticity in 43%
at 4 weeks, spasticity in 46%
at 12 months, spasticity in 46% and severe spasticity in 29%
for prediction of spasticity at 12 months, reduced sensorimotor function at
10 days poststroke had 85% sensitivity and 90% specificity for any or severe spasticity
4 weeks poststroke had 91% sensitivity and 92% specificity for severe spasticity
Reference - Neurology 2015 Sep 8;85(10):873 full-text, editorial can be found in Neurology 2015
Sep 8;85(10):878
modified Rankin Scale
0 - no symptoms
1 - no significant disability despite symptoms; able to perform all usual activities
2 - slight disability; not able to do all previous activities but can look after self without assistance
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3 - moderate disability; requiring some help, but able to walk without assistance
4 - moderately severe disability; unable to walk without assistance and unable to attend to own
bodily needs without assistance
5 - severe disability; bedridden, incontinent, and requiring constant nursing care and attention
Reference - Stroke 1988 May;19(5):604
systematic review which questions interobserver reliability of modified Rankin Scale score can be
found in Stroke 2009 Oct;40(10):3393
Prognostic tools
baseline NIHSS score may help predict likelihood of good recovery or severe disability at 7
days and 6 months after stroke (level 2 [mid-level] evidence)
based on retrospective validation cohort study
1,268 patients within 24 hours of onset of acute stroke had NIHSS score calculated
each additional NIHSS point associated with decreased likelihood of excellent outcomes by
24% at 7 days and by 17% at 3 months
Reference - Neurology 1999 Jul 13;53(1):126
Acute Stroke Registry and Analysis of Lausanne (ASTRAL) score
high ASTRAL score at admission helps predict unfavorable outcome at 3 months after acute
ischemic stroke (level 1 [likely reliable] evidence)
based on prospective cohort study with independent derivation and validation cohorts
derivation cohort included 1,645 patients (mean age 62 years) with acute ischemic stroke and
mean NIHSS score at admission 8.9 points from Acute Stroke Registry and Analysis of
Lausanne (ASTRAL) database
34% had unfavorable outcome (modified Rankin Scale score > 2) at 3 months
ASTRAL score was derived using risk factors significantly associated with unfavorable
outcome at 3 months in derivation cohort
age = 1 point for every 5 years counted from 0
severity = 1 point for every NIHSS point
time delay from onset to admission > 3 hours = 1 point
any stroke related visual field defect = 2 points
acute glucose < 3.7 mmol/L or > 7.3 mmol/L = 1 point
level of consciousness decreased = 3 points
ASTRAL score cutoff of 31 points corresponded to 50% risk of unfavorable outcome in
derivation cohort
validation cohorts were
1,659 patients (mean age 70 years, mean NIHSS score 9.2) with acute ischemic stroke
from Athens registry, of whom 39% had unfavorable outcome
653 patients (mean age 65 years, mean NIHSS score 5.3) with acute ischemic stroke
from Vienna registry, of whom 21% had unfavorable outcome
performance of ASTRAL score with cutoff of 31 points for prediction of unfavorable
outcome at 3 months in validation cohorts
in Athens registry cohort
sensitivity 77.5%
specificity 93.5%
positive likelihood ratio 11.9
in Vienna registry cohort
sensitivity 26.7%
specificity 96.5%
positive likelihood ratio 7.8
Reference - Neurology 2012 Jun 12;78(24):1916
ASTRAL score predicts unfavorable outcome at 3 and 12 months after acute ischemic
stroke(level 1 [likely reliable] evidence)
based on prognostic validation cohort study
3,755 patients (mean age 67 years, 39.6% women) with acute ischemic stroke and mean
NIHSS score at admission 8.1 points from China National Stroke Registry (CNSR) database
incidence of unfavorable outcome (modified Rankin Scale score > 2) was
39.7% (1,473 patients) at 3 months
38.3% (1,349 patients) at 12 months
ASTRAL score of 26 points corresponded to 50% incidence of unfavorable outcome and
score of 31 corresponded to about 75% incidence
ASTRAL score had good discrimination for predicting unfavorable outcome at 3 and 12
months (C-statistic 0.82 for each timepoint)
Reference - Stroke 2013 May;44(5):1443
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ASTRAL score predicts unfavorable outcome and mortality at 5 years in patients with acute
ischemic stroke (level 1 [likely reliable] evidence)
based on validation cohort study
1,520 patients (median age 72 years) with first acute ischemic stroke were assessed with
ASTRAL score and followed for 5 years
each 1-point increase in ASTRAL score associated with increased risk of
5-year unfavorable functional outcome (modified Rankin Scale score 3-6) (hazard ratio
1.09, 95% CI 1.08-1.1)
5-year mortality (hazard ratio 1.09, 95% CI 1.08-1.1)
mean survival at 5 years
57.4% in first ASTRAL score quartile
53% in second ASTRAL score quartile
46% in third ASTRAL score quartile
27.3% in fourth ASTRAL score quartile
Reference - Stroke 2013 Jun;44(6):1616
5-item risk score may predict poor outcome 30 days after cortical middle cerebral artery territory
infarction (level 2 [mid-level] evidence)
based on derivation and validation cohort study with unclear analysis of validation cohort
derivation cohort was 129 patients with unilateral hemispheric infarct within middle cerebral artery
territory > 15 mm in diameter who had diffusion-weighted magnetic resonance imaging (MRI)
within 48 hours of symptom onset at one institution
validation cohort was 74 patients with cortical middle cerebral artery infarct in DEFUSE trial
registry, using diffusion-perfusion weighted MRI done 3-6 hours after IV thrombolysis
poor outcome defined as modified Rankin Scale score > 2 at 30 days
risk factors significantly associated with poor outcome in derivation cohort and points assigned to
derive risk score (total score 0-9 points)
infarct volume - 0 points if 0-20 cm3, 1 point if 21-50 cm3, 2 points if 51-99 cm3, 3 points if ≥
100 cm3
admission National Institutes of Health Stroke Scale (NIHSS) score - 0 points if 0-5 points, 1
point if 6-14 points, 2 points if ≥ 15 points
age - 0 points if < 50 years old, 1 point if 51-79 years, 2 points if ≥ 80 years old
admission white blood cell count - 0 points if < 8,500/mm3, 1 point if > 8,500/mm3
hyperglycemia - 0 points if no, 1 point if yes
observed rate of poor outcome in derivation cohort
Results:
Stroke Risk Score Poor Outcome
0-2 points 8%
3-4 points 51%
5-9 points 91%
risk score appears to be less accurate in validation cohort, but results in validation cohort only
reported as 83% sensitivity and 86% specificity (so results of applying specific scores unclear)
Reference - Stroke 2011 Mar;42(3):645
Totaled Health Risks in Vascular Events (THRIVE) score for predicting mortality after acute stroke
THRIVE score predicts mortality at 3 months after acute stroke (level 1 [likely reliable]
evidence)
based on validation cohort study
5,724 patients from Virtual International Stroke Trials Archive (VISTA) were evaluated with
THRIVE score
THRIVE score (total score 0-9 points) previously derived in patients receiving endovascular
treatment for stroke
age = 1 point for 60-79 years and 2 points for ≥ 80 years
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National Institutes of Health Stroke Scale (NIHSS) = 2 points for score 11-20 and 4
points for score ≥ 21
hypertension = 1 point
diabetes = 1 point
atrial fibrillation = 1 point
each 1-point increase in THRIVE score associated with
increased mortality at 3 months (odds ratio [OR] 1.57, 95% CI 1.5-1.64)
decreased risk of good functional outcome (modified Rankin Scale score 0-2) at 3
months (OR 0.55, 95% CI 0.53-0.57)
mortality at 3 months by THRIVE score (estimated from figure)
4% for score 0-2
15% for score 3-5
33% for score 6-9
THRIVE score had significantly greater predictive performance for 3-month mortality
compared to each of Houston Intra-Arterial Therapy (HIAT) score, HIAT2 score, and Stroke
Prognostication using Age and NIHSS (SPAN-100) score
online calculator can be found at THRIVE Score Calculator
Reference - Stroke 2013 Dec;44(12):3365
increasing THRIVE score associated with poor outcome at 3 months following cardioembolic
and noncardioembolic ischemic stroke (level 2 [mid-level] evidence)
based on retrospective cohort study in China
3,879 patients with acute ischemic stroke who did not receive thrombolytic therapy were
analyzed
505 patients had cardioembolic stroke
3,374 patients had noncardioembolic stroke
patients with cardioembolic stroke were more likely to be women, older, and with higher
National Institutes of Health Stroke Scale (NIHSS) score
mortality 19.4% in patients with cardioembolic stroke and 6.2% in patients with
noncardioembolic stroke
at 3 months, increasing THRIVE score associated with (per 1-point increase)
decreased chance of good outcome (defined as modified Rankin Scale score 0-2) (odds
ratio [OR] 0.59, 95% CI 0.51-0.67) in patients with cardioembolic stroke
decreased chance of good outcome (OR 0.53, 95% CI 0.49-0.57) in patients with
noncardioembolic stroke
increased mortality (OR 1.48, 95% CI 1.28-1.7) in patients with cardioembolic stroke
increased mortality (OR 1.95, 95% CI 1.76-2.16) in patients with noncardioembolic
stroke
Reference - Stroke 2014 Jun;45(6):1689
Get With The Guidelines (GTWG)-Stroke Program for predicting risk of in-hospital mortality
GTWG-Stroke Program risk prediction tool predicts in-hospital mortality (level 1 [likely
reliable] evidence)
based on cohort of 274,988 ischemic stroke patients admitted to 1,036 hospitals 2001-2007
cohort randomly divided into derivation sample (164,993 patients, 60%) and validation
sample (109,995 patients, 40%)
in-hospital mortality 5.51%
total point score derived from
age - 9 points if 60-70 years, 17 points if 70-80 years, 28 points if ≥ 80 years
mode of arrival to hospital - 70 points if ambulance from scene, 68 points if not
presenting to emergency department
presence of
atrial fibrillation 27 points
coronary artery disease 11 points
peripheral vascular disease 12 points
diabetes mellitus 4 points
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higher-risk classification with either CHADS2 or CHA2DS2-VASc also associated with increasing
risk of
stroke recurrence (p < 0.01 for trend for each)
cardiovascular events (p < 0.001 for trend for each)
Reference - Neurology 2013 Mar 12;80(11):1009
SOAR score
SOAR score predicts in-hospital and 7-day mortality after acute stroke (level 1 [likely reliable]
evidence)
based on validation cohort study
3,547 patients with acute stroke (92% ischemic) were assessed
SOAR score previously derived in independent derivation cohort and based on 4 risk factors
(total score 0-7)
1 point if hemorrhagic stroke
age
1 point if 66-85 years
2 points if > 85 years old
Oxfordshire Community Stroke Project Classification
1 point if posterior circulation stroke
2 points if total anterior circulation stroke
prestroke modified Rankin Scale stroke score
1 point if modified Rankin Scale stroke score is 3-4 points
2 points if modified Rankin Scale stroke score is 5 points
in-hospital and 7-day mortality by SOAR score
SOAR Score Number of Patients Inpatient Mortality 7-day Mortality
0 points 346 1.45% 0.20%
1 point 1,201 4.75% 1.33%
2 points 887 9.36% 2.82%
3 points 611 23.08% 8.84%
4 points 318 47.46% 19.5%
5 points 151 58.94% 32.45%
6 points 33 63.64% 21.21%
predictive performance of SOAR score with cutoff 3 points
for in-hospital mortality, sensitivity 73.5% and specificity 76.3%
for 7-day mortality, sensitivity 80.37% and specificity 71.8%
Reference - Stroke 2013 Jul;44(7):2010
modified SOAR score including National Institutes of Health Stroke Scale to SOAR predicts
90-day mortality following acute stroke (level 1 [likely reliable] evidence)
based prognostic cohort study with independent derivation and validation cohorts
derivation cohort included 1,002 patients (median age 78 years) with acute stroke (93%
ischemic stroke)
inpatient mortality 10.5% during median 9 day hospital stay in derivation cohort
modified-SOAR (mSOAR) incorporated baseline National Institutes of Health Stroke Scale
(NIHSS) score into SOAR score
NIHSS score 5-10 = 1 point
NIHSS score ≥ 11 = 2 points
validation cohort included 1,012 similar patients (median age 71 years, 91% with ischemic
stroke)
90-day mortality 12% in validation cohort
inpatient mortality in derivation cohort and 90-day mortality in validation cohort by mSOAR
score
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mortality and severe dependence by PLAN score in validation cohort (estimated from figures)
Death or Severe
Total Score 30-day Mortality Dependence at 1-year Mortality
Discharge
< 6 points 1% 1% 2%
6-9 points 2% 2% 8%
10-12 points 8% 10% 20%
13-15 points 22% 29% 38%
16-19 points 46% 55% 65%
20-25 points 70% 79% 83%
Reference - Arch Intern Med 2012 Nov 12;172(20):1548, editorial can be found at Arch Intern Med
2012 Nov 12;172(20):1536
risk prediction in patients having endovascular treatment
Houston Intra-Arterial Therapy 2 score (HIAT2) predicts poor outcome in patients with acute
ischemic stroke after intra-arterial therapy for anterior circulation large artery occlusion
(level 1 [likely reliable] evidence)
based on prognostic cohort study with independent derivation and validation cohorts
derivation cohort included 163 patients (median age 66 years) with acute ischemic stroke who
had intra-arterial therapy for anterior circulation large artery occlusion
validation cohort included 198 similar patients (median age 65 years)
72% in derivation cohort and 59% in validation cohort had poor outcome at discharge
(modified Rankin Scale score 4-6 points)
Houston Intra-Arterial Therapy 2 (HIAT2) score derived using factors associated with poor
outcome (total score 0-10 points)
2 points if age 60-79 years, 4 points if ≥ 80 years old
1 point if NIHSS score = 11-20, 2 points if NIHSS score ≥ 21
1 point if admission blood glucose ≥ 150 mg/dL
3 points if Alberta Stroke Program Early CT Score ≤ 7
rates of poor outcome at hospital discharge in derivation and validation cohorts by HIAT2
score
57.6% and 40.4% for 0-4 points
87.7% and 78.4% for 5-7 points
100% and 88.2% for 8-10 points
HIAT2 score had consistent performance for predicting poor outcome at 90 days and after
adjusting for recanalization, time from symptom onset to reperfusion, general anesthesia use,
and stent retriever use
Reference - Stroke 2013 Dec;44(12):3324, correction can be found in Stroke 2013
Dec;44(12):e240
Pittsburgh Outcomes After Stroke Thrombectomy (POST) score predicts good outcome at 90
days in patients with anterior circulation large vessel occlusion stroke having endovascular
therapy (level 1 [likely reliable] evidence)
based on prognostic study with independent derivation and validation cohorts
derivation cohort included 247 adults with anterior circulation large vessel occlusion stroke
having endovascular therapy within 8 hours
good outcome defined as modified Rankin Scale (mRS) score 0-2 at day 90
Pittsburgh Outcomes After Stroke Thrombectomy (POST) score derived from clinical and
imaging factors significantly associated with good outcome
POST score = age + (0.5 × final infarct volume) + 15 if parenchymal hematoma types 1 or 2
present
validation cohort 1 included 393 similar patients from University of Pittsburgh Medical
Center endovascular stroke registry and validation cohort 2 included 105 similar patients from
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A2DS2 score predicts in-hospital pneumonia after acute ischemic stroke (level 1 [likely reliable]
evidence)
based on prospective cohort study with independent derivation and validation cohorts
derivation cohort included 15,335 patients (mean age 71 years) with acute ischemic stroke, and
validation cohort included 45,085 patients (mean age 72 years) with acute ischemic stroke
rates of in-hospital pneumonia were 7.2% in derivation cohort and 7.8% in validation cohort
A2DS2 score derived using factors significantly associated with incidence of pneumonia in
derivation cohort (total score 0-10 points)
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Risk of In-hospital
Risk Category Validation Cohort
Pneumonia*
Very low risk Internal 3.6%-4.6%
Prognostic factors
Clinical factors
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2,785 patients with first-ever acute stroke had clinical evaluation on admission, at 1 week and yearly
for up to 10 years
mean follow-up 47 months
40.9% were normal weight (body mass index [BMI] < 25 kg/m2), 41% were overweight (BMI 25-
29.9 kg/m2) and 18.1% were obese (BMI ≥ 30 kg/m2) on admission
no significant differences in National Institutes of Health Stroke Scale on admission
1-week survival (p < 0.0001)
90.2% for normal weight
92.8% for overweight
96.4% for obese
10-year survival (p < 0.0001)
41.5% for normal weight
47.4% for overweight
52.5% for obese
Reference - Stroke 2011 Jan;42(1):30
undernutrition at admission may predict poststroke complications and poor outcome at 3 months in
patients with acute ischemic stroke
based on prospective cohort study
131 patients (mean age 64.8 years) with acute ischemic stroke patients had nutrition assessment
within 24 hours and 1 week after symptom onset
undernutrition observed in 16 (12.2%) patients at admission and in 26 (19.8%) at 1 week
undernutrition predicted poor outcomes
undernutrition at admission independently predicted poststroke complications (odds ratio
[OR] 6.72, 95% CI 1.09-41.56, p = 0.04)
undernutrition at 1 week independently predicted poor 3-month outcomes (OR 4.49, 95% CI
1.07-18.94, p = 0.04)
1-week National Institutes of Health Stroke Scale (NIHSS) score independently predicted
poor 3-month outcomes (OR 1.76, 95% CI 1.31-2.37, p < 0.001)
Reference - Arch Neurol 2008 Jan;65(1):39, editorial can be found in Arch Neurol 2008
Jan;65(1):15
side of hemispheric stroke may not affect mortality
based on cohort study
1,644 placebo-treated patients from 3 clinical trials with documented hemispheric lateralization
were evaluated
no significant differences at 90 days comparing left hemisphere vs. right hemisphere stroke in
mortality (22.1% vs. 19.5%)
cardiac adverse events
Reference - Stroke 2008 Dec;39(12):3335
factors associated with increased mortality in patients with severe stroke
based on case-control study
188 patients who died of severe stroke were compared to 188 stroke survivors in same neurological
intensive care unit
among patients who died, 58% had hemorrhagic stroke, 33% had ischemic stroke, and 9% had
mixed stroke
factors associated with increased mortality in patients with stroke
brain herniation (odds ratio [OR] 18.15, 95% CI 2.17-151.91)
multiple organ failure (OR 13.12, 95% CI 2.66-64.67)
dyslipidemia (OR 4.64, 95% CI 1.75-12.32)
community-acquired lung infection (OR 4.15, 95% CI 2.35-7.32)
use of mechanical ventilation (OR 3.37, 95% CI 1.97-5.75)
hypoproteinemia (OR 2.29, 95% CI 1.08-4.84)
history of hypertension (OR 2.03, 95% CI 1.17-3.53)
hospital-acquired pneumonia (OR 1.75, 95% CI 1.02-3.02)
Reference - J Clin Nurs 2018 Jan;27(1-2):450
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Blood pressure
elevated systolic blood pressure (≥ 140 mm Hg) reported in 69% patients presenting with acute
stroke
based on national cohort study with 563,704 patients with stroke evaluated in United States
emergency departments
initial systolic blood pressure was
< 140 mm Hg in 31%
140-184 mm Hg in 56%
185-219 mm Hg in 13%
≥ 220 mm Hg in 0.1%
Reference - Am J Emerg Med 2007 Jan;25(1):32 full-text
reduction in blood pressure may occur within 24 hours
based on cohort study
115 consecutive patients admitted within 24 hours of symptom onset had blood pressure
measurements for first 24 hours of hospital admission
patients treated according to emergency room protocol that recommended captopril as first-line
treatment for blood pressure > 220/120 mm Hg
mean blood pressure at admission was 160/94 mm Hg
all patients had blood pressure drop in first 24 hours, either spontaneously or with medication
59% patients received antihypertensive medication (captopril)
4% also received clonidine
at 24 hours, mean blood pressure 166/97 mm Hg in patients receiving antihypertensive medication
vs. 154/93 mm Hg in patients not receiving antihypertensive medication (not significant)
amount of decrease in systolic blood pressure
not related to use of antihypertensive medication
related to higher admission systolic blood pressure (p = 0.003)
Reference - Neurology 2003 Oct 28;61(8):1047
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304 patients with acute ischemic stroke had systolic and diastolic blood pressure at admission
in emergency department and for first 24 hours after admission to a stroke unit in Spain
stroke severity assessed at time of presentation, at 48 hours, and at 90 days
threshold for abnormal systolic blood pressure was 180 mm Hg
threshold for abnormal diastolic blood pressure was 100 mm Hg
groups with highest or lowest values of systolic or diastolic blood pressures had higher
occurrence of early neurologic deterioration, poor neurologic outcome, and higher mortality
(U-shaped curve)
systolic blood pressure
patients with systolic blood pressure at admission ≤ 120 mm Hg
62% had early neurologic deterioration
80% had poor neurologic outcome
30% mortality
patients with systolic blood pressure at admission 161-180 mm Hg
8% had early neurologic deterioration
44% had poor neurologic outcome
10% mortality
patients with systolic blood pressure at admission > 200 mm Hg
32% had early neurologic deterioration
76% had poor neurologic outcome
12% mortality
diastolic blood pressure
patients with diastolic blood pressure at admission ≤ 70 mm Hg
54% had early neurologic deterioration
72% had poor neurologic outcome
28% mortality
patients with diastolic blood pressure at admission 91-100 mm Hg
12% had early neurologic deterioration
34% had poor neurologic outcome
6% mortality
patients with diastolic blood pressure at admission > 110 mm Hg
32% had early neurologic deterioration
68% had poor neurologic outcome
14% mortality
for each 10 mm Hg increase in systolic blood pressure > 180 mm Hg on admission
risk of neurologic deterioration increased by 40% (p < 0.05)
risk of poor neurologic outcome increased by 23% (p < 0.05)
no change in mortality
5.5 cm3 increase in mean infarct size on neuroimaging
with incremental decreases in systolic blood pressure < 180 mm Hg, increase in stroke
volume on neuroimaging seen
for each 10 mm Hg decrease in systolic blood pressure ≤ 180 mm Hg on admission,
mean 7.3 cm3 increase in infarct size on neuroimaging
for each 20 mm Hg decrease in systolic blood pressure ≤ 180 mm Hg on admission,
mean 61 cm3 increase in infarct size on neuroimaging
Reference - Stroke 2004 Feb;35(2):520
higher initial blood pressure may be associated with better neurologic outcome in acute
ischemic stroke
based on retrospective study of 92 patients with acute ischemic stroke
systolic blood pressure range 140-220 mm Hg, diastolic blood pressure range 70-110 mm Hg
group with better outcomes had lacunar infarcts
no evidence that lowering blood pressure was beneficial
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Reference - Arch Intern Med 2003 Jan 27;163(2):211, commentary can be found in Arch
Intern Med 2003 Nov 24;163(21):2651
initial blood pressure < 155/70 mm Hg associated with 2-fold increase in mortality
based on observational study
357 patients with acute ischemic stroke presenting to emergency department within 24 hours
of symptom onset
75 died within 90 days
optimal blood pressure range 155-220/70-105 mm Hg
Reference - Neurology 2005 Oct 25;65(8):1179, commentary can be found in Neurology
2006 May 23;66(10):1609
falling blood pressure in first 24 hours associated with worse outcome in acute stroke
greater degree of blood pressure reduction during first 24 hours associated with poor outcome
(level 2 [mid-level] evidence)
based on post hoc analysis of NINDS tissue-type plasminogen activator (t-PA) stroke study
551 patients did not receive prerandomization antihypertensive treatment and had blood
pressure data available
greater decreases in systolic blood pressure correlated with lower likelihood of favorable
outcomes
Reference - J Neurol Sci 2008 Aug 15;271(1-2):61 full-text
decrease in systolic blood pressure by > 20 mm Hg within 24 hours of admission associated
with increased mortality and poor neurological outcome in patients with systolic blood
pressure ≤ 180 mm Hg at admission for acute ischemic stroke
based on cohort study
304 patients with acute ischemic stroke were assessed for blood pressure (BP) and other
characteristics within 24 hours of onset, treated at physician's discretion, and followed for 3
months
decrease in systolic BP > 20 mm Hg within 24 hours of admission associated with increased
risk of death within 3 months and poor neurological outcome (Canadian Stroke Scale ≤ 7)
Systolic Blood Pressure Change within 24 Hours of Admission and Percentage of Patients
with Stroke Outcome:
Decrease > 20 Decrease 0-20 Between-group
Outcome Increase
mm Hg mm Hg Significance*
Death within 3
23.5% 10.6% 13% p = 0.066
months
Poor neurological
90.2% 49% 57.4% p < 0.001
outcome
* Statistical pairwise comparisons not reported.
in adjusted multivariate analysis, decrease in systolic BP > 20 mm Hg within 24 hours of
admission associated with
in patients with systolic BP ≤ 180 mm Hg at admission
increased mortality (adjusted odds ratio [OR] 38.9, 95% CI 4.2-358)
increased risk of poor neurological outcome (adjusted OR 61, 95% CI 1-3,705)
in patients with systolic BP > 180 mm Hg at admission
no significant difference in mortality
increased risk of poor neurological outcome (adjusted OR 8.8, 95% CI 1.9-55.6)
Reference - Stroke 2004 Feb;35(2):520
greater degree of blood pressure reduction in first 24 hours after admission for stroke
associated with poor clinical outcome at 3 months (level 2 [mid-level] evidence)
based on cohort study
115 consecutive patients admitted within 24 hours of symptom onset had blood pressure
measurements for first 24 hours of hospital admission and then patients reassessed by
telephone at 90 days
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patients treated according to emergency room protocol that recommended captopril as first-
line treatment for blood pressure > 220/120 mm Hg
mean blood pressure at admission was 160/94 mm Hg (range 110-260/60-170 mm Hg)
all patients had blood pressure drop in first 24 hours, either spontaneously or with medication
59% of patients received antihypertensive medication (captopril)
4% also received clonidine
at 24 hours, mean blood pressure 166/97 mm Hg in patients receiving antihypertensive
medication vs. 154/93 mm Hg in patients not receiving antihypertensive medication (not
significant)
amount of decrease in systolic blood pressure
not related to use of antihypertensive medication
related to higher admission systolic blood pressure (p = 0.003)
comparing patients with good vs. poor neurologic outcome at 3 months
mean diastolic blood pressure on admission 96 mm Hg vs. 89 mm Hg (p = 0.04)
decrease in mean systolic blood pressure over first 24 hours 26 mm Hg vs. 31 mm Hg
(p = 0.04)
other significant associations included older age, higher body temperature in first 24
hours, total anterior circulation stroke, lack of antiplatelet use in first 24 hours, and
nonlacunar stroke
larger fall in systolic blood pressure during first 24 hours independently predicted higher risk
of severe stroke-related disability at 3 months
in adjusted analysis, degree of systolic blood pressure reduction in first 24 hours associated
with poor neurologic outcome (odds ratio 1.89 per 10% decrease, p = 0.047)
antihypertensives neither correlated with systolic blood pressure reduction nor poor outcome
Reference - Neurology 2003 Oct 28;61(8):1047, commentary can be found in Neurology
2003 Oct 28;61(8):1030
diastolic blood pressure lowering predicts poor neurologic outcome
based on cohort study
372 patients with acute ischemic stroke evaluated
diastolic blood pressure decrease at least 25% in first hospital day increased risk (3.8 times)
for poor neurologic outcome on day 5
antihypertensives neither correlated with systolic blood pressure reduction nor poor outcome
Reference - Ann Emerg Med 2003 Nov;42(5):619, commentary can be found in Am Fam
Physician 2004 Jun 15;69(12):2920
Temperature
elevated body temperature associated with increased risk of mortality and poorer functional
outcomes
based on meta-analysis of 39 studies with 14,431 patients with stroke
Reference - Stroke 2008 Nov;39(11):3029
Hyperglycemia
persistent in-hospital hyperglycemia during first 24 hours after acute ischemic stroke associated with
worse outcomes than normoglycemia(1)
reasonable to treat hyperglycemia to achieve blood glucose levels in range of 140-180 mg/dL and to
closely monitor to prevent hypoglycemia (AHA/ASA Class IIa, Level C-LD)(1)
stress hyperglycemia associated with increased 30-day mortality in ischemic stroke patients without
diabetes
systematic review of 32 cohort studies
stress hyperglycemia in patients without diabetes associated with 3.07 relative risk (95% CI 2.5-
3.79) for in-hospital or 30-day all-cause mortality
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stress hyperglycemia was not significantly associated with short-term mortality in patients with
diabetes or in patients with hemorrhagic stroke
stress hyperglycemia also associated with increased long-term mortality and poor functional
recovery
Reference - Stroke 2001 Oct 1;32(10):2426 full-text
elevated plasma glucose concentration (> 8 mmol/L [144 mg/dL]) after acute stroke predicts poor
prognosis in patients without diabetes
based on cohort study
750 patients without diabetes with acute stroke, 86% ischemic and 14% hemorrhagic were
evaluated
mortality increased with increasing age, hemorrhagic stroke, time to resolution of symptoms > 72
hours and hyperglycemia
effect of glucose level on survival was greatest in first month
Reference - BMJ 1997 May 3;314(7090):1303 full-text
hyperglycemia ≥ 155 mg/dL (8.6 mmol/L) within 48 hours of acute ischemic stroke predicts poor
outcome at 3 months
based on cohort of 476 patients
Reference - Stroke 2009 Feb;40(2):562
hyperglycemia associated with worse outcome in acute stroke
based on literature review
Reference - Arch Neurol 2001 Aug;58(8):1209 full-text
Biomarkers
783 patients (median age 71 years) with acute ischemic stroke were assessed for plasma copeptin
levels within 24 hours of symptom onset
90-day mortality 15.1%
unfavorable outcome (modified Rankin Scale score 3-6) within 90 days in 38.3%
complications (symptomatic intracerebral hemorrhage, space-occupying cerebral edema,
pneumonia, seizures, or death within 10 days of admission) in 23.6%
each 10-fold increase in copeptin levels associated with increased risk of
mortality (adjusted hazard ratio 2.4, 95% CI 1.6-3.6)
unfavorable outcome (adjusted odds ratio [OR] 2.7, 95% CI 1.46-3.22)
complications (adjusted OR 1.93, 95% CI 1.33-2.8)
no significant association between copeptin levels and risk of intracerebral hemorrhage or seizure
Reference - Neurology 2013 Apr 2;80(14):1278, editorial can be found in Neurology 2013 Apr
2;80(14):1270
elevated troponin T level at hospital admission associated with increased risk for in-hospital
mortality (from 13% to 40%)
based on 181 patients admitted with acute ischemic stroke
Reference - BMJ 2000 Jun 3;320(7248):1502 full-text
high blood and cerebrospinal fluid glutamate levels may predict high probability of neurologic
deterioration within 48 hours of stroke onset
based on prospective study of 128 patients with acute ischemic stroke
Reference - Lancet 1997 Jan 11;349(9045):79
presence of antiphospholipid antibodies may not predict subsequent vascular occlusive events in
patients with ischemic stroke unless both anticardiolipin and lupus anticoagulant antibodies are
positive
prospective cohort study of 1,770 patients with ischemic stroke who took part in randomized trial
comparing warfarin (target INR 14-2.8) vs. aspirin 325 mg/day
baseline blood samples analyzed for anticardiolipin antibodies and lupus anticoagulant antibodies
prior to randomization
720 (41%) had positive antiphospholipid antibodies (anticardiolipin and/or lupus anticoagulant
antibodies) but this did not have any effect on 2-year risk of thrombo-occlusive events overall, with
warfarin, or with aspirin
patients with baseline positivity to both antiphospholipid antibodies had higher event rate than
patients who tested negative to both antibodies (31.7% vs. 24%, p = 0.07)
Reference - JAMA 2004 Feb 4;291(5):576, commentary can be found in JAMA 2004 Jun
9;291(22):2701
Imaging studies
some early ischemic and preexisting signs on brain scans associated with decreased likelihood of
independent functioning at 6 months and increased risk of symptomatic intracranial hemorrhage in
patients with acute stroke (level 2 [mid-level] evidence)
based on prespecified secondary analysis of IST-3 trial
3,017 patients with acute stroke in IST-3 trial of alteplase who had brain scans (98% had CT scans
and 2% had MRI) prior to randomization were included in analysis
9% had normal scans, 51% had preexisting signs without early ischemic signs, and 41% had
early ischemic signs with or without preexisting signs
early ischemic signs included tissue hypoattenuation, large lesion size, lesion swelling, and
artery hyperattenuation
preexisting signs included presence of old infarct, atrophy, and leukoaraiosis (diffuse white
matter abnormalities on MRI)
results based on multivariable analyses adjusting for age, National Institutes of Health Stroke Scale
(NIHSS) score, time to randomization, individual imaging signs, use of alteplase, and use of
antiplatelet drugs immediately before stroke
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early ischemic signs and preexisting signs associated with decreased likelihood of independent
functioning (defined as Oxford Handicap Scale score 0-2) at 6 months included
large lesion size (adjusted odds ratio [OR] 0.54, 95% CI 0.39-0.74)
artery hyperattenuation (adjusted OR 0.71, 95% CI 0.55-0.92)
severe leukoaraiosis (adjusted OR 0.59, 95% CI 0.45-0.79)
early ischemic signs and preexisting signs associated with increased risk of symptomatic
intracranial hemorrhage included
artery hyperattenuation (adjusted OR 1.61, 95% CI 1.07-2.42)
old infarct (adjusted OR 1.67, 95% CI 1.13-2.46)
Reference - Lancet Neurol 2015 May;14(5):485 full-text
computed tomography findings may predict neurological deterioration in large middle cerebral
artery strokes (level 2 [mid-level] evidence)
based on retrospective study of 36 patients with large middle cerebral artery (MCA) infarctions
22 (61%) had neurologic deterioration
2 computed tomography (CT) findings which had significant predictive ability for neurologic
deterioration were
hyperdense middle cerebral artery sign at any time (91% positive predictive value)
involvement of > 50% of MCA territory in first 12 hours of symptoms (75% positive
predictive value)
Reference - Mayo Clin Proc 2003 Feb;78(2):156
greater severity of white matter disease as assessed by magnetic resonance imaging visual rating
scales associated with increased disability at 1 year after first ischemic stroke (level 2 [mid-level]
evidence)
based on prognostic cohort study with population not representative of patients for whom testing
would be appropriate
101 patients aged ≥ 18 years with first ischemic stroke were evaluated for white matter disease and
disability 1 year after stroke
patients were assessed 3-7 days after stroke with blood tests and magnetic resonance imaging
(MRI)
1-year assessment of disability with modified Rankin Scale carried out by telephone interview
all patients had mild stroke (National Institutes of Health Stroke Scale scores 0-8 on 42 point scale
at time of testing, higher score indicates more severe stroke)
white matter disease severity scored using Fazekas (0-3) and Wahlund (0-30) visual rating scales
(higher score indicates greater severity on each scale)
Fazeka scores significantly associated with disability at 1 year after ischemic stroke
for Fazeka score 2, adjusted odds ratio (OR) 8.4 (95% CI 2.35-30)
for Fazeka score 3, adjusted OR 4.2 (95% CI 1.04-17)
Wahlund score > 10 was predictive of disability only in analysis that did not account for glucose
levels
Reference - Stroke 2012 Nov;43(11):3046 full-text
swelling on magnetic resonance diffusion-weighted imaging associated with increased risk of poor
neurologic outcome in patients with acute stroke
based on retrospective cohort study
97 patients with acute stroke in placebo group of 2 randomized trials were assessed
all patients had baseline and ≥ 1 follow-up brain magnetic resonance diffusion-weighted
imaging
good neurologic outcome defined as modified Rankin Scale score 0-2 and poor outcome
defined as score 3-6
68% had swelling and 42% had infarct growth
swelling associated with increased risk of poor outcome at 90 days (adjusted odds ratio 1.09, 95%
CI 1.03-1.17)
infarct growth not significantly associated with increased risk of poor outcome at 90 days
Reference - Stroke 2014 Dec;45(12):3643
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magnetic resonance diffusion-weighted imaging early after acute ischemic stroke does not appear to
have prognostic value
magnetic resonance diffusion-weighted imaging (MR DWI) not shown to have prognostic value in
study of 82 patients (Neurology 2006 Apr 25;66(8):1159) or study of 382 patients (Stroke 2007
Jun;38(6):1820 full-text)
earlier derivation studies suggested prognostic value (Lancet 2001 Jun 30;357(9274):2095, Stroke
2000 Nov;31(11):2597 full-text)
combination of acute MR DWI, mean transmit time lesion volumes, and National Institutes of
Health Stroke Scale (NIHSS) score may predict outcomes after acute stroke better than NIHSS
score alone (level 2 [mid-level] evidence)
based on derivation study (cohort of 55 patients with acute ischemic stroke who had magnetic
resonance imaging (MRI) within 9 hours of symptom onset and were followed for 3 months)
without validation
Reference - Stroke 2010 Aug;41(8):1728 full-text
carotid stenosis and increased carotid intima-media thickness on ultrasound each associated with
increased risk of cardiovascular events after stroke
based on substudy of prospective cohort
599 patients (mean age 71 years) having first noncardioembolic ischemic stroke < 30 days evaluated
for carotid intima-media thickness and carotid stenosis by ultrasound
19.5% had carotid stenosis > 50% and 18.4% had carotid intima-media thickness ≥ 1.1 mm without
stenosis
increased risk of cardiovascular events associated with
stenosis compared to no stenosis (p = 0.0001)
carotid intima-media thickness ≥ 1.1 mm compared to thickness < 1.1 mm (p = 0.032)
Reference - Stroke 2011 Nov;42(11):3099
activation of fewer intracranial collateral vessels associated with poor recovery in patients with
internal carotid artery dissection
based on cohort study
66 patients with stroke with internal carotid artery occlusion due to spontaneous artery dissection
had transcranial Doppler ultrasound ≤ 24 hours from symptom onset to evaluate cerebral arteries
and patency of ophthalmic, anterior, and posterior communicating arteries
diagnosis of carotid dissection and stroke were made by brain and neck magnetic resonance
angiography (MRA) and brain computerized tomography (CT)
collateral flow through 0-1 intracranial collateral vessels in 39%
collateral flow through 0-1 intracranial collateral vessels (vs. > 2 vessels) associated with increased
risk of poor recovery (modified Rankin Scale score > 2) (adjusted relative risk 14.9, 95% CI 3.24-
68.46)
Reference - Stroke 2011 Jan;42(1):139
Other factors
gender does not appear to affect 28-day mortality in patients with first stroke
based on cohort of 1,316 patients with first stroke from the North East Melbourne Stroke Incidence
Study
no significant difference in 28-day mortality after adjustment for age, comorbidities, and stroke
severity
Reference - Neurology 2010 Mar 23;74(12):975, editorial can be found in Neurology 2010 Mar
23;74(12):947
weeknight admission associated with decreased 30-day survival compared to weekday admission in
patients with acute stroke
based on population-based cohort study
74,307 adults admitted to hospital with acute stroke from Sentinel Stroke National Audit
Programme in England and Wales were followed for 30 days
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88% had ischemic stoke, 11% had primary intracerebral hemorrhage, and 2% were undetermined
compared to weekday admission (from 8 AM to 7:59 PM),
weeknight admission (from 8 PM to 7:59 AM) associated with decreased 30-day survival
(adjusted odds ratio 0.9, 95% CI 0.82-0.99)
weekend night admission associated with nonsignificant decrease in 30-day survival (adjusted
odds ratio 0.89, 95% CI 0.78-1.01)
no significant differences in 30-day survival with weekend day admission
Reference - Lancet 2016 Jul 9;388(10040):170, editorial can be found in Lancet 2016 Jul
9;388(10040):170
weekend hospital admission associated with higher mortality
based on 26,676 patients admitted to 606 hospitals in Canada for ischemic stroke 2003-2004
6,629 (25%) admissions occurred on weekends
7-day stroke mortality was 8.5% for weekend admissions vs. 7.4% for weekday admissions
Reference - Stroke 2007 Apr;38(4):1211
prestroke statin use associated with improved function 90 days after ischemic stroke (level 2 [mid-
level] evidence)
based on systematic review of observational studies
systematic review of 12 observational studies (9 cohort studies, 3 case-control studies) comparing
statin use vs. no statin use prior to stroke in 11,695 patients with ischemic stroke
2,013 patients used statins prior to stroke
improved function defined as modified Rankin Scale score ≤ 2 at 90 days
prestroke statin used associated with improved function at 90 days (odds ratio 1.62, 95% CI 1.39-
1.88), results limited by significant statistical heterogeneity
Reference - Stroke 2011 May;42(5):1314
about 25% of patients discharged after stroke do not adhere to prevention medication therapy
based on cohort study
2,888 adults admitted for ischemic stroke or transient ischemic stroke
75.5% reported taking all secondary prevention medications prescribed at discharge at 3 months
adherence to therapy associated with decreasing number of medication classes prescribed,
increasing age, medical history, less severe stroke disability, having insurance, working status,
understanding why medications are prescribed and how to refill them, increased quality of life,
financial hardship, geographic region, and hospital size
Reference - Arch Neurol 2010 Dec;67(12):1456
increased high-density lipoprotein cholesterol following stroke associated with reduced risk of
progression of symptomatic intracranial atherosclerotic stenosis
based on cohort analysis of data from randomized trial
230 patients with acute stroke and symptomatic intracranial atherosclerotic stenosis (middle cerebral
artery or basilar artery) who were randomized to cilostazol vs. clopidogrel were analyzed
14% had progression of intracranial atherosclerotic stenosis on imaging during 7 months' follow-up
mean change in high-density lipoprotein cholesterol during follow-up was +6.5 mg/dL in patients
without progression vs. -1 mg/dL in patients with progression (p < 0.01)
Reference - Stroke 2012 Jul;43(7):1824 full-text
use statins with intensive lipid-lowering effects to reduce risk of stroke and
cardiovascular events in patients with ischemic stroke or transient ischemic attack
(TIA) of presumed atherosclerotic origin and either
low-density lipoprotein cholesterol level ≥ 100 mg/dL with or without evidence
of other atherosclerotic cardiovascular disease (AHA/ASA Class I, Level B)
low-density lipoprotein cholesterol level < 100 mg/dL even if no other evidence
of atherosclerotic cardiovascular disease (AHA/ASA Class I, Level C)
patients with ischemic stroke or TIA and other comorbid atherosclerotic cardiovascular
disease should be managed according to 2013 ACC/AHA cholesterol guidelines
(AHA/ASA Class I, Level A)
statins reduce subsequent cerebrovascular events in adults with history of stroke or TIA
(level 1 [likely reliable] evidence)
blood pressure reduction
treat previously untreated patients with blood pressure ≥ 140 mm Hg systolic or ≥ 90
mm Hg diastolic (AHA/ASA Class I, Level B) and previously treated patients with
known hypertension (AHA/ASA Class I, Level A)
target blood pressure level should be individualized, but reasonable goal is systolic
pressure < 140 mm Hg and diastolic pressure < 90 mm Hg (AHA/ASA Class IIa, Level
B), or systolic blood pressure < 130 mm Hg in patients with recent lacunar stroke
(AHA/ASA Class IIb, Level B)
calcium channel blockers more effective than beta blockers and similar to angiotensin-
converting enzyme (ACE) inhibitors and diuretics in preventing stroke in patients with
hypertension (level 1 [likely reliable] evidence)
optimal medication for patients with history of stroke or TIA unclear, but evidence
suggests diuretics or combination of diuretics plus ACE inhibitors are useful
(AHA/ASA Class I, Level A)
antihypertensive medications may reduce risk of adverse cardiovascular events in
patients without hypertension but with history of cardiovascular disease or diabetes
(level 2 [mid-level] evidence)
smoking cessation (AHA/ASA Class I, Level C)
avoiding heavy alcohol use (AHA/ASA Class I, Level C)
following noncardioembolic stroke or TIA - antiplatelet agents recommended over anticoagulation
(ACCP Grade 1B; AHA/ASA Class I, Level A; CSBPR Evidence Level A)
options include
combination of aspirin 25 mg plus extended-release dipyridamole 200 mg twice daily
(Aggrenox, Asasantin) (AHA/ASA Class I, Level B; CSBPR Evidence Level A)
aspirin with suggested dose ranges including 75-100 mg once daily (ACCP), 50-325
mg/day (AHA/ASA Class I, Level A), and 81-325 mg/day (CSBPR Evidence Level A)
clopidogrel (Plavix) 75 mg once daily (AHA/ASA Class IIa, Level B; CSBPR
Evidence Level A)
cilostazol (Pletal) 100 mg twice daily (ACCP); FDA approved only for intermittent
claudication
clopidogrel or combination aspirin plus extended-release dipyridamole suggested over aspirin
alone (ACCP Grade 2B) or cilostazol (ACCP Grade 2C)
combination of aspirin plus clopidogrel
not usually recommended for long-term secondary prevention of stroke (AHA/ASA
Class III, Level A; CSBPR Evidence Level A) due to increased risk of life-threatening
or major bleeding (level 1 [likely reliable] evidence)
might be considered if initiated ≤ 24 hours after minor ischemic stroke or TIA and
continued for 90 days (AHA/ASA Class IIb, Level B)
triflusal (Aflen, Disgren, Grendis, Triflux) also has evidence to support use (level 2 [mid-
level] evidence)
anticoagulation appears to increase adverse events without increased benefits compared to
aspirin in patients with nonembolic stroke or TIA (level 2 [mid-level] evidence)
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Quality Improvement
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time targets for emergency department management of patients with suspected acute stroke(1)
brain imaging studies within 20 minutes in at least 50% of patients (AHA/ASA Class I, Level B-
NR)
door to CT interpretation ≤ 45 minutes
door-to-needle time (initiation of thrombolytics) ≤ 60 minutes in at least 50% of patients
(AHA/ASA Class I, Level B-NR
it may be reasonable to establish a secondary door-to-needle time goal of achieving door-to-
needle times within 45 minutes in ≥ 50% of patients with acute ischemic stroke who were
treated with IV alteplase (AHA/ASA Class IIb, Level C-EO)
door to stroke unit admission ≤ 3 hours
multicomponent quality improvement initiatives, which include emergency department education and
multidisciplinary teams with access to neurological expertise, are recommended to safely increase IV
thrombolytic treatment (AHA/ASA Class I, Level A)
stroke system care quality improvement process
healthcare institutions should organize a multidisciplinary quality improvement committee to review
and monitor stroke care quality benchmarks, indicators, evidence-based practices, and
outcomes(AHA/ASA Class I, Level B-NR)
continuous quality improvement processes, implemented by each major element of a stroke system
of care and the system as a whole, can be useful in improving patient care or outcomes (AHA/ASA
Class IIa, Level B-NR)
stroke outcome measures should include adjustments for baseline severity (AHA/ASA Class I,
Level B-NR)
see Medicare/Joint Commission National Hospital Inpatient Quality Measures for additional information
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OP-23 Head Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Scan Results for Acute
Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation
Within 45 Minutes of emergency department (ED) Arrival
measured as proportion of emergency department patients with acute ischemic stroke or
hemorrhagic stroke arriving at the emergency department within 2 hours of the time last known well
with an order for a head CT or MRI scan whose time from emergency department arrival to
interpretation of the head CT scan is within 45 minutes of arrival
see Medicare Hospital Outpatient Department Quality Measures for additional information
see Physician Quality Reporting System Quality Measures for additional information
STIA1. Contractor establishes and maintains a register of patients with stroke or transient ischemic attack
(TIA)
STIA9. Percentage of patients with stroke or transient ischemic attack (TIA) who have had influenza
immunization in the preceding 1 August to 31 March
STIA7. Percentage of patients with stroke shown to be nonhemorrhagic, or history of transient ischemic
attack (TIA), who have a record in preceding 12 months that antiplatelet agent or anticoagulant is being
taken
STIA8. Percentage of patients with stroke or transient ischemic attack (TIA) diagnosed on or after 1 April
2014 who have a record of referral for further investigation between 3 months before or 1 month after date
of latest recorded stroke or first TIA
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Australasian Faculty of Rehabilitation Medicine recommends against using Mini Mental State
Examination as the only tool to assess cognitive deficit in acquired brain injury. (Choosing Wisely
Australia 2018 Feb 15 )
American Heart Association (AHA) scientific statement on indications for performance of intracranial
endovascular neurointerventional procedures can be found in Circulation 2018 May 22;137(21):e661
American College of Chest Physicians (ACCP) evidence-based clinical practice guideline (ninth edition)
on antithrombotic and thrombolytic therapy for ischemic stroke can be found in Chest 2012 Feb;141(2
Suppl):e601S full-text
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Institute for Clinical Systems Improvement (ICSI) guideline on diagnosis and initial treatment of ischemic
stroke can be found at ICSI 2016 Dec PDF
American College of Emergency Physicians (ACEP) clinical policy on use of intravenous tissue
plasminogen activator for management of acute ischemic stroke in the emergency department can be
found in Ann Emerg Med 2015 Sep;66(3):322
American College of Radiology (ACR) Appropriateness Criteria for cerebrovascular disease can be found
at ACR 2016 PDF
American Geriatrics Society (AGS) 2015 Beers Criteria for potentially inappropriate medication use in
older adults can be found in J Am Geriatr Soc 2015 Nov;63(11):2227, commentary can be found in J Am
Geriatr Soc 2016 Apr;64(4):920
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National Institute for Health and Care Excellence (NICE) guideline on diagnosis and initial management
of acute stroke and transient ischemic attack (TIA) can be found at NICE 2008 Jul:CG68 PDF, updated
March 2017, summary can be found in BMJ 2008 Jul 24;337:a786, commentary can be found in BMJ
2008 Jul 24;337:a833, BMJ 2008 Aug 18;337:a1339
National Institute of Health and Care Excellence (NICE) guidance on alteplase for treatment of acute
ischemic stroke can be found at NICE 2012 Sep:TA264 PDF
Scottish Intercollegiate Guidelines Network (SIGN) national clinical guideline on stroke (rehabilitation,
prevention, and management of complications and discharge planning) can be found at SIGN 2010 Jun
PDF
Royal College of Physicians (RCP) national clinical guideline on stroke can be found at RCP 2016 Oct 3
PDF
United Kingdom expert consensus on stroke: early supported discharge can be found in Stroke 2011
May;42(5):1392, commentary can be found in Nat Rev Neurol 2011 Sep 5;7(9):482
Canadian guidelines
Telestroke can be found at CSBPR 2017 Apr or in Int J Stroke 2017 Oct;12(8):886
Registered Nurses Association of Ontario (RNAO) guideline on stroke assessment across continuum of
care can be found at RNAO 2005 Jun PDF, supplement can be found at RNAO 2011 Aug PDF
European guidelines
European Academy of Neurology and European Stroke Organization (EAN/ESO) consensus statement on
pre-hospital management of stroke can be found in Eur J Neurol 2018 Mar;25(3):425
French Society of Intensive Care (Société de Réanimation de Langue Française [SRLF]) expert
recommendations on
stroke care in ICU: general supportive treatment can be found in Rev Neurol (Paris) 2012
Jun;168(6-7):490 [French]
stroke management in intensive care unit: intracranial hypertension can be found in Rev Neurol
(Paris) 2012 Jun;168(6-7):501 [French]
stroke management in intensive care unit: treatment of arterial and venous brain ischemia can be
found in Rev Neurol (Paris) 2012 Jun;168(6-7):512 [French]
stroke management in intensive care unit: specific treatment for intracerebral hemorrhage can be
found in Rev Neurol (Paris) 2012 Jun;168(6-7):522 [French]
European Association of Echocardiography (EAE) recommendation on echocardiography use in diagnosis
and management of cardiac sources of embolism can be found in Eur J Echocardiogr 2010
Jul;11(6):461 full-text
Luxembourg guidelines on
treatment of acute stroke can be found at Conseil Scientifique Nov 2017 PDF [French]
management of acute stroke - clinical itinerary can be found at Conseil Scientifique Nov 2017 PDF
[French]
German Cardiac Society/German Stroke Society guideline on cardiac workup after cerebral ischemia can
be found in Nervenarzt 2010 Apr;81(4):444 [German]
European Society of Cardiology (ESC) guideline on management of atrial fibrillation can be found in Eur
J Cardiothorac Surg 2016 Nov;50(5):e1 or in Europace 2016 Nov;18(11):1609
Haute Autorité de Santé conseils pour accident vasculaire cérébral: prise en charge précoce (alerte, phase
préhospitalière, phase hospitalière initiale, indications de la thrombolyse) se trouvent sur le site Haute
Autorité de Santé 2009 Mai [French], portions also published in English
Dutch Federation for Neurology (Nederlandse Vereniging voor Neurologie [NVvN]) guideline on
diagnostics, treatment, and care for stroke patients can be found at NVvN 2008 PDF [Dutch]
Asian guidelines
Indian national clinical guideline on stroke management can be found in Ann Indian Acad Neurol 2011
Jul;14(Suppl 1):S82 full-text
Singapore Ministry of Health (SMOH) guideline on stroke and transient ischaemic attacks: assessment,
investigation, immediate management, and secondary prevention can be found at SMOH 2009 Jul PDF or
in Int J Stroke 2011 Jun;6(3):251
Japan Stroke Society 2009 guideline on stroke management can be found at Minds guideline listing (医療
情報サービスマインズ) [Japanese 日本語]
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Mexican guidelines
expert clinical guideline on prevention, diagnosis, and treatment of ischemic cerebral disease can be found
in Rev Med Inst Mex Seguro Soc 2012 May-Jun;50(3):335 [Spanish]
National Stroke Foundation (NSF) clinical guideline on stroke management can be found at Stroke
Foundation 2017
African guidelines
South African Stroke Society (SASS) guideline on management of ischemic stroke and transient ischemic
attack can be found in S Afr Med J 2010 Nov 10;100(11 Pt 2):747, commentary can be found in S Afr
Med J 2011 Jan;101(1):7
South African guideline on management of ischemic stroke and transient ischemic attack:
recommendations for resource-constrained healthcare setting can be found in Int J Stroke 2011
Aug;6(4):349
Quality indicators
21 quality indicators on care of stroke in vulnerable elders can be found in J Am Geriatr Soc 2007 Oct;55
Suppl 2:S431
Review articles
review of management of acute ischemic stroke can be found in Mayo Clin Proc 2004 Nov;79(11):1459
review of endovascular treatment of cerebrovascular diseases and intracranial neoplasms can be found in
Lancet 2004 Mar 6;363(9411):804
review of medical treatment in acute and long-term secondary prevention after transient ischaemic attack
and ischaemic stroke can be found in Lancet 2011 May 14;377(9778):1681
review of stroke telemedicine can be found in Mayo Clin Proc 2009;84(1):53 full-text, editorial can be
found in Mayo Clin Proc 2009;84(1):3, commentary can be found in Mayo Clin Proc 2009 May;84(5):482
review of established treatments for acute ischemic stroke can be found in Lancet 2007 Jan
27;369(9558):319
review of experimental treatments for acute ischemic stroke can be found in Lancet 2007 Jan
27;369(9558):331, commentary can be found in Lancet 2007 Mar 31;369(9567):1080
review of perinatal stroke can be found in Pediatrics 2007 Sep;120(3):609 full-text
review of perioperative stroke can be found in N Engl J Med 2007 Feb 15;356(7):706, commentary can be
found in N Engl J Med 2007 May 31;356(22):2325
case presentation can be found in N Engl J Med 2006 May 25;354(21):2263 full-text
case presentation can be found in N Engl J Med 2004 Feb 12;350(7):707, correction can be found in N
Engl J Med 2004 Jul 15;351(3):306, commentary can be found in N Engl J Med 2004 May
20;350(21):2213
case presentation of acute ischemic stroke caused by basilar artery embolism in 18-year-old man with
patent foramen ovale can be found in N Engl J Med 2012 Oct 11;367(15):1450, commentary can be found
in N Engl J Med 2013 Jan 10;368(2):193
MEDLINE search
to search MEDLINE for (Stroke) with targeted search (Clinical Queries), click therapy, diagnosis, or
prognosis
Patient Information
handout from Centers for Disease Control and Prevention PDF
handout from American Heart Association
handout from National Institute of Neurological Disorders and Stroke (NINDS) or in Spanish
handout from National Institute on Aging PDF or in Spanish
handout on recovery after stroke from National Stroke Association PDF
handout on prevention of stroke can be found in Am Fam Physician 2003 Dec 15;68(12):2389
handout from Patient UK PDF
handout from Kids Health
ICD-9/ICD-10 Codes
ICD-9 codes
ICD-10 codes
I61 intracerebral haemorrhage
I61.0 intracerebral haemorrhage in hemisphere, subcortical
I61.1 intracerebral haemorrhage in hemisphere, cortical
I61.2 intracerebral haemorrhage in hemisphere, unspecified
I61.3 intracerebral haemorrhage in brainstem
I61.4 intracerebral haemorrhage in cerebellum
I61.5 intracerebral haemorrhage, intraventricular
I61.6 intracerebral haemorrhage, multiple localized
I61.8 other intracerebral haemorrhage
I61.9 intracerebral haemorrhage, unspecified
I62 other nontraumatic intracranial haemorrhage
I62.0 subdural haemorrhage (acute)(nontraumatic)
I62.1 nontraumatic extradural haemorrhage
I62.9 intracranial haemorrhage (nontraumatic), unspecified
I63 cerebral infarction
I63.0 cerebral infarction due to thrombosis of precerebral arteries
I63.1 cerebral infarction due to embolism of precerebral arteries
I63.2 cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries
I63.3 cerebral infarction due to thrombosis of cerebral arteries
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References
General references used
1. Powers WJ, Rabinstein AA, Ackerson T, et al, American Heart Association Stroke Council. 2018
Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare
Professionals From the American Heart Association/American Stroke Association. Stroke. 2018
Mar;49(3):e46-e110 full-text, corrections can be found in Stroke 2018 Mar;49(3):e138 and Stroke 2018
Jun;49(6):e233
2. Yew KS, Cheng E. Acute stroke diagnosis. Am Fam Physician. 2009 Jul 1;80(1):33-40 full-text
3. Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet. 2008 May 10;371(9624):1612-23,
commentary can be found in Lancet 2008 Sep 20;372(9643):1035
4. Casaubon LK, Boulanger JM, Blacquiere D, et al; Heart and Stroke Foundation of Canada Canadian
Stroke Best Practices Advisory Committee. Canadian Stroke Best Practice Recommendations (CSBPR):
Hyperacute stroke care guidelines, update 2015. Int J Stroke 2015 Aug;10(6):924-40
5. Casaubon LK, Boulanger JM, Glasser E, et al; Heart and Stroke Foundation of Canada Canadian Stroke
Best Practices Advisory Committee. Canadian Stroke Best Practice Recommendations: Acute inpatient
stroke care guidelines, update 2015. Int J Stroke 2016 Feb;11(2):239-52
6. Jauch EC, Saver JL, Adams HP Jr, et al; American Heart Association Stroke Council, Council on
Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology.
Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare
professionals from the American Heart Association/American Stroke Association. Stroke. 2013
Mar;44(3):870-947 full-text
American Heart Association/American Stroke Society (AHA/ASA) 2018 grading system for
recommendations
classifications of recommendations
Class I - procedure or treatment should be performed or administered
Class IIa - reasonable to perform procedure or administer treatment, but additional studies
with focused objectives needed
Class IIb - procedure or treatment may be considered; additional studies with broad objectives
needed, additional registry data would be useful
Class III - procedure or treatment should not be performed or administered because it is not
helpful or may be harmful
Class III ratings may be subclassified as Class III No Benefit or Class III Harm
levels of evidence
Level A - high-quality evidence from > 1 randomized controlled trial or meta-analysis of
high-quality randomized controlled trials
Level B-R - moderate-quality evidence from ≥ 1 randomized controlled trial or meta-analysis
of moderate-quality randomized controlled trials
Level B-NR - moderate-quality evidence from ≥ 1 well-designed nonrandomized trial,
observational studies, or registry studies, or meta-analysis of such studies
Level C-LD - randomized or nonrandomized studies with methodological limitations or meta-
analyses of such studies
Level C-EO - consensus of expert opinion based on clinical experience
Reference - AHA/ASA 2018 guideline on early management of patients with acute ischemic stroke
(Stroke 2018 Mar;49(3):e46), correction can be found in Stroke 2018 Mar;49(3):e138
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American Heart Association/American Stroke Association (AHA/ASA) 2011-2015 grading system for
recommendations
classifications of recommendations
Class I - procedure or treatment should be performed or administered
Class IIa - reasonable to perform procedure or administer treatment, but additional studies
with focused objectives needed
Class IIb - procedure or treatment may be considered; additional studies with broad objectives
needed, additional registry data would be useful
Class III - procedure or treatment should not be performed or administered because it is not
helpful or may be harmful
Class III ratings may be subclassified as Class III No Benefit or Class III Harm
levels of evidence
Level A - data derived from multiple randomized clinical trials or meta-analyses
Level B - data derived from single randomized trial or nonrandomized studies
Level C - only expert opinion, case studies, or standard of care
References
AHA/ASA guidelines on prevention of stroke in patients with stroke or transient ischemic
attack (Stroke 2014 Jul;45(7):2160 PDF)
AHA/ASA guidelines for primary prevention of stroke (Stroke 2011 Feb;42(2):517 full-text)
AHA/ASA guideline on management of spontaneous intracerebral hemorrhage (Stroke 2015
Jul;46(7):2032 full-text)
AHA/ASA guidelines on secondary prevention of stroke in patients with paroxysmal or
permanent atrial fibrillation (Stroke 2014 Jul;45(7):2160 PDF)
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Level C
established either as useful/predictive or not useful/predictive for diagnostic measure
established as effective, ineffective, or harmful for therapeutic intervention
requires ≥ 2 class III studies
Good Clinical Practice (GCP) - recommended best practice based on experience of guideline
development group
Reference - ESO guideline on ischaemic stroke and transient ischaemic attack (ESO 2011 PDF)
Systematic searches will be conducted for any clinical questions where systematic searches
were not already completed through DynaMed content development.
Evidence will be summarized for recommendation panel review including for each outcome,
the relative importance of the outcome, the estimated effects comparing intervention and
comparison, the sample size, and the overall quality rating for the body of evidence.
Recommendation panel members will be selected to include at least 3 members that together
have sufficient clinical expertise for the subject(s) pertinent to the recommendation,
methodological expertise for the evidence being considered, and experience with guideline
development.
All recommendation panel members must disclose any potential conflicts of interest
(professional, intellectual, and financial), and will not be included for the specific panel if a
significant conflict exists for the recommendation in question.
Panel members will make Strong recommendations if and only if there is consistent
agreement in a high confidence in the likelihood that desirable consequences outweigh
undesirable consequences across the majority of expected patient values and preferences.
Panel members will make Weak recommendations if there is limited confidence (or
inconsistent assessment or dissenting opinions) that desirable consequences outweigh
undesirable consequences across the majority of expected patient values and preferences. No
recommendation will be made if there is insufficient confidence to make a recommendation.
All steps in this process (including evidence summaries which were shared with the panel,
and identification of panel members) will be transparent and accessible in support of the
recommendation.
Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in
recommendation drafting or development, with explicit confirmation that Strong recommendations
are adequately supported.
Recommendations are published only after consensus is established with agreement in phrasing and
strength of recommendation by all editors.
If consensus cannot be reached then the recommendation can be published with a notation of
"dissenting commentary" and the dissenting commentary is included in the topic details.
If recommendations are questioned during peer review or post publication by a qualified individual,
or reevaluation is warranted based on new information detected through systematic literature
surveillance, the recommendation is subject to additional internal review.
Special acknowledgements
Alexander Rae-Grant, MD, FRCP(C), FAAN (Deputy Editor, Neurology DynaMed Plus; Neurologist,
Cleveland Clinic; Ohio, United States)
Dr. Rae-Grant declares no relevant financial conflicts of interest.
Eddy Lang, MDCM, CCFP(EM), CSPQ (Zone Clinical and Academic Department Head for Emergency
Medicine and Professor of Emergency Medicine, University of Calgary; Senior Researcher, Alberta
Health Services; Alberta, Canada)
Dr. Lang declares his position as Chair of the Canadian Association of Emergency Physicians Stroke
Practice Committee.
Dr. Lang declares no relevant financial conflicts of interest.
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DynaMed Plus topics are written and edited through the collaborative efforts of the above individuals.
Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice.
Recommendations Editors are actively involved in development and/or evaluation of guidelines.
How to cite
National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):
DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No.
143427, Stroke (acute management); [updated 2018 Mar 19, cited place cited date here]; [about 85
screens]. Available from http://www.dynamed.com/login.aspx?
direct=true&site=DynaMed&id=143427. Registration and login required.
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