AHA Acute Stroke Online

Immediate Neurologic Assessment by Stroke Team or Designee (Step 4) goal for neurologic assessment is within _______ minutes of the patient's arrival in the ED

25

the __________________ is alive but dysfunctional because of altered membrane potentials. The dysfunction is potentially reversible.

penumbra

Ischemic stroke rarely leads to death within _______ hour(s).

1

hemorrhagic strokes can be further classified as intracerebral = _______% or subarachnoid = _______%

10, 3

Identification of ischemic stroke in less than_______ hours of onset of symptoms may enable fibrinolytic therapy.

3

classify strokes as either ischemic = ______% or hemorrhagic = _____%

87, 13

_______________ circulation = (carotid artery territory) stroke = Stroke that follows occlusion of branches of the carotid artery. Such strokes usually involve the _____________ ______________. This is the most common type of stroke, occurring in 80% of all ischemic stroke patients.

Anterior, cerebral hemispheres

Rapid triage, evaluation, and management within the ED

Data

Stroke expertise and therapy selection

Decision

Rapid EMS identification, management, and transport

Delivery

Rapid recognition of stroke symptoms

Detection

Early activation and dispatch of EMS by calling 9-1-1

Dispatch

Rapid admission to stroke unit or critical care unit

Disposition

Appropriate triage to stroke center

Door

_________ responder checks for 3 physical findings: Facial droop (Figure 5) Arm drift (Figure 6) Abnormal speech

EMS

most common cause of acute ischemic stroke is __________________ of the carotid or vertebrobasilar artery.

atherosclerosis

__________ ______________ remains the most frequent cause of cardioembolic stroke.

atrial fibrillation

_______________ accident or stroke refers to the acute neurologic impairment that follows an interruption in blood supply or a rupture of a blood vessel to a specific region of the brain

cerebrovascular

8 D's of Stroke Care = major steps in diagnosis and treatment and are:

detection, dispatch, delivery, door, data, decision, drug, disposition

_______________ stroke = Intravascular material, most often a blood clot, separates from a proximal source and flows through an artery until it occludes an artery in the brain. Many of these are cardioembolic—originating from the heart—in patients with atrial fibrillation, valvular heart disease, acute myocardial infarction (AMI), or rarely, endocarditis.

embolic

Glasgow Coma Scale: total score ranges from 3 to 15. It is the sum of the best response the patient displays for 3 functions: ________opening (1 through 4), ____________ responses (1 through 5), and _____________ function (1 through 6).50 The patient who has no verbal response, has no eye opening, and is flaccid has a GCS score of 3. In general, a GCS score of _______or less is associated with an ominous prognosis.

eye, verbal, motor, 8

_________________ stoke = A more global pattern of brain infarction that results from low blood flow or intermittent periods of no flow. Hypoperfusion stroke often occurs in patients who recover cardiac function after sudden cardiac arrest.

hypoperfusion

EMS assessments and actions for patients with suspected stroke include the following steps: Rapid ____________ of patients with signs and symptoms of acute stroke (√ Detection) Support of ________ functions Prearrival ____________ of the receiving facility _________ transport of the patient to the receiving facility

identification, vital, notification, rapid

Rapid diagnosis and treatment in hospital Ability to rapidly determine patient eligibility for fibrinolytic therapy Administration of fibrinolytic therapy to appropriate candidates within target times Initiation of the stroke pathway and patient admission to a stroke unit if available

in-hospital acute stroke care

___________________ hemorrhagic stroke (10%): Occurs when blood leaks directly into the brain parenchyma, usually from small _________________ arterioles damaged by chronic hypertension. _______________ is the most common cause. Among the elderly, amyloid angiopathy appears to play a major role.

intracerebral, intracerebral, hypertension

Reperfusion therapy with recombinant tissue plasminogen activator (rtPA) is appropriate for ____________ stroke only. ____________ stroke is an absolute contraindication to rtPA therapy. rtPA can be fatal if given mistakenly to a patient having a ______________ stroke.

ischemic, hemorrhagic, hemorrhagic

In ST-segment elevation myocardial infarction (STEMI), time is __________. When acute ischemic stroke occurs, time is _________, so the reperfusion concept was expanded to include not only patients with acute coronary syndromes (STEMI) but also highly selected stroke patients.

muscle, brain

_______________ circulation (vertebrobasilar artery territory) stroke = Stroke that follows occlusion of branches of the vertebrobasilar artery. These strokes usually involve the _______________ or _____________.

posterior, brainstem, cerebellum

ambulance may bypass a hospital if: The facility does not have the ___________for acute stroke care The facility lacks an ________________ commitment to treat patients with a stroke A more appropriate hospital is available within a ______________ transport interval

resources, institutional, reasonable

_____________ ____________ is the key mechanism of most thrombotic and embolic strokes in patients without valvular heart disease or atrial fibrillation

ruptured plaque

Patients with acute ischemic stroke have a time-dependent benefit for fibrinolytic therapy similar to that of patients with STEMI, but this time-dependent benefit is much (shorter/longer)________________.

shorter

__________________ hemorrhagic stroke (3%): Occurs when blood leaks from a cerebral vessel into the _________________ space. If the rupture occurs in a cerebral artery, the blood is released at systemic arterial pressure, which causes sudden, painful, and dramatic symptoms. _________________ cause most subarachnoid hemorrhages. Arteriovenous malformations cause approximately 5% of these strokes.

subarachnoid, subarachnoid, aneurysms

Ischemic Stroke Times: Immediate general assessment by the stroke team, emergency physician, or another expert within ______ minutes of arrival; urgent noncontrast computed tomographic (CT) scan ordered Neurologic assessment by the stroke team or their designee and CT scan performed within ______ minutes of hospital arrival Interpretation of the CT scan within ______minutes of ED arrival Initiation of fibrinolytic therapy in appropriate patients (those without contraindications) within _____ hour of hospital arrival and within _____ hours from symptom onset Door-to-admission time of _____ hours

10, 25, 45, 1, 3, 3

Fibrinolytic or endovascular therapy

Drug/device

_____________ __________ __________ ________ or RIND= Any focal neurologic deficit that resolves completely and spontaneously within 24 hours. (RINDs were previously called TIAs.) Any patient with a persistent neurologic deficit beyond 24 hours is said to have had a stroke. New diagnostic techniques have shown that _______% of patients with a TIA or RINDs have definite evidence of brain infarction.

Reversible ischemic neurologic deficit, 60

____________ infarcts are one example of the type of thrombotic stroke caused by chronic hypertension. They are thought to result from occlusion of a small perforating artery to the ______________ areas of the brain. A major cerebrovascular burden imposed by chronic hypertension is _______________ stroke.

lacunar, subcortical, hemorrhagic

Rapid recognition and reaction to stroke warning signs Rapid EMS dispatch Rapid EMS system transport and prearrival notification to the receiving hospital

out-of-hospital acute stroke care

Key Components of a Focused __________ Patient History Time of symptom onset Recent past medical history Stroke TIA Atrial fibrillation Acute coronary syndromes (myocardial infarction) Trauma or surgery Bleeding disorder Complicating disease Hypertension Diabetes mellitus Medication use [Anticoagulants (warfarin) or newer anticoagulant agents (direct thrombin inhibitors or factor Xa inhibitors) Antiplatelet agents (aspirin, clopidogrel, ticagrelor)] Antihypertensives

stroke

_______________ stroke = An acute clot that occludes an artery, is superimposed on chronic arterial narrowing, acutely altered endothelial lining, or both. This pathophysiology parallels that for acute coronary syndromes (ACS), in which a ruptured or eroded plaque is the proximate cause of most episodes of ACS.

thrombotic

_____________ __________ __________ or ____--also called a mini-stroke = A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. Clinically, most TIAs resolve completely and spontaneously within 1 hour.

transient ischemic attack, TIA