Ischemic Stroke – Acute
Generally speaking, all acute CVA patients should be transferred from ER to ANMC for full stroke workup and better access to consistent PT/OT/SLP.
Patients who decline transfer, particularly those without hemorrhage who have returned to neurologic baseline, could be monitored for 1-2 days at YKHC to monitor for worsening, screen for arrhythmia on telemetry, and work with our physical therapy colleagues. These patients should then be referred to ANMC neurology for MRI, echo, and carotid imaging (if not done in Bethel).
YKHC Stroke Clinical Guideline Development
Drs. Jeremy Wood and Peek Ehlinger created the YKHC stroke guideline with the goal of improving care for our patients treated both in the YKHC hospital and nearby region. One of the goals was to encourage earlier identification of strokes that may be amenable to thrombectomy. The emergence of an intervention for large vessel occlusion strokes has changed the diagnostic pathway and treatment algorithm for stroke. It is an area of active development that we should expect will change over the next few years.
Thrombectomy for appropriate large vessel occlusion strokes appears to have a much more hopeful risk versus benefit ratio than does thrombolytics for the undifferentiated ischemic stroke, however, in general the area of stroke treatment has a fair bit of controversy and you will likely hear different things from different people. We tried to emphasize the importance of bringing neurology along in this decision, and it’s OK to defer to them.
Thrombolytics have been shown to provide net benefit in a select group of patients, however, they also can harm at rates that increase due to a number of factors, such as time from stroke onset (i.e. data stronger for <3 hours than between 3 and 4.5) and patient specific risk factors. Be sure to take your time with the exclusion criteria and consideration of stroke mimics.
We currently have stocked tenectaplase in the ED, which is the direction that most stroke centers are going.
Shared decision making is often difficult in a patient with a disabling stroke and may not be necessary or possible in all patients. As the patient may not have capacity to participate in decisions, you may need to enlist the help of a surrogate decision maker or proceed under presumed consent in such cases when the benefits clearly outweigh the harms. The included consent form is a suggested reference to review anticipated risks and benefits. There is an online resource that has been clinically validated (iScore) which also may be of some use.
Verbal Consent example from UpToDate
- "There is a treatment for your stroke called alteplase that must be given within 4.5 hours after the stroke started. It is a 'clot-buster' drug. Getting alteplase reduces your risk of being disabled. People who get alteplase for stroke have a better chance of recovering without disability and getting back to the activities they enjoy compared to people who do not receive the treatment. All medicines have some risk. With alteplase, there is a risk of serious bleeding. However, time is important as well. We know that the sooner we start treatment with alteplase, the greater the chance that patients will have a good outcome."
Revision of Written Consent form—numbers from Lancet 2014 article
Benefits:
- < 3 hours: 33% of stroke patients given alteplase had good outcome, whereas 23% of stroke patients controls (no alteplase) also got better. 10 people would have to get the drug to help 1 person have a good outcome.
- Between 3 and 4. 5 hours from stroke onset: 35% of patients receiving alteplase had a good outcome, and 30% of patients who didn’t get the drug also got better. You would have to treat 20 people to help 1 person have a good clinical outcome.
Risks:
- In large series of stroke patients, 6.8% of them had bleeding in their brain after receiving alteplase for stroke, versus 1.3% of those stroke patients who did not receive the drug. If we give this drug 18 times, chances are it will make one person have bleeding in their brain.
- 2% of people given this drug die from a hemorrhage (absolute risk) however by 3-6 months out those that receive the drug within 3 hours have a 10% (absolute increase) increased chance of disability-free survival, and that drops to 5% between 3 and 4.5 hours.
Resources/References
- Acute Ischemic Stroke YKHC Clinical Guideline
- Stroke RMT Guide
- iScore
- Siket Matt, Marcolini Evadne, Ganti Latha. Transient Ischemic Attack and Acute Ischemic Stroke. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recEAr4nPXQE4eOBH/Transient-Ischemic-Attack-and-Acute-Ischemic-Stroke.
- Emberson J et al.; Stroke Thrombolysis Trialists' Collaborative Group. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014 Nov 29;384(9958):1929-35. doi: 10.1016/S0140-6736(14)60584-5. Epub 2014 Aug 5. PMID: 25106063; PMCID: PMC4441266.
- Alaska Stroke Systems of Care (PowerPoint Presentation)
