This document discusses acute ischemic stroke (AIS) management. It notes that AIS is caused by focal cerebral, spinal or retinal infarction. It highlights the importance of rapid identification, stabilization, and transport to a certified stroke center to reduce treatment delays. For thrombolysis to be effective, it must be administered within 4.5 hours of symptom onset. The document outlines evaluation and treatment protocols for AIS patients in the pre-hospital and emergency department settings. Overall, it emphasizes minimizing time delays to improve outcomes through coordinated systems of stroke care.

3. ◘ AIS is defined as an episode of neurological
dysfunction caused by focal cerebral, spinal or
retinal infarction.
◘ In developed countries stroke had dropped from the
2nd to the 5th cause of death (after heart diseases,
cancer, chronic lower respiratory diseases and
accidents).
◘ On the other hand, in developing countries stroke
still impacted as the 2nd cause of death.

4. ◘ 20% of stroke survivors are unable to return to
work, 10% will have another stroke within one
year, 30% require assistance with activities of
daily living, 18% require assistance with
ambulation, and 16% require institutional care.
◘ Better stroke prognosis is attributed to greater
awareness of stroke symptoms and improved
care within the first hours of onset.

5. ◘ In 1996, the FDA approved IV r-tPA as the only
therapy for early AIS management and since
this date many efforts had spent to reduce the
stoke onset/needle time due to the narrow
therapeutic window.
◘ Many stroke patients are elderly who reside
alone or with their spouse with limited
support from younger generations. These
patients are unable to do anything beyond
alarming the system.

7. ◘ Till intra-arterial reperfusion, 2 million neurons
are lost each minute and every 30-min delay
reduces the relative likelihood of a good
clinical outcome by 15%.
◘ < 1.4 % of AIS patients receive IV r-tPA in the
first 60 minutes.
◘ The rate of IV thrombolysis in the window is
3.4 – 9.1 % of AIS patients.

12. ◘ The call to the EMS stroke center is the first
link in the SCS which must be activated at
once.
◘ The dispatcher must not leave the scene before
establishing the Time ZERO which is defined as
the time at which the patient was last known
or seen normal. .

13. 1- Describe the various types of stroke and their etiology.
2- Discuss the imperatives for best practice in regard to
EMS stroke management.
3- List 5 or more risk factors for acute stroke.
4- Define “penumbra” and how this concept is important in
stroke.
5- Generally describe the major vessels involved in acute
ischemic stroke.
6- Discuss the “therapeutic window” for thrombolytic
therapy in stroke.
7- Identify interventions that individual EMS providers can
make to improve outcomes in stroke.

14. 1- ABC and IV access.
2- O2 administration if Sa O2 < 95% (routine use is not recommended).
3- No need for pre-hospital management of high blood pressure or
elevated body temperature.
4- For hypotension, horizontal placement of the stretcher head and
isotonic saline.
5- No need for insulin administration in hyperglycemia.
6- IV glucose if RBS is below 60 mg/dl.
7- No benefits from the pre-hospital use of neuroprotective e.g.
nimodipine or magnesium sulphate.

15. (1) Rapid stroke identification.
(2) Early stabilization of vital functions.
(3) Rapid transport to closest available certified
stroke ready hospital.
- Bypass the stroke non-ready hospitals.
- Air medical transport is considered when ground
transport is >1 hour.
(4) Pre-arrival hospital notification.

16. Theprobabilityofstrokeis 72%in patientwith1 probabilityand85%inwhomhas3 probabilities

19. ◘ EMS personnel should provide prehospital
notification to improve the readiness of the
hospital team which shorten the door to
needle time by about 15 minutes.
◘ Teleradiology systems had approved for sites
without in-house imaging interpretation
expertise.

20. ◘ Tele-stroke/teleradiology evaluations of AIS
patients can be effective for correct IV r-tPA
eligibility decision making.
◘ Administration of IV r-tPA guided by tele-stroke
consultation for patients with AIS which is as
safe as the stroke centers.

23. ◘ ABCs should be reassessed and rechecked
frequently.
◘ Stroke assessment focusing on the 4 key issues:
1- Level of consciousness.
2- Type of stroke (hemorrhagic versus non-
hemorrhagic).
3- Location of stroke (carotid versus vertebra-basilar).
4- Severity of stroke.

24. ◘ Obtaining the exact time of stroke onset (time zero).
◘ NIHSS.
◘ CT initiation & interpretation.
◘ Anticoagulants and fibrinolytic agents should be withheld until CT has ruled
out a brain hemorrhage.
◘ Stroke Mimics (Chameleons):
- Unrecognized seizures. - Confusional states.
- Syncope. - Toxic or metabolic disorders.
- Hypoglycemia. - Brain tumors.
- Subdural hematoma. - Psychogenic.

25. ◘ For ( * ) marked investigations, IV r-tPA should not be delayed while awaiting their results.
◘ Non-contrast brain CT or brain MRI
◘ Blood glucose
◘ Oxygen saturation
◘ Serum electrolytes/renal function tests *
◘ Complete blood count, including platelet
count *
◘ Markers of cardiac ischemia *
◘ PT/INR *
◘ Activated PTT *
◘ ECG *
All patients Selected patients
◘ Ecarin clotting time & thrombin time (if pt.
receiving direct thrombin or direct factor
Xa inhibitors).
◘ Hepatic function tests
◘ Toxicology screen
◘ Blood alcohol level
◘ Pregnancy test
◘ Arterial blood gas tests
◘ Chest radiography
◘ Lumbar puncture (if SAH is suspected
and CT scan is negative)
◘ EEG (if seizures are suspected)

26. ◘ General care includes, (but is not limited to):
1- Prevention of aspiration.
2- Management of hypertension.
3- Management of hyper/hypo-glycemia.
4- Management of seizures.
5- Management of elevated intra-cranial pressure
(ICP).

34. ◘ The front-line stroke-ready hospitals quickly administer r-tPA then transport patients to a more advanced
center withbetter stroke treatment facilities.

35. ◘ Written emergency stroke care protocols.
◘ Written transfer agreement to a hospital with
neurosurgical expertise in less than 2 hours.
◘ Director of stroke care to oversee hospital stroke
policies and procedure.
◘ 24 / 7 ability to administer IV r-tPA.
◘ 24 / 7 ability to perform emergency brain CT.
◘ 24 / 7 ability to perform emergency laboratory
testing.
◘ No need of invasive catheter procedure or specialized
stroke ICU.

36. ◘ Availability of advanced imaging techniques,
including MRI/MRA, CTA, DSA and TCD.
◘ Ready for all CVS management i.e. ischemic,
hemorrhagic and SAH.
◘ 24 / 7 ready IV r-tPA and endovascular team able for
mechanical thrombectomy.
◘ Availability of specialized stroke ICU.
◘ 24 /7 neurosurgical team able to perform aneurysm
clipping, vascular malformation surgery and carotid
endarterectomy.

39. ◘ Bringing swift treatment to the patient, instead
of the conventional approach of awaiting the
patient’s arrival at the hospital.
◘ This strategy is based on the use of an
ambulance (mobile stroke unit) equipped
with an imaging system, a point-of-care
laboratory, a telemedicine connection to the
hospital, and appropriate medication.

42. ◘ While building a SCS system, do not look for
the unreachable solutions, but always adjust
the system regarding the available resources.
◘ SCS is a dynamic process that needs continuous
evaluation, quality assessment and updating
to identify and solve gaps as well as disparities
in providing stroke care.
◘ Do not think about mobile stroke units while
you are wasting > extra 40 minutes in the
door / needle time.

43. ◘ The EAN is not convinced in the value of
generalization the German STEMO trial which
decreases the alarm / needle time by about 25
minutes (52 minutes STEMO vs. 77 minutes
ordinary SCS).
◘ In Australia, air medical transport reduced alarm
/ needle time by 30 minutes.
◘ The clinical data regarding the value pre-hospital
laboratory investigations in reducing the door /
needle time are contradictory.

44. 1- Increasing social awareness.
2- Training the EMS staff.
3- Arrangement with the Directorate of Health
Affairs in Gharbia Governorate to set up the
drip and ship strategy.
4- Financial support (governmental, third party
agencies and the civil society institutions), for
reimbursement of the r-tPA.
5- The administrative procedures, laboratory
investigations and imaging steps should be done
in the same building and simultaneously rather
than consecutively.

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46. Center of Neurology and Psychiatry,
Tanta University