26.1 Triage and Initial Management

Despite ongoing efforts aimed to minimize the risk of acute ischemic stroke (AIS), it still remains the fourth leading cause of death and one of the greatest causes of disability in the United States. Because the brain is highly sensitive to ischemia, it is not surprising that the overall outcome is highly dependent on the management of the patient within the first few hours after the first symptoms of AIS. The main goal within the first hour after presentation to the emergency department is to confirm the diagnosis of AIS and to determine the patient’s eligibility for intravenous (IV) thrombolysis and other therapies. This process begins outside the hospital.

Emergency medical services should transport patients with signs and symptoms of AIS to the “highest level of care available within the shortest period of time.” ¹ Upon arrival to the emergency department, several processes should happen quickly and in parallel (► Table 26.1). A basic evaluation of the patient’s airway, breathing, and circulation should be performed as well as a focused neurologic assessment to determine the presence and severity of new neurologic deficits. At this time, the patient should be placed on a cardiac monitor with frequent blood pressure monitoring, placed on supplemental oxygen for a saturation of at least 94%, positioned supine, and IV fluids should be started and lab work drawn. Contemporaneously, a focused medical history should be obtained. This rapid interview should concentrate on when the patient’s symptoms first occurred, if known, or when the patient was last seen without the current deficits. The interview should also focus on elements of the medical history that may exclude the use of IV thrombolytics (► Table 26.2). Also during this initial evaluation, a noncontrasted computed tomographic (CT) scan of the head should be performed and immediately evaluated, specifically for intracranial hemorrhage, which would be a contraindication for IV thrombolysis.

26.2 Administration of Thrombolytics

The use of IV thrombolytics, specifically tissue plasminogen activator (tPA), has been widely studied and considered to be the mainstay of initial AIS treatment. ¹ , ³ , ⁴ To safely administer tPA, there should be no contraindications (► Table 26.2), and the patient’s blood pressure should be below 185/110 mm Hg. Once tPA is administered, the blood pressure should be maintained below 180/105, which is typically achieved by IV antihypertensive medications (e.g., labetalol and nicardipine). Recently, the American Heart Association (AHA) guidelines for the administration of tPA have been liberalized, and some medical conditions that initially precluded the use of tPA have been determined to carry minimal risk of adverse events and therefore have been eliminated from the list of contraindications (► Table 26.3). ⁵ In most circumstances, given the low risk of adverse outcomes described in stroke mimics, additional confirmatory or ancillary testing, such as magnetic resonance imaging (MRI) of the brain, CT angiography, and perfusion studies should not delay treatment with tPA. ¹ , ⁶ , ⁷