Management of Adult Patients Presenting to the Emergency Department with Acute Ischemic Stroke

Publication Date: May 11, 2023
Last Updated: May 12, 2023

Summary of Recommendations

In adult patients with suspected stroke, either the Los Angeles Motor Scale (LAMS) or Rapid Arterial Occlusion Evaluation Scale (RACE) may be used to identify patients with increased likelihood of an LVO. (C)
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Obtain CTP or MR-based diffusion/perfusion imaging in patients with acute ischemic stroke because of LVO, especially if the time the patient was last known normal was between 6 and 24 hours before arrival to the ED. (C)
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Use either tenecteplase or alteplase in patients with acute ischemic stroke who qualify for thrombolysis. (B)
For tenecteplase, use 0.25 mg/kg maximum dose 25 mg bolus; for alteplase, use 0.9 mg/kg maximum dose 90 mg with 10% given as a bolus and the remaining as an infusion over 60 minutes.
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In addition to a standard comprehensive history and physical examination, physicians may use specific findings such as ABCD2 score, ocular motor examination, presence of additional neurologic deficits, and HINTS to risk stratify patients with a possible stroke. (C)
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Before employing a maneuver such as HINTS, physicians should have sufficient education to perform the technique. (U)
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Critical Issues in the Management of Adult Patients Presenting to the Emergency Department with Acute Ischemic Stroke

Authoring Organization

Publication Month/Year

May 11, 2023

Last Updated Month/Year

February 14, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

This clinical policy from the American College of Emergency Physicians addresses key issues in acute 55 stroke management in adult patients presenting to the emergency department. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: 1) In adult patients with a suspected acute ischemic stroke, can a clinical decision instrument be used to identify patients who have a large vessel occlusion on computed tomography angiography or magnetic resonance angiography? 2) In adult patients with a suspected acute ischemic stroke, does the addition of perfusion imaging to a computed tomography angiography or magnetic resonance angiography identify patients more likely to benefit from thrombectomy? 3) In adult patients with a suspected acute ischemic stroke qualifying for intravenous thrombolysis, is tenecteplase safe and effective compared with alteplase? (4) In adult patients who present with acute vertigo with possible stroke, are there history or physical examination findings (eg, Head Impulse-Nystagmus-Test of Skew examination) that can risk stratify for acute ischemic stroke? Evidence was graded, and recommendations were made based on the strength of the available data.

Target Patient Population

This guideline is intended for adult patients 18 years and older presenting to the ED with acute ischemic stroke.

Target Provider Population

This guideline is intended for adult patients 18 years and older presenting to the ED with acute ischemic stroke.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Emergency care, Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Treatment

Diseases/Conditions (MeSH)

D000083242 - Ischemic Stroke

Keywords

Acute Ischemic Stroke, AIS

Methodology

Number of Source Documents
83
Literature Search Start Date
November 17, 2020
Literature Search End Date
February 4, 2021