Ischemic Anterior Circulation Stroke Edward C. Jauch, MD, MS Assistant Professor Department of Emergency Medicine University of Cincinnati College of Medicine

Ischemic Anterior Circulation StrokeIschemic Anterior Circulation Stroke

Edward C. Jauch, MD, MSEdward C. Jauch, MD, MS

Assistant ProfessorAssistant ProfessorDepartment of Emergency MedicineDepartment of Emergency Medicine

University of Cincinnati College of MedicineUniversity of Cincinnati College of MedicineCincinnati, OHCincinnati, OH

andandGreater Cincinnati/Northern Kentucky Greater Cincinnati/Northern Kentucky

Stroke TeamStroke Team

Edward Jauch, MD, MS

Lecture GoalsLecture Goals

• Review Emergency Department evaluation of acute ischemic stroke

• Identify issues specific to thrombolytic therapy in acute stroke

• Identify treatment options for acute ischemic stroke

Introduction


61 year old male, with acute aphasia, 61 year old male, with acute aphasia,

right facial droop, and right sided weaknessright facial droop, and right sided weakness

• 12:30 Sudden onset while working in yard

• 12:45 Family calls 911

• 13:05 Advanced squad evaluates and

rapidly transports

• 13:15 Squad notifies receiving

hospital of possible stroke patient

Case


61 year old male with possible stroke 61 year old male with possible stroke arrives at Our Lady of Faint Hopearrives at Our Lady of Faint Hope

• 13:30ED triage andphysician evaluation

• 13:45 Stroke Team responds

• 14:00CT scan performed

• 14:15Discuss with family and PMD

• 14:20Labs back: gluc 97BP remains 150/70’s

Case


Neurologic ExaminationNeurologic ExaminationNIH Stroke ScaleNIH Stroke Scale

ItemItem DescriptionDescription ScoreScore

1a1a

1b1b1c1c2233445566778899

1010111112121313

Level of ConsciousnessLevel of ConsciousnessLOC QuestionsLOC QuestionsLOC CommandsLOC CommandsBest GazeBest GazeBest VisualBest VisualFacial PalsyFacial PalsyMotor Arm LeftMotor Arm LeftMotor Arm RightMotor Arm RightMotor Leg LeftMotor Leg LeftMotor Leg RightMotor Leg RightLimb AtaxiaLimb AtaxiaSensorySensoryNeglectNeglectDysarthriaDysarthriaBest LanguageBest Language

00 0000111122002200220011000011

Case


61 yo male with possible stroke61 yo male with possible stroke

• 14:20CT reading: No hemorrhage or

early ischemia

• 14:25Checklist done: No exclusion

criteria met

• 14:30Decision timeCase


Impact of StrokeImpact of Stroke

• 3rd leading cause of death in the U.S.

• A leading cause of adult disability

• 600,000 new strokes per year in U.S.

• 85% are ischemic

Introduction


Death Rates from StrokeDeath Rates from Stroke

10594 94

104

75

58 56 58 60

0

20

40

60

80

100

120

1900 1920 1945 1950 1980 1990 1992 1993 1995Year

Str

oke

Dea

ths

per

100

k

(Dept Health and Human Services)(Dept Health and Human Services)Epidemiology


Stroke OutcomesStroke Outcomes

• In the 4.5 million US stroke survivors:

10% Recover almost completely

25% Recover with minor impairments

40% Experience moderate to severe impairments requiring special

care

10% Require care in a nursing home or other long-term care facility

15% Die shortly after the strokeOutcomes

(NSA, 2001)(NSA, 2001)


Stroke OutcomesStroke Outcomes

• Medical morbidity associated with stroke:30% Develop pneumonia within first month

10% Risk of recurrent stroke per year10% Deaths post-stroke from pulmonary

embolisms

• Other morbidity from stroke:23% Develop multi-infarct dementia

70%* Develop depression (27% major)

40% Depression common among care-givers

Outcomes *High end of estimates*High end of estimates


Stroke Risk FactorsStroke Risk Factors

• Modifiable risk factors

– High blood pressure– Cigarette smoking– Transient ischemic

attacks– Heart disease– Diabetes mellitus– Hypercoagulopathy– Carotid stenosis– Other

• Unmodifiable risk factors

– Age– Gender– Race– Prior stroke– Family History

• Other possible risk factors– Sickle cell disease– Apolipoproteins– Others

Epidemiology


Influence of Initial Medical ContactInfluence of Initial Medical Contacton Arrival Times to the E.D.on Arrival Times to the E.D.

0

50

100

150

200

250

300

350

400

Time from Onset to ED

Arrival(mins)

911 Private MD Hospital

Mean

Median

(Barsan, Arch Int Med, 1993)(Barsan, Arch Int Med, 1993)Epidemiology

Edward Jauch, MD, MS(Pancioli JAMA 1998; Kothari Stroke 1997)(Pancioli JAMA 1998; Kothari Stroke 1997)

DetectionDetection

• What are Signs & Symptoms?– 43% general public didn’t know any– 39% of acute stroke patients didn’t know any

• What are Risk Factors?– 32% general public didn’t know any– 43% of acute stroke patients didn’t know any


Where Are We Today?Where Are We Today?

• Poorly informed

• Too slow

• Too late

• Ill prepared

• Fatalistic

Epidemiology


Forces of ChangeForces of Change

• Public expectations– Aware of “Draino for the Braino” – Nihilistic attitude of stroke changing

• Medical - legal pressures

• Managed care cost concerns

• New treatments of stroke on horizon

• Change in treating physicians perceptions of “risk”

Epidemiology


Organized Stroke Care Organized Stroke Care Saves LivesSaves Lives

• 21% reduction in early mortality

• 18% reduction in 12 month mortality

• Decreased length of hospital stay

• Decreased need for institutional care

(Jorgensen, Stroke 1994)(Jorgensen, Stroke 1994)Epidemiology


Patient Aversion to Patient Aversion to Various Stroke OutcomesVarious Stroke Outcomes

0123456789

10

Languagedeficits

Cognitivedeficits

Motordeficits

Death

Mild

Moderate

Severe

(Solomon, Stroke 1994)(Solomon, Stroke 1994)

Aversion:Aversion:

Epidemiology


Tissue-Plasminogen Activator inTissue-Plasminogen Activator inAcute Ischemic StrokeAcute Ischemic Stroke

• Double-blinded, randomized

• Placebo controlled

• 0.9 mg / kg IVP dose

• 624 patients

• Treated within 3 hours– 1/2 within 90 minutes– 1/2 within 91-180 minutes

Management


Benefits of ThrombolyticsBenefits of Thrombolyticsin the NINDS Trialin the NINDS Trial

No/Minimal Moderate No/Minimal Moderate Severe Severe DeadDead

For every 16 patients:


0

1

2

3

4

5

6

7

8

50 60 70 80 90 100 110 120 130 140 150 160 170 180

Minutes from Stroke Onset to Start of Treatment

Od

ds

Rat

io f

or

Fav

ora

ble

O

utc

om

e at

3 M

on

ths

Relationship of Time to Thrombolytic Treatment

Odds Ratio of Favorable Outcome

Benefit for rt-PA

No Benefit for rt-PA

Management

Time is Brain!Time is Brain!


Symptomatic Hemorrhages Symptomatic Hemorrhages by CT Findings in NINDS Trialby CT Findings in NINDS Trial

31

6

0

5

10

15

20

25

30

35

Yes No

Percent of Patients that Developed Symptomatic HemorrhagesPercent of Patients that Developed Symptomatic Hemorrhages

(Broderick, Stroke 1997)(Broderick, Stroke 1997)

%

Edema or Mass Effect Seen on Initial CTEdema or Mass Effect Seen on Initial CT


Symptomatic Hemorrhages by Symptomatic Hemorrhages by Baseline NIHSS in the NINDS TrialBaseline NIHSS in the NINDS Trial

23

54

17

02468

1012141618

0-5 6-10 11-15 16-20 >20

Baseline NIH Stroke Scale Score

Percentage of t-PA Patients with Symptomatic ICHPercentage of t-PA Patients with Symptomatic ICH

(Broderick, Stroke 1997)(Broderick, Stroke 1997)


Cost Effectiveness for rt-PA Cost Effectiveness for rt-PA in Acute Ischemic Strokein Acute Ischemic Stroke

rt-PA placebo p value

LOS 10.9 12.4 0.02

Discharge home 48% 36% 0.002

With rt-PA, considering 1,000 eligible patients:

Hospitalization costs $1.7 million more

Rehabilitation costs $1.4 million less

Nursing home costs $4.8 million less

564 quality-adjusted life-years saved

(Fagan, Neurology 1998)(Fagan, Neurology 1998)Epidemiology


STARS StudySTARS Study

• Prospective Phase IV study mandated by FDA• Multicenter (24 academic, 33 community)• NINDS protocol used for 389 patients• Median times:

Onset to treatment 2.7 hrs Arrival to treatment 1.6 hrs Less than 4% treated in under 90 mins

• Median NIHSS 13 (14 mean)

(Albers, JAMA 2000)(Albers, JAMA 2000)Management



• Results – Outcome– Favorable outcome 35% (mR1) – Functionally independent 43% (mR2) – 30 day mortality rate 13%

• Results – Complications– Symptomatic ICH* 3.3%

* Within 3 days

– Fatal ICH 1.8%

(Albers, JAMA 2000)(Albers, JAMA 2000)Management



• Predictors of favorable outcome– Baseline NIHSS < 10– Absence of significant CT abnormalities– Age < 85 years– Lower mean arterial pressure

• Predictors of lack of response– NIHSS (22% decrease in OR per 5 points)– NIHSS > 10 75% decrease in OR– Significant CT findings 87% decrease in OR– Increased mean arterial pressure 19% decrease in OR

Management (Albers, JAMA 2000)(Albers, JAMA 2000)


Cleveland Area ExperienceCleveland Area Experience

• Historical prospective cohort study

• Conducted July 1997 through June 1998

• Multicenter –29 hospitals (academic and community)

• No coordination or fixed protocol (NINDS protocol assumed)

• 3948 patients reviewed

(Katzen, JAMA 2000)(Katzen, JAMA 2000)Management



• Results –– 3984 AIS patients admitted to 29 hospitals in 1 yr– 17% admitted within 3 hours of stroke onset– 1.8% received t-PA at 16 hospitals

(0 - 10.2% of stroke patients)– Of the top 4 hospitals in Cleveland, utilization

ranged from 0-28% within 3 hour window




• Results – Complications in tPA patients– Total ICH rate 22%– Symptomatic ICH* 15.7%– Fatal ICH 8.6%

• Results – Mortality rate– tPA patients 15.7%– Patients in 3 hours ø tPA 7.2%– All patients ø tPA 5.1%

Management (Katzen, JAMA 2000)(Katzen, JAMA 2000)



• Results – Protocol violations– Total NINDS violations 50%– Antiplatelets / anticoagulants 37.1%– Beyond 3 hours 12.9%

(3.15-6.25 hrs)– Risk of complications not associated with

protocol violations (p=0.74)



How to Evaluate and Treat How to Evaluate and Treat Acute Ischemic Stroke in 2000Acute Ischemic Stroke in 2000

Evaluation


Acute Myocardial InfarctionAcute Myocardial Infarction

This paradigm has shifted –

• Chest pain / SOB / dysrhythmiaChest pain / SOB / dysrhythmia• Rapid access to EMSRapid access to EMS• Prehospital identification and callPrehospital identification and call• Prehospital ECGPrehospital ECG• Team and protocols in place in EDTeam and protocols in place in ED• ““Door to Drug - 30 Minutes”Door to Drug - 30 Minutes”• What is the mortality and morbidity?What is the mortality and morbidity?

Evaluation


2000 American Stroke Association2000 American Stroke AssociationNew GuidelinesNew Guidelines

• EMS systems should implement a stroke protocol

• Potential fibrinolytic candidates should be taken to hospitals capable of providing acute stroke care

• E.D. AIS triage should be similar to AMI

• Intravenous fibrinolysis for AIS is Class I

• Intra-arterial fibrinolysis for AIS is Class IIb

(ASA, Circulation 2000)(ASA, Circulation 2000)Evaluation


Stroke Chain of Survival & RecoveryStroke Chain of Survival & Recovery

• Detection: Early recognition

• Dispatch: Early EMS activation

• Delivery: Transport & management

• Door: ED triage

• Data: ED evaluation & management

• Decision: Specific therapies

• Drug: Thrombolytic & future agents

Evaluation


NIH Symposium RecommendationsNIH Symposium Recommendations

• Door-to-MD: 10 minutes

• Door-to-Stroke 15 minutes Team notification:

• Door-to-CT scan: 25 minutes

• Door-to-Drug: 60 minutes

(80% compliance)

• Door-to-Admission: 3 hoursEvaluation


Detection: Detection: Stroke Public AwarenessStroke Public Awareness

Evaluation


Dispatch: Call 911Dispatch: Call 911Delivery: Transport & ManagementDelivery: Transport & Management

• Priority dispatch• ABC’s• Time of onset• Neurological evaluation /

Prehospital stroke scale• Check glucose• Stroke recognition• Early hospital

notification• Rapid Transport

Evaluation


Door:Door: Emergent TriageEmergent TriageData: Data: ED EvaluationED Evaluation

Evaluation


PreparationPreparation

• Check glucose• Two large IV lines• Oxygen as needed• Cardiac monitor• Continuous pulse-ox• Non-contrast CT scan• ECG• CXR

• Perform the NIH stroke scale

• Get rt-PA – Prepare to mix– Have pharmacy alerted

• Make sure family is available

• Contact primary care provider

Evaluation


PreparationPreparation

• Systems and personnel need to be in place

• Know your Stroke Team before you need them!

Evaluation


General Stroke ManagementGeneral Stroke Management

• Oxygen– Use to correct hypoxia– Suggestion it may hurt

one year survival 69% 3L NC vs 73% control

• Glucose– Maintain euglycemia – Treat glucose < 50 with D50– Treat glucose > 300 mg/dl with insulin

(Rønning, Stroke 1999)(Rønning, Stroke 1999)Evaluation


General Stroke ManagementGeneral Stroke Management

• Cardiac monitor– Observe for ischemic changes or atrial fibrillation

• Intravenous fluids – Avoid D5W and excessive fluid administration– IV normal saline at 50 cc / hr unless otherwise required

• NPO– Aspiration risk is great, avoid oral intake until swallowing

assessed

• Temperature– Avoid hyperthermia, PO/PR acetaminophen prn

Evaluation


The True Time of OnsetThe True Time of Onset

• Multiple sources

• How normal were they?– Who saw them this

morning?– Clearly no symptoms?

• Times of reference– The time the basketball

game started

Evaluation


Neurologic ExaminationNeurologic ExaminationNIH Stroke ScaleNIH Stroke Scale

• Value of the NIHSS:

– Correlates with size of stroke and prognosis

– Strokes with NIHSS < 4 do well and are not typically thrombolytic candidates

– Strokes with NIHSS > 20 are large with extremely poor prognosis and fair response to IV thrombolytics

ItemItem DescriptionDescription ScorScoree

1a1a

1b1b1c1c2233445566778899

1010111112121313

Level of Level of ConsciousnessConsciousnessLOC QuestionsLOC QuestionsLOC CommandsLOC CommandsBest GazeBest GazeBest VisualBest VisualFacial PalsyFacial PalsyMotor Arm LeftMotor Arm LeftMotor Arm RightMotor Arm RightMotor Leg LeftMotor Leg LeftMotor Leg RightMotor Leg RightLimb AtaxiaLimb AtaxiaSensorySensoryNeglectNeglectDysarthriaDysarthriaBest LanguageBest Language

0-30-3

0-20-20-20-20-20-20-30-30-30-30-40-40-40-40-40-40-40-40-40-40-20-20-20-20-20-20-30-3

Evaluation


Middle Cerebral ArteryMiddle Cerebral ArteryStroke SyndromesStroke Syndromes

• Dominant hemisphereContralateral hemiparesis arm, face > legContralateral sensory lossContralateral homonymous hemianopia; Ipsilateral eye deviationBroca’s and Wernicke’s aphasias

• Non-dominant hemisphereContralateral hemiparesis arm, face > legContralateral sensory loss with extinctionContralateral homonymous hemianopia; Ipsilateral eye deviationDysarthria without aphasiaIpsilateral hemineglect, inattention, extinction on double

stimulation

Evaluation


Anterior and Posterior Cerebral Anterior and Posterior Cerebral Arteries Stroke SyndromesArteries Stroke Syndromes

• Anterior Cerebral ArteryContralateral hemiparesis leg > arm, face

Contralateral sensory loss

Change in personality, speech perserveration

Bilateral occlusions produce paraplegia, anarthria, akinetic mutism

• Posterior Cerebral ArteryContralateral hemianopia (patients frequently unaware)

Brain stem findings (varied)

Bilateral occlusions produce cortical blindness

Evaluation


Early CT Changes in Ischemic StrokeEarly CT Changes in Ischemic Stroke

• Loss of insular ribbon

• Loss of gray-white interface

• Loss of sulci

• Acute hypodensity*

• Mass effect*

• Dense MCA sign

Evaluation

* Relative contraindication* Relative contraindication


Considerations:Considerations:Who will it and won’t it helpWho will it and won’t it help

• Factors associated with worse outcomes:– Increased patient age– History of diabetes mellitus– Increased time from onset– Increased blood pressure– Increased stroke severity– Baseline CT findings of stroke

• All subgroups (age, race, gender, co-morbid illnesses, and stroke location and size) benefited from thrombolytics compared to placebo in the NINDS trial

Evaluation


Factors Associated with Factors Associated with Increased Risk of ICHIncreased Risk of ICH

• Treatment initiated > 3 hours

• Increased thrombolytic dose

• Elevated blood pressure

• NIHSS > 20

• Acute hypodensity or mass effect on baseline CT

Evaluation


Differential DiagnosisDifferential Diagnosis

• Intracerebral hemorrhage

• Hypoglycemia / Hyperglycemia

• Seizure

• Migraine headache

• Hypertensive crisis

• Epidural / subdural

• Tumor

• Meningitis / Encephalitis / Abscess

Evaluation


Stroke Diagnosis - TIAStroke Diagnosis - TIA

• TIA definition an arbitrary definition from 1970’s

• TIA’s lasting longer than several minutes can produce focal defects on neuroimaging

• Median duration 14 mins / 8 mins

• If symptoms persist more than 1 hour, only 14% resolved by 24 hours

• NINDS placebo group only had 2% improvement to baseline at 24 hours

(CSOTIA)(CSOTIA)Evaluation


Exclusions to ThrombolyticsExclusions to Thrombolytics

• Stroke or head trauma in 3 mos• Major surgery within 14 days• Any history of intracranial

hemorrhage• SBP > 185 mm Hg• DBP > 110 mm Hg• Rapidly improving or minor

symptoms• Symptoms suggestive of

subarachnoid hemorrhage• Glucose < 50 or > 400 mg/dl

• GI hemorrhage within 21 days• Urinary tract hemorrhage within

21 days• Arterial puncture at non-

compressible site past 7 days • Seizures at the onset of stroke• Patients taking oral

anticoagulants• Heparin within 48 hours AND an

elevated PTT• PT >15 sec• Platelet count <100 X 109/L

Evaluation


Exclusions to ThrombolyticsExclusions to Thrombolytics

• “Patients were also excluded if aggressive measures were required to lower the blood pressure to within specified limits”

Evaluation


Blood Pressure ManagementBlood Pressure Management

• “Gentle” management if thrombolytic candidate SBP > 180 mm Hg

DBP > 110 mm Hg

• Choices:– Labetalol 10 - 20 mg IV– Enalapril 1.25 mg IV– Nitropaste 1” to chest wall

• No nipride or nitroglycerin gtts

Evaluation


Blood Pressure ManagementBlood Pressure Management

• Management in non-thrombolytic candidates only if:

SBP > 220 mm HgDBP > 120 mm HgMAP > 130 mm Hg

• Also consider BP management in:– Acute myocardial infarction– Aortic dissection– True hypertensive encephalopathy– Severe left ventricular failure

Evaluation


What are the Options?What are the Options?

• No thrombolytics– Nothing– Aspirin– Heparin

• Intravenous rt-PA *Only approved therapy for acute stroke

• Other– Intra-arterial thrombolysis– Low dose IV rt-PA followed by IA rt-PA– Investigation procedure

Treatment


Stroke Treatment – Stroke Treatment – Aspirin / HeparinoidsAspirin / Heparinoids

• Aspirin– Two large trials:

International Stroke Trial (IST)International Stroke Trial (IST)

Chinese Acute Stroke Trial (CAST)Chinese Acute Stroke Trial (CAST)

– Death / nonfatal strokes reduced 11%– If not a thrombolytic candidate, give within first 24 hrs

• Heparin– Two important trials

International Stroke Trial (IST)International Stroke Trial (IST)

TOAST (Trial of ORG 10172)TOAST (Trial of ORG 10172)

– No net stroke benefitTreatment


rt-PA Dosingrt-PA Dosing

• 0.9 mg/kg (max = 90 mg)

• 10% bolus (over 1 minute)

• Remainder as a 1 hour infusion

• Have the rt-PA in the Emergency Department, not the Pharmacy!

Treatment


Post-Treatment CarePost-Treatment Care

Treatment


Patient MonitoringPatient Monitoring

• ICU admission (24 hours)

• Neuro checks – Q 15 minute X 6 hours– Q 1 hour X 18 hours

• BP checks– Call on the FIRST abnormal reading! – Do not hesitate to use a drip

• Watch for bleedingTreatment


Contingency Plan - ICH OrdersContingency Plan - ICH Orders

• STAT Repeat CT

• STAT Labs (Fibrinogen, CBC, PT/PTT)

• Type and screen

• Cryoprecipitate / Platelets

• Neurosurgical consult

Treatment


Blood Pressure ManagementBlood Pressure ManagementAfter ThrombolyticsAfter Thrombolytics

• SBP 180 - 230 or DBP 105-120 mm Hg– Labetalol 10 mg IV, may repeat / double to 150 mg max– Labetalol drip 2-8 mg / min

• SBP > 230 or DBP 121 - 140 mm Hg– Above– Sodium nitroprusside

• DBP > 140 mm Hg– Sodium nitroprusside (0.5 µg/kg per minute)

• May consider enalapril in patients with CHF, asthma, abnormal cardiac conduction

Treatment


Post-treatment IssuesPost-treatment Issues

• Management of seizures

• Management of increased ICP

• Risk factor identification and modification

• Swallowing assessment

• Early rehabilitation

Treatment


The Future of The Future of Acute Stroke TreatmentAcute Stroke Treatment

• Establishment of tiered “Stroke Centers”• New diagnostic tools Neuroimaging, markers

• Thrombolytics ProUK, TNK, rPA, ANCROD*

• Intra-arterial approaches IA, stents, angioplasty

• Combination agents Antiplatelets, LMWH, neuroprotectives

• Cerebral protection Hypothermia, HBO

• Surgical Hemicraniectomy

* fibrinogenolytic

Future


Primary Stroke Center ProposalPrimary Stroke Center Proposal

• Patient care areas– Acute stroke teams– Written care protocols– EMS participation– Emergency Department

participation– Stroke unit*– Neurosurgical services**

• Support services– Organizational

support– Stroke center director– Neuroimaging– Laboratory– Outcome & quality

measures– CME

(Brain Attack Coalition, JAMA 2000)(Brain Attack Coalition, JAMA 2000)

* Individualized by institution

** Within 2 hours

Future


Intra-arterial ThrombolysisIntra-arterial Thrombolysis

Future


Intra-Arterial Thrombolytic Intra-Arterial Thrombolytic Efficacy vs.Time of DeliveryEfficacy vs.Time of Delivery

0

10

20

30

40

50

60

70

80

3.3 4.2 5.3 >6

Time from Onset (hrs)

Goo

d O

utco

me

(% m

RS

0-2

)

EMS

PROACT

GC/NK

Control

(Ernst, Stroke 2000)(Ernst, Stroke 2000)Future


61 yo male with acute stroke:61 yo male with acute stroke:The Decision to TreatThe Decision to Treat

• 14:35IV rt-PA given. 0.9 mg/kg total10% bolus - 9 mg

90% over 1 hr - 81 mg

• 15:45Patient goes to ICU

Report personally given to ICU staff

• 15:50Pathway actions begin

(HOB, BP, aspiration precautions, carotid ultrasound)

Case


61 year old male s/p rt-PA: 61 year old male s/p rt-PA: 24 Hour Follow-up24 Hour Follow-up

• Initial NIHSS = 10• 24 hr NIHSS = 3

Mild facial palsy

Right arm drift

Mild dysarthria

• Repeat CT shows areas of infarct

Case


• Carotid U/S shows 60 -80% stenosis left ICA

• Speech recommends swallowing II diet and daily checks

• Physical therapy ongoing

• CEA performed day 4

• Patient discharged day 7

61 year old male s/p t-PA:61 year old male s/p t-PA:Hospital CourseHospital Course

Case


ConclusionsConclusions

• Acute stroke is an emergency

• Multidisciplinary systems must be in place in every institution

• Strict adherence to protocols minimizes complications

• Acute stroke treatment is and will remain the responsibility of the Emergency Physician

Conclusion

Documents

Ischemic Anterior Circulation Stroke Edward C. Jauch, MD, MS Assistant Professor Department of Emergency Medicine University of Cincinnati College of Medicine