1. Ray Taylor Valencia Community College
Department of Emergency Medical Services

2. Overview Background Anatomy/Physiology Major Stroke Syndromes
Assessment and Evaluation
Diagnosis
Prehospital Case Studies
Summary

3. Questions

4. Question Hemorrhagic stroke accounts for what percent of all strokes?
A. Less than 5%
B. 15% - 20%
C. 50%
D. 80%

5. Question
Which one of the following events causes the majority of ischemic strokes?
A. Ventricular fibrillation
B. Thromboembolism
C. Atrial fibrillation
D. Intracerebral hemorrhage

6. Question
In a patient suspected of having an acute brain attack, which one of the following is the best way to differentiate between an ischemic or hemorrhagic cause?
A. The history
B. The physical examination
C. A CT scan of the brain
D. An MRI scan of the brain

7. Question
A patient has sudden weakness of the left arm and leg. EMS is called and the patient’s blood pressure is found to be 250/150mmHg. The most appropriate action to be taken by EMS is to monitor and record the blood pressure and:
A. Administer labetalol 15mg IV
B. Administer nifedipine 10mg SL
C. Administer NTG SL
D. Do not administer any antihypertensive agent

8. Question Which one of the following pairings is incorrect?
A. Left brain dysfunction – right sided weakness
B. Brainstem dysfunction – slurred speech
C. Cerebellum dysfunction – dyscoordination
D. Subarachnoid hemorrhage – inappropriate speech

9. Question
Which one of the following is true regarding the “ischemic penumbra”?
A. It is brain tissue with irreversible ischemia
B. It is unaffected by the use of TPA
C. It is worsened by hypotension
D. Can be seen on a CT scan of the brain

10. Question
All of the following are true statements regarding stroke, except:
A. It is the leading cause of disability in the US
B. It is a preventable condition
C. Death from stroke may be reduced by the treatment with TPA
D. Its incidence increases with age

11. Question All of the following are signs of a brainstem stroke, except:
A. Aphasia
B. Hemisensory loss
C. Nausea and vomiting
D. Vertigo

12. Question
All of the following assessments are components of the initial on-site prehospital stroke examination, except:
A. Reflexes
B. Speech
C. Facial symmetry
D. Arm strength

13. Background (USA) #1 Disability #3 Killer 50 million dollars per year
20% mortality
50 million dollars per year
Old therapy
rehabilitation
reduce risk of future strokes
Current therapy
acute interventions
reduce brain area of ischemia
Blood sugar
Blood pressure

14. Background Median Hours to ED Arrival (EMS vs Car) 2nd Goal Goal
Kothari.(Cincinnati) Ann Emerg Med 1999; 33: 1.

15. Background Median Time (Hours) Spent Evaluating Stroke Patients
(Prehospital = time at home + EMS [small part])
Kothari (Cincinnati). Ann Emerg Med 1999; 33: 1.

16. Background - Who is Eligible
O’Connor RE. Ann Emerg Med 1999; 33: 9-14

18. Anatomy & Physiology Posterior cerebral
Anterior Cerebral Artery
leg > arm - opposite side of ischemia
sensory deficits = motor deficit sites
frontal lobe - impaired judgement/insight
Middle Cerebral Artery
face/arm > leg: ignore side/site of deficit
sensory = motor deficit sites
aphasia = speech
Posterior cerebral
vision/mentation
Vertebrobasilar
vertigo/gait/cranial nerves (face/eyes/tongue)
syncope***

19. Anatomy & Physiology Ischemic Stroke Hemorrhagic Stroke TIA low flow
occluded blood vessel (carotid)
embolic - clot travels from heart
80%
Hemorrhagic Stroke
20%
bleed into brain - stop
TIA
temporary deficit - < minutes
high risk of future stroke

20. Ischemic Stroke Most common cause: thromboembolism
CLOT
INFARCT
Most common cause: thromboembolism
Possible sources of clot:
Heart
Large artery (to brain)
Small artery (in brain)
Clot occluding artery

21. Ischemic Stroke: Modifiable Risk Factors
Hypertension (systolic and diastolic)
Cigarette smoking
Prior stroke/ TIA
Heart disease
Diabetes mellitus, hyperlipidemia
Hypercoagulable states
Carotid bruit
Cocaine, excess alcohol

22. Ischemic Stroke: Nonmodifiable Risk Factors
Advanced age
Male gender
African-American heritage
Family history of early stroke or MI

23. Intracerebral Hemorrhage
Most common cause:
chronic hypertension
Other causes:
Vessel malformation
Tumor, bleeding abnormalities
Bleeding into brain

24. Subarachnoid Hemorrhage
Most common cause:
aneurysm rupture
Other causes:
Vessel malformation
Tumor, bleeding abnormalities
Bleeding around brain

25. Transient Ischemic Attack (TIA)
Reversible focal dysfunction, usually lasts mins
Among TIA pts who go to ED:
5% have stroke in next 2 days
25% have recurrent event in next 3 months
Decrease stroke risk with proper therapy:
artery source—antiplatelet (ASA), surgery
heart source—anticoagulation (warfarin)

26. Background
Risk of Stroke Following A
Transient Ischemic Attack

27. Time Is Brain: Save The Penumbra
Core
Clot in Artery

28. Time is Brain: Save the Penumbra
In first few hours of ischemic stroke, brain tissue can still be saved
Zone of reversible ischemia (“penumbra”) surrounds core of irreversible infarction
Patient symptoms due to both infarcted core and ischemic penumbra
One cannot determine by exam how much brain can still be saved

29. Time is Brain: Save the Penumbra
Thrombolytic (fibrinolytic) agent t-PA can limit brain damage safely if given w/in 3 h—it reduces risk of disability due to ischemic stroke by 30%
Administer t-PA only if:
clinical diagnosis confirmed by CT scan
within 3 hours of onset
age 18 or older
no other contraindications

30. Major Stroke Syndromes
LEFT HEMISPHERE
RIGHT HEMISPHERE
BRAINSTEM
CEREBELLUM
HEMORRHAGE 1 1 2 2 5 3 4 4 5 3

31. Left (Dominant) Hemisphere: Typical Signs (Right Side and Aphasia)
Right Visual Field Deficit
Aphasia
Left Gaze Preference
Right Hemiparesis
Right Hemisensory Loss

32. Right (Nondominant) Hemisphere: Typical Signs (Left Side)
Left Hemi-inattention
Left Visual Field Deficit
Right Gaze Preference
Left Hemiparesis
Left Hemisensory Loss

33. Brainstem: Typical Signs (Both Sides)
Crossed Signs (1 side of face and contralateral body
Quadriparesis
Sensory Loss in All 4 Limbs
Hemiparesis Hemisensory Loss

34. Brainstem: Typical Signs (continued)
Decreased LOC
Nausea, Vomiting
Hiccups, Abnormal Respirations
Vertigo, Tinnitus
Eye Movement Abnormalities:
Diplopia
Dysconjugate Gaze
Gaze Palsy
Oropharyngeal Weakness:
Dysarthria, Dysphagia

35. Cerebellum: Typical Signs (Coordination)
Ipsilateral Limb Ataxia (dyscoordination)
Truncal or Gait
Ataxia (imbalance)

36. Symptoms Suggestive of Hemorrhage
Both Subarachnoid and Intracerebral Hemorrhage:
Headache
Nausea, Vomiting
Decreased LOC
Subarachnoid Hemorrhage:
Intolerance to Light
Neck Stiffness / Pain
Intracerebral Hemorrhage:
Focal Signs Such as Hemiparesis

37. The Focused Neurologic Assessment and Evaluation

38. Cincinnati and LA Prehospital Stroke Scales
Perform on scene during Primary Survey
under “D” – Disability:
Speech
Facial Droop
Arm Drift
Grip
“Speech, Droop, Drift, Grip!”

39. (Aphasia = left hemisphere Dysarthria = cranial nerves)
Speech: Repeat Phrase
“You can’t teach an old dog new tricks.”
Abnormal:
Wrong or inappropriate words (aphasia)
Slurred words (dysarthria) or unable to speak
(Aphasia = left hemisphere
Dysarthria = cranial nerves)

40. Facial Droop (Cranial Nerves): Show Teeth or Smile
Abnormal:
One side of face does not move as well as the other side
Right-sided droop
© AHA 1997

41. Arm Drift (Motor): Close Eyes, Hold Out Arms
Abnormal:
One arm does not move or drifts down
Right-sided drift
© AHA 1997

42. Prehospital Stroke Scale
Grip
Normal right and left
Abnormal right or absent right
Abnormal left or absent left
Comparison of sides

43. Prehospital Stroke Identification
Smith. Prehospital Emerg Care 1998; 2: 170.
Kidwell (Los Angelos) Stroke 2000; 31: 71.
Kothari (Cincinnati). Ann Emerg Med 1999; 33: 373.

44. Cincinnati Prehospital Stroke Scale Normal Patient
Click picture to play video

45. Miami Emergency Neurologic Deficit Exam Expanded Prehospital Stroke Exam
MENTAL STATUS
CHECK IF ABNORMAL
Level of Consciousness (AVPU)
Speech “You can’t teach an old dog new tricks.” (repeat)
Abnormal = wrong words, slurred speech, no speech
Questions (age, month)
Commands (close, open eyes)
CRANIAL NERVES
Facial Droop (show teeth or smile) RT LT
Abnormal - one side does not move as well as other
Visual Fields (four quadrants)
Horizontal Gaze (side to side)
LIMBS
Motor–Arm Drift (close eyes and hold out both arms) RT LT
Abnormal–arm can’t move or drifts down
Leg Drift (open eyes and lift each leg separately)
Sensory–Arm and Leg (close eyes and touch, pinch)
Coordination–Arm and Leg (finger to nose, heel to shin)

46. Miami Emergency Neurologic Deficit Exam Normal Patient
Click picture to play video

47. Cincinnati Prehospital Stroke Scale Left Hemispheric Stroke
Click picture to play video

48. Miami Emergency Neurologic Deficit Exam Left Hemispheric Stroke
Click picture to play video

49. Diagnosis and Management
Prehospital
Exclude masqueraders
hypoglycemia/hyperglycemia
drugs/toxins
trauma
hypoxia
Neurologic screen
Cincinnati/LA prehospital stroke scale
not meant to be 100% accurate

50. Management - Glucose
Neurologic Effects of Lo glucose vs. Very Hi glucose
on Infarcted Brain (Rabbit Model)
Thoralf. Stroke 1999; 30:

51. Management - Glucose
Pulsinelli. Am J Med 1983; 74: 540.

52. Management - Blood Pressure
Relationship of CNS tissue perfusion (SPECT scan)
to drop in BP after treatment
Lisk. Arch Neurol 1993; 50: 855.

53. Acute Stroke Patients: Indications for Antihypertensive Therapy
In general:
Consider: absolute level of BP?
If BP: >185/>110 mm Hg = fibrinolytic therapy contraindicated
Consider: other than BP, is patient candidate for fibrinolytics?
If patient is candidate for fibrinolytics: treat initial BP >185/>110 mm Hg
Consider: response to initial efforts to lower BP in ED?
If treatment brings BP down to <185/110 mm Hg: give fibrinolytics
Consider: ischemic vs hemorrhagic stroke?
Treat BP in the / mm Hg range the same
The obvious: no fibrinolytics for hemorrhagic stroke

54. Treatment of High BP in Acute Stroke Patients
BP Level
>185/>110 mm Hg
During/after fibrinolytic treatment BP may rise:
DBP >140 mm Hg
>230/ mm Hg
/ mm Hg
Fibrinolytic Candidate
Nitropaste or labetalol IV
if BP remains elevated:
no fibrinolytics
Nitroprusside
infusion
Labetalol, then prn
nitroprusside
Labetalol
Not a Fibrinolytic Candidate
No acute therapy indicated
Nitroprusside
infusion
Labetalol
Acute therapy only if hypertensive urgency also present
Review suggested antihypertensive therapy for patients with suspected ischemic stroke.
Note: Course participants with a first printing of the 1997 ACLS Textbook should correct it to reflect the most recent versions of Tables 7 and 8 as published in the 1997 ECC Handbook.
MAP is estimated by one third the sum of systolic and double diastolic pressure.
Labetalol should be avoided in patients with asthma, cardiac failure, or severe abnormalities in cardiac conduction. For refractory hypertension, alternative therapy may be considered with sodium nitroprusside, enalapril, or nicardipine.

55. Diagnosis and Management
ED Diagnosis
History and Physical in ED
Supplemented with CT
normal in 1st hours
Thrombolytic Therapy

56. Emergent CT Scan Is necessary to rule out nonstroke cause of symptoms
Is necessary to differentiate ischemic vs. hemorrhagic stroke
Exam alone cannot distinguish stroke vs. nonstroke or ischemia vs. hemorrhage

57. Noncontrast CT Scan: Ischemic Stroke (Left Hemisphere)
R Hours L
R Days L
Subtle blurring and compression of sulci
Obvious dark changes of infarction

58. Noncontrast CT Scan: Hemorrhagic Strokes
Intracerebral Hemorrhage
Subarachnoid Hemorrhage
R L
R L
“Ball” of white
blood in thalamus
White blood in
cisterns & 4th ventricle

59. What Pathology Does This Scan Show?
Scan A
Scan A has a well-defined hypodensity in the left hemisphere consistent with a significant acute ischemic event (3 hours in duration). As a result, this patient would not be a candidate for fibrinolytics. Note that if the hypodensity is thought to be 3 months old, it does not constitute a contraindication to fibrinolytics.
There are hyperdense (white) areas that represent calcification in the choroid plexus rather than bleeding.

60. What Pathology Does This Scan Show?
Scan A
Hypodense area:
Ischemic area with edema, swelling
Indicates >3 hours old
No fibrinolytics!
Scan A has a well-defined hypodensity in the left hemisphere consistent with a significant acute ischemic event (3 hours in duration). As a result, this patient would not be a candidate for fibrinolytics. Note that if the hypodensity is thought to be 3 months old, it does not constitute a contraindication to fibrinolytics.
There are hyperdense (white) areas that represent calcification in the choroid plexus rather than bleeding.
Right
Left

61. What Pathology Does This Scan Show?
Scan B
Scan B shows a large left frontal intracerebral hemorrhage. Intraventricular hemorrhage is present. This patient is not a candidate for fibrinolytics.

62. What Pathology Does This Scan Show?
Scan B
(White areas indicate
hyperdensity = blood)
Large left frontal
intracerebral hemorrhage.
Intraventricular bleeding
is also present
No fibrinolytics!
Scan B shows a large left frontal intracerebral hemorrhage. Intrav- entricular hemorrhage is present. This patient is not a candidate for fibrinolytics.
Right
Left

63. What Pathology Does This Scan Show?
Scan C
Scan C shows diffuse areas of white (hyperdense) images consistent with an acute subarachnoid hemorrhage. The hemorrhage is visible in several areas on the surface of the brain.
A patient like this is not a candidate for fibrinolytic therapy. CT findings may be more subtle than these.

64. What Pathology Does This Scan Show?
Scan C
Acute subarachnoid hemorrhage
Diffuse areas of white (hyperdense) images
Blood visible in ventricles
and multiple areas on surface of brain
Scan C shows diffuse areas of white (hyperdense) images consistent with an acute subarachnoid hemorrhage. The hemorrhage is visible in several areas on the surface of the brain.
A patient such as this is not a candidate for fibrinolytic therapy. CT findings may be more subtle than these.

65. Management - Thrombolytics
Percent of Patients with Minimal/No deficit at 3 months
NINDS. New Engl J Med 1995; 333: 1581.

66. Fibrinolytic Therapy: Yes/No Checklist
Inclusion Criteria
(all “Yes” boxes must be checked before
fibrinolytics are given)
Yes
 Age 18 years or older
 Clinical diagnosis of ischemic stroke causing a measurable neurologic deficit
 Time of symptom onset well established to be <180 minutes before treatment would begin
Review inclusion criteria: all must be present for fibrinolytic therapy to be initiated.

67. Fibrinolytic Therapy: Yes/No Checklist
Exclusion Criteria
(all “No” boxes must be checked before fibrinolytics are given): No
 Evidence of intracranial hemorrhage on noncontrast head CT
 Only minor or rapidly improving stroke symptoms
 High suspicion of subarachnoid hemorrhage even if CT is normal
 Active internal bleeding (eg, gastrointestinal bleeding or urinary bleeding within last 21 days)
 Known bleeding diathesis, including but not limited to
— Platelet count < mm3
— Patients who received heparin in last 48 hours; have elevated PTT
— Recent anticoagulant use (eg, coumadin); have elevated PT
Review exclusion criteria: all must be absent for fibrinolytic therapy to be initiated.
Note: The instructor has the option of indicating the presence of one exclusion criterion to determine if participants will later correctly exclude the patient from fibrinolytic therapy if the ischemic stroke branch is used.

68. Fibrinolytic Therapy: Yes/No Checklist
Exclusion Criteria (cont’d)
(all “No” boxes must be checked before fibrinolytics are given): No
 <3 mo ago: intracranial surgery, head trauma, previous stroke
 <14 days ago: major surgery or serious trauma
 <7 days ago: lumbar puncture
 Recent arterial puncture at noncompressible site
 History of intracranial hemorrhage, AV malformation, or aneurysm
 Witnessed seizure at start of stroke
 Recent acute myocardial infarction
 SBP >185 mm Hg/DBP >110 mm Hg; confirmed several times
 BP must be treated aggressively to bring within these limits
Review exclusion criteria: all must be absent for fibrinolytic therapy to be initiated.

69. Management - thrombolytics
Requirements - all within 3 hours
Recognition/identification
potentially eligible patients
History
Awaken with weakness does NOT count)
Exclusion criteria
Exam
detailed
NIH stroke scale
CT scan
must be read by neuro-radiologist (subtle exclusions)
Consent

70. Management - other options
New neuroprotective agents
Selective intra-arterial
thrombolytics
angioplasty?
Stents/coils?
EXTENDS window to 4-6 hours

71. Acute Stroke Algorithm
Suspected Stroke
EMS assessments and actions
Immediate assessments performed by EMS
personnel include
Cincinnati Prehospital Stroke Scale (includes difficulty speaking, arm weakness, facial droop)
Los Angeles Prehospital Stroke Screen
Alert hospital to possible stroke patient
Rapid transport to hospital
Detection
Dispatch
Delivery
Door
Immediate assessment:
<10 minutes from arrival
Assess ABCs, vital signs
Provide oxygen by nasal cannula
Obtain IV access; obtain blood samples (CBC, electolytes, coagulation studies)
Check blood sugar; treat if indicated
Obtain 12-lead ECG, check for arrhythmias
Perform general neurological screening assessment
Alert Stroke Team: neurologist, radiologist, CT technician
Immediate neurological assessment:
<25 minutes from arrival
Review patient history
Establish onset (<3 hours required for fibrinolytics)
Perform physical examination
Perform neurological examination:
Determine level of consciousness (Glasgow Coma Scale)
Determine level of stroke severity (NIH Stroke Scale or Hunt and Hess Scale)
Order urgent noncontrast CT scan (door-to–CT scan performed: goal <25 minutes from arrival)
Read CT scan (door-to–CT read: goal <45 minutes from arrival)
Perform lateral cervical spine x-ray (if patient comatose/history of trauma)
Have students follow the algorithm in their textbook or in the 2000 ECC Handbook.

72. Case-Based Prehospital Scenarios

73. Click picture to play video
Case 1: On scene
Click picture to play video

74. Case 1:Transport (patient is 60 / month is December)
Click picture to play video

75. Case 1: Discussion 1. Is this more likely a stroke or stroke mimic?
2. What are the physical findings?
3. Where in the brain is the abnormality?
4. Is the radio report complete?
5. Is this patient a candidate for t-PA?
1. What stroke syndrome do you suspect?
- Left hemisphere
2. What are the physical findings?
- Expressive aphasia
- Right facial droop
- Right visual field cut
- Left gaze preference. Right gaze deficit.
- Right arm drift
- Right leg drift
- Right hemi-sensory loss
- Normal coordination, but limited on right by weakness
3. Is the radio report complete? -
4. Is this patient a candidate for thrombolytics?
- Yes

76. Click picture to play video
Case 2: On Scene
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77. Case 2:Transport (patient is 45 / month is December)
Click picture to play video

78. Click picture to play video
Case 2: Radio Report
Click picture to play video

79. Case 2: Discussion 1. Is this more likely a stroke or stroke mimic?
2. What are the physical findings?
3. Where in the brain is the abnormality?
4. Is the radio report complete?
5. Is this patient a candidate for t-PA?

80. Click picture to play video
Case 3: On Scene
Click picture to play video

81. Case 3:Transport (patient is 48 / month is October)
Click picture to play video

82. Click picture to play video
Case 3: Radio Report
Click picture to play video

83. Case 3: Discussion 1. Is this more likely a stroke or stroke mimic?
2. What are the physical findings?
3. Where in the brain is the abnormality?
4. Is the radio report complete?
5. Is this patient a candidate for t-PA?

84. Click picture to play video
Case 4: On Scene
Click picture to play video

85. Case 4:Transport (patient is 69 / month is December)
Click picture to play video

86. Click picture to play video
Case 4: Radio Report
Click picture to play video

87. Case 4: Discussion 1. Is this more likely a stroke or stroke mimic?
2. What are the physical findings?
3. Where in the brain is the abnormality?
4. Is the radio report complete?
5. Is this patient a candidate for t-PA?

88. Maximum Intervals Recommended by NINDS
Summary Key Evaluation Targets for Stroke Patient: Potential Fibrinolytic Candidate?
Maximum Intervals Recommended by NINDS
Door-to–doctor first sees patient …….………… 10 min
Door-to–CT completed …….………………….. 25 min
Door-to–CT read ...…………..………………… 45 min
Door-to–fibrinolytic therapy starts …………… min
Neurologic expertise available* …..…………… 15 min
Neurosurgical expertise available* …………… 2 hours
Admitted to monitored bed ..……...…………… 3 hours
Review times.
Answer 1: Review the patient’s history, verify time of symptom onset, and perform brief physical and neurologic examinations.
Answer 2: The NIHSS measures neurologic function, which correlates with ischemic stroke severity and long-term outcome. It can be performed in 7 minutes and can be performed simultaneously with initial admission procedures, so it should not delay other assessment or therapy. It enables performance of serial standardized neurologic evaluation over time by a nurse or physician. This stroke scale is shown in the ACLS Textbook and the 2000 ECC Handbook.
The NIHSS is not a comprehensive neurologic exam, and further studies may be required. The NIHSS evaluates the following 5 areas, and the resulting score (0-42) will guide decisions about therapy:
Level of consciousness
Visual assessment
Motor function
Sensation and neglect
Cerebellar function
Training in the NIHSS is beyond the scope of this course but will be included in the advanced ACLS course. Videotapes are available to teach the use of this scale.
Additional scales: Hunt and Hess Scale for subarachnoid hemorrhage and Glasgow Coma Scale. See the ACLS Textbook.

89. Thank You
I’M OUTTA HERE