4. Emergency Department Evaluation and Management of Patients with Transient Ischemic Attack and Acute Stroke
Recommendations and/or Clinical Considerations
4.1 Initial Emergency Department Evaluation
- All patients presenting to an emergency department with suspected acute stroke should be immediately assessed and undergo investigations without delay to establish a diagnosis and determine eligibility for thrombolysis and/or endovascular thrombectomy (EVT) [Strong recommendation; High quality of evidence].
- Patients with suspected acute stroke should have a rapid initial evaluation for airway, breathing, and circulation [Strong recommendation; High quality of evidence].
- Patients with suspected stroke should be triaged as Canadian Triage Acuity Scale (CTAS) Level 2 in most cases and as CTAS Level 1 for patients with compromised airway, breathing, or cardiovascular function [Strong recommendation; Low quality of evidence].
- Patients with suspected acute stroke should have a rapid neurological examination to determine focal neurological deficits using a validated scale such as FAST (Face, Arm, Speech, Time) [Strong recommendation; Moderate quality of evidence]; and to assess for stroke severity using a validated screen [Strong recommendation; High quality of evidence].
- A standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) should be included in the initial assessment [Strong recommendation; High quality of evidence].
- Initial assessment should include consideration of time of stroke symptom onset, stroke mimics, development of a plan for further management, and establishment of goals for care [Strong recommendation; Low quality of evidence] Refer to Section 2 Triage and Initial Diagnostic Evaluation of Transient Ischemic Attack and Non-Disabling Stroke for additional information.
- Patients with suspected acute stroke should undergo an assessment of heart rate and rhythm, blood pressure, temperature, oxygen saturation, point-of-care glucose, and presence of seizure activity [Strong recommendation; High quality of evidence].
- (NEW FOR 2022) Use or non-use of anticoagulants, including the timing of the last dose taken, should be sought and recorded [Strong recommendation; Moderate quality of evidence].
- Acute blood work should be conducted as part of the initial evaluation [Strong recommendation; Moderate quality of evidence].
- Initial blood work should include electrolytes, random glucose, complete blood count (CBC), coagulation status (INR, aPTT), and creatinine [Strong recommendation; High quality of evidence]. Refer to Table 2A for additional information on recommended laboratory investigations for acute stroke and TIA.
Note: Initial blood work tests should not delay imaging or treatment decisions and treatment initiation for intravenous thrombolysis and EVT.
- Seizure assessment: Seizure in the presence of suspected acute stroke is not a contraindication for reperfusion and could be treated using appropriate short-acting medications (e.g., lorazepam IV) if the seizures are not self-limited [Strong recommendation; High quality of evidence]. Refer to Section 9 Inpatient Prevention and Management of Complications Following Stroke for additional information.
Note: If initial brain imaging reveals a hemorrhagic stroke, refer to CSBPR Management of Intracerebral Hemorrhage module for additional information.
4.2 Neurovascular (Brain and Vascular) Imaging
- All patients with suspected acute stroke should undergo brain and vascular imaging computerized tomography (CT) or magnetic resonance imaging (MRI) [Strong recommendation; High quality of evidence].
- Vascular imaging should be preformed from arch-to-vertex and include the extra- and intra-cranial circulation to determine eligibility for acute treatment [Strong recommendation; High quality of evidence]. Refer to target timelines in the Performance Measures section below.
Note: Primary stroke centres should make all efforts to perform combined CT and CTA on patient arrival. The CT and CTA should be done at same time and not in separate visits to the imaging suite. Stroke centres that cannot do CTA should have pre-planned arrangements for rapid transfer of appropriate patients. They should complete non-contrast CT (NCCT) and offer intravenous thrombolysis as appropriate and then rapidly transfer the patient to a comprehensive stroke centre for more advanced imaging and consideration for EVT. (Refer to IV thrombolysis Section 5 for additional information).
- All patients with suspected acute ischemic stroke who arrive at hospital within 6 hours who are potentially eligible for intravenous thrombolysis and/or EVT should undergo immediate non-contrast CT (NCCT) combined with CT angiography (CTA) of the head and neck, performed and interpreted without delay [Strong recommendation; High quality of evidence]. Refer to eligibility criteria in Boxes 4A, 4B, 5A, 5B, and 5C
- All patients with suspected ischemic stroke due to large vessel occlusion (LVO) arriving 6 to 24 hours after stroke symptom onset (including stroke on awakening or with unknown onset time) and who are potentially eligible for late window EVT should undergo immediate brain imaging with NCCT with CTA and CT perfusion (CTP); or magnetic resonance imaging (MRI) with MR angiography (MRA) and MR perfusion (MRP) [Strong recommendation; High quality of evidence]; or CT with multiphase CTA [Strong recommendation; Moderate quality of evidence]. Refer to Section 4.1 for criteria regarding screening with use of validated screening tools. Refer to Box 4C for additional information.
- A validated triage tool, such as ASPECTS, should be used to rapidly identify patients who may be eligible for EVT and who may require transfer to a different facility for EVT [Strong recommendation; Moderate quality of evidence].
- Advanced CT imaging such as CT perfusion (CTP) or multiphase CTA to assess pial collateral vessels is strongly encouraged as part of initial imaging to aid patient selection for EVT [Strong recommendation; Moderate quality of evidence]. However, advanced imaging must not substantially delay decision-making and treatment with intravenous thrombolysis or EVT. Refer to Boxes 4A, 4B, 4C, 5A, 5B and 5C for additional information.
Note: If there are signs of hemorrhage on initial CT images there is no need to proceed to CTP imaging as part of initial imaging and CTA should be completed based on the clinical judgement of the treating physician.
Note: In most Canadian centres a CT approach may be more practical and more readily available than an MR approach. Choice of imaging modality should be based on most immediate availability and local resources.
Refer to Section 5 Acute Ischemic Stroke Treatment for information on administration of intravenous thrombolysis and EVT.
Section 4.2 Clinical Considerations
- MRI as a first line for imaging can be challenging to obtain urgently in an emergency department setting. Obtaining an MRI scan should not delay decision-making regarding intravenous thrombolysis and EVT eligibility.
- Patients with a known allergy to contrast dye or with existing renal failure should not be excluded from consideration for EVT.
4.3 Acute Blood Pressure Management
- Patients with ischemic stroke eligible for thrombolytic therapy: Blood pressure should be lowered and sustained below 185/110 while initiating and during IV thrombolysis therapy, and for the next 24 hours for ischemic stroke patients who are eligible for thrombolytic therapy [Strong recommendation; Low quality of evidence].
- Patients with ischemic stroke not eligible for thrombolytic therapy: Patients with moderate blood pressure elevation (up to 220 mmHg systolic) should not be routinely treated if they are not eligible for thrombolytic therapy [Conditional recommendation; Low quality of evidence].
- Patients with extreme blood pressure elevation (e.g., systolic BP >220 or diastolic BP >120 mmHg) should be considered for blood pressure lowering therapy if they are not eligible for thrombolytic therapy [Conditional recommendation; Low quality of evidence].
- Rapid or excessive lowering of blood pressure should be avoided as this might exacerbate existing ischemia or might induce ischemia, particularly in the setting of intracranial or extracranial arterial occlusion [Conditional recommendation; Low quality of evidence].
- Reducing the blood pressure by approximately 15% and not >25% over the first 24 hours, with further gradual reduction thereafter to targets for long-term secondary stroke prevention, may be considered [Conditional recommendation; Low quality of evidence].
Note: Refer to CSBPR Management of Intracerebral Hemorrhage module for information on blood pressure management of hemorrhagic stroke.
Section 4.3 Clinical Considerations
- The choice of agents to manage blood pressure should be based on current Hypertension Canada blood pressure treatment guidelines. Refer to www.hypertension.ca.
4.4 Cardiovascular Investigations
- Patients with acute ischemic stroke or TIA should have a 12-lead ECG to assess cardiac rhythm and identify atrial fibrillation or flutter or evidence of structural heart disease (e.g., myocardial infarction, left ventricular hypertrophy) [Strong recommendation; Moderate quality of evidence].
- Unless a patient is hemodynamically unstable, ECG should not delay assessment for intravenous thrombolysis and EVT and can be deferred until after a decision regarding acute treatment is made [Strong recommendation; Moderate quality of evidence].
Note: For patients being investigated for an acute embolic ischemic stroke or TIA of undetermined source whose initial short-term ECG monitoring does not reveal atrial fibrillation but a cardioembolic mechanism is suspected, refer to CSBPR Secondary Prevention of Stroke module, Section 7 for additional information.
Refer to CSBPR Secondary Prevention of Stroke module for additional information on echocardiography and rhythm monitoring.
4.5 Blood Glucose Abnormalities
- All patients with suspected acute stroke should have their blood glucose concentration checked on arrival to the emergency department (or review glucose provided by EMS for any immediate management required) [Strong recommendation; Moderate quality of evidence]. Refer to Table 2A Recommended Laboratory Investigations for Patients with Acute Stroke or Transient Ischemic Attack for additional information. Refer to Section 3 Emergency Medical Services Management of Acute Stroke for additional information on EMS management.
- Hypoglycemia should be corrected immediately using local protocols [Strong recommendation; High quality of evidence].
- Although no optimal glucose target has been identified in the acute stage, it may be reasonable to treat hyperglycemia (glucose >20 um/l) as per local protocols as this has been associated with increased risk of hemorrhagic transformation when treating with intravenous thrombolysis [Conditional recommendation; Low quality of evidence].
4.6 Additional Management Considerations in the Emergency Department
- Chest X-ray: A routine chest x-ray is not required for acute stroke; chest x-ray should be considered if there is concern for acute cardio-pulmonary disease [Strong recommendation; Low quality of evidence]; otherwise, this should not delay the CT scan and decisions regarding reperfusion [Strong Recommendation; Moderate Quality of evidence].
- Swallowing assessment: All patients with acute stroke or TIA should have a swallowing screen completed as soon as possible as part of initial assessment by a practitioner trained to use a validated swallowing screening tool; however, screening should not delay decision-making regarding eligibility for reperfusion treatments [Strong recommendation; High quality of evidence].
- Ideally swallowing screens should be done within 24 hours of hospital arrival, including for patients that receive acute stroke treatments such as intravenous thrombolysis and EVT [Strong recommendation; Moderate quality of evidence].
- Patients should remain NPO (nil per os [no oral intake]) until a swallowing screen is completed, for patient safety [Strong recommendation; High quality of evidence].
- Oral medications should not be administered until a swallowing screen using a validated tool has been completed and found to be normal [Strong recommendation; Moderate quality of evidence]; alternate routes such as intravenous and rectal administration should be considered while a patient is NPO.
- A patient’s clinical status can change in the first hours following a stroke or TIA; therefore, patients should be closely monitored for changes in swallowing ability following initial screening [Strong recommendation; Low quality of evidence].
- Patients found to have abnormal swallowing ability on screening should remain NPO and be referred to a healthcare professional with expertise in this area for further swallowing assessment [Strong recommendation; Moderate quality of evidence].
Note: Swallow assessments are particularly important for patients discharged to the community directly from the emergency department or repatriated to a lower level of care.
Refer to Section 9 Inpatient Prevention and Management of Complications Following Stroke, and CSBPR Rehabilitation and Recovery following Stroke module, Section 7 for additional information on screening for swallowing ability and dysphagia management.
- Urethral catheters: The use of indwelling urethral catheters should generally be avoided due to the risk of urinary tract infections [Strong recommendation; Moderate quality of evidence]. Refer to Section 9 Inpatient Prevention and Management of Complications Following Stroke for additional information.
- Insertion of an indwelling urethral catheter should be considered for patients undergoing EVT when necessary, but this should not delay beginning the procedure. The need to retain the catheter should be reconsidered after the end of the EVT procedure, and the use of the catheter should be discontinued as soon as the patient is able to resume voiding on their own [Conditional recommendation; Low quality of evidence].
- Insertion of an indwelling urethral catheter is not routinely needed prior to intravenous thrombolysis unless the patient is acutely retaining urine and is unable to void. If inserted for patient-specific reasons, it should not delay acute treatment [Strong recommendation; Moderate quality of evidence].
- If used, indwelling catheters should be reassessed daily and removed as soon as possible [Strong recommendation; High quality of evidence].
- Fluid status and urinary retention should be included as part of routine monitoring of vital sign assessments [Strong recommendation; Moderate quality of evidence].
- Temperature: Temperature should be routinely monitored and treated per local protocols [Strong recommendation; Moderate quality of evidence]. Refer to Section 9 Inpatient Prevention and Management of Complications Following Stroke for additional information.
- Oxygen: Supplemental oxygen is not required for patients with normal oxygen saturation levels [Strong recommendation; Moderate quality of evidence].
4.7 Virtual Acute Stroke Care (Telestroke)
Note: The recommendations in Section 4.7 are mainly aimed at Level 3, 4, and 5 stroke centres (based on CSBPR categories; refer to Figure 2, Acute Stroke Service Capability). Patients with suspected acute stroke presenting to a Level 1 or 2 hospital that does not have acute stroke capability should be immediately transferred to the closest Level 3, 4, or 5 stroke centre per local bypass protocols and agreements.
- Virtual acute stroke care delivery modalities should be integrated into stroke care planning and service delivery to ensure equitable access to care across geographic regions in Canada [Strong recommendation; Moderate quality of evidence].
4.7.1 Organization of Virtual Healthcare Services for Acute Stroke Management
- Virtual acute stroke care networks should be in place and readily available when stroke expertise is not available on-site, to allow access to consultations with stroke experts for acute stroke assessment, diagnosis, and treatment, including acute thrombolytic therapy and decision-making for EVT [Strong recommendation; Moderate quality of evidence].
- Consulting and referring sites should have standardized protocols and processes in place to ensure access to stroke experts through virtual healthcare modalities, available 24 hours a day, seven days a week to provide equitable access to time-driven advanced stroke care across Canada [Strong recommendation; Moderate quality of evidence].
- The consultant should be a physician with specialized training in acute stroke management and must have timely access to diagnostic-quality neurovascular (e.g., brain CT, CTA) images during the virtual acute stroke consultation [Strong recommendation; High quality of evidence]. Refer to CSBPR Virtual Stroke Care Implementation Toolkit for additional information.
Note: The decision to use acute stroke therapies in emergency management requires imaging to rule out hemorrhage. Refer to Sections 4, 5, and 6 in this document for additional information on imaging and revascularization.
- Real-time two-way audiovisual communication should be in place to enable remote clinical assessment of the patient by the consulting stroke expert [Strong recommendation; Moderate quality of evidence].
- Virtual acute stroke modalities including video-conferencing and teleradiology systems may be considered to support screening and decision-making regarding candidacy for thrombolysis and/or EVT in appropriate cases and to facilitate transfer to endovascular-enabled stroke centres [Strong recommendation; Moderate quality of evidence].
- The benefits of telephone consultation without video are not well-established and every attempt should be made to connect via a video link [Conditional recommendation; Low quality of evidence].
- All laboratory and diagnostic results required by the consultant should be made readily available during the virtual acute stroke care consultation [Strong recommendation; Moderate quality of evidence].
- Referring physicians should follow an established protocol or algorithm that describes the critical steps and inclusion/exclusion criteria for thrombolysis and/or recanalization therapies, which are agreed to by both the referring and consulting sites [Strong recommendation; High quality of evidence]. Refer to Section 3 Emergency Medical Services Management of Acute Stroke;for additional information.
- Referring physicians and nursing staff who may be involved in virtual acute stroke consultations should ideally be trained in administration of the NIHSS, so they can assist the telestroke consultant efficiently and competently during the remote video neurological examination [Strong recommendation; Moderate quality of evidence].
- The most responsible physician remains the attending physician at the referring site. Decision-making is a consensus process that is achieved in consultation with the attending medical staff at the referring site, the patient and family, and the consulting physician with stroke expertise [Strong recommendation; Low quality of evidence].
- A consulting physician with stroke expertise should remain accessible as they may be required to provide ongoing guidance to the referring site following initial consultation [Strong recommendation; Low quality of evidence].
- Protocols should be in place that define patient transfer criteria to a more advanced stroke care facility when clinically indicated (e.g., for endovascular [if available], neurosurgical intervention) [Strong recommendation; Low quality of evidence].
- The virtual acute stroke care system should identify the stroke centres that are able to provide endovascular and neurosurgical care [Strong recommendation; Low quality of evidence].
- For patients who are deemed eligible for endovascular treatment or neurosurgical interventions, protocols should be in place to define the process for patient transfer [Strong recommendation; Moderate quality of evidence]. Refer to Section 6 Acute Antithrombotic Therapy for additional information.
- The use of standardized documentation should be considered for both the referring site and the consulting site, in accordance with hospital processes, jurisdictional legislation, and regulatory bodies [Strong recommendation; Low quality of evidence]. This may include:
- A consultation note provided by the consulting physician to the referring site at the end of the consultation, to be included in the patient medical record [Strong recommendation; Low quality of evidence].
- A discharge summary sent by the referring site to the consulting virtual acute stroke physician to provide feedback about the patient’s outcome [Strong recommendation; Low quality of evidence].
- For patients who are transferred to another hospital (e.g., “drip and ship”), a discharge summary from the receiving hospital to the referring physician and the virtual acute stroke physician [Strong recommendation; Low quality of evidence].
- Processes should be in place to ensure timely and effective transfer of up-to-date, relevant information in the patient medical record (e.g., patient progress, treatment plans, plans for ongoing follow-up, discharge recommendations) from the consulting healthcare provider to the referring site, in accordance with clinical care processes, organizational requirements, jurisdictional legislation, and regulatory requirements [Strong recommendation; Low quality of evidence]. Refer to CSBPR Transitions and Community Participation Following Stroke Section 3.3 for additional information.
- Data related to the virtual acute stroke consultation and outcome should ideally be collected by the virtual acute stroke program for continuing quality improvement [Strong recommendation; Low quality of evidence].
4.7.2 Staff Training and Ongoing Education
- Consulting physicians and other healthcare professionals involved in virtual acute stroke consults should have expertise and experience in managing patients with stroke [Strong recommendation; Low quality of evidence].
- It is recommended that virtual acute stroke care providers attain and maintain the necessary competencies required in provide safe, competent virtual care and to create a satisfactory telehealth encounter for both the patient and the healthcare provider [Strong recommendation; Low quality of evidence].
- Referring and consulting service providers should be trained to use the virtual acute stroke system and should understand their roles and responsibilities for the technical and clinical aspects of an acute virtual stroke care consultation [Strong recommendation; Low quality of evidence].
- Virtual stroke care training should include physicians, nurses, therapists, and any support staff (e,g., members of technology department) who may be involved in any virtual acute stroke consultation or therapy appointment [Strong recommendation; Low quality of evidence].
- Ongoing virtual acute stroke training and education with a regular update cycle is useful to ensure competency of providers [Strong recommendation; Low quality of evidence]. Refer to CSBPR Virtual Stroke Care Implementation Toolkit for additional information and resources for staff training.
- Continuing education in online and face-to-face formats is useful to ensure remote-based practitioners have access to ongoing education [Strong recommendation; Low quality of evidence].
- Mock acute stroke patient scenarios and practice cases may be helpful, especially for acute/emergent virtual stroke care at new sites, and where the ongoing volume of cases is low.
- Routine checks of acute virtual stroke care equipment (both video-conferencing and imaging systems such as PACS) should be done to ensure the equipment will function properly in an emergency. This may be done as part of routine checks on other emergency equipment such as crash carts. Some systems may have a back-up system or alarms for malfunctioning equipment.
- Where electronic health records are available, health information sharing regulations that comply with provincial and federal privacy legislation should be developed, to allow an individual patient’s record to be shared with referring and consulting facilities.
- Efforts should be made to design telestroke technology, so it is easy to use and operate, to facilitate adoption of the technology and decrease the time needed to meet educational requirements.
Patients with suspected stroke often have significant comorbidities which may complicate management of stroke. In addition, factors that may explain the cause of the stroke or predict later complications (e.g., space-occupying infarction or bleeding, or recurrent stroke), will have an impact on treatment decisions; therefore, an efficient and focused assessment is required to understand the needs of each patient. Given that up to 20% of clinicians may disagree on the clinical diagnosis of stroke (versus non stroke), one of the most important initial assessments is brain imaging. Since it is impossible to differentiate a lesion’s etiology, which may be ischemic or hemorrhagic in nature, by clinical examination alone, a CT scan or MRI is essential to identify patients who may be eligible for time-sensitive treatments. Other essential initial investigations include monitoring of vital signs, blood work, cardiovascular investigations, dysphagia screens, and seizure assessment.
Initial management of elevated blood pressure in acute patients with stroke remains controversial due to the lack of evidence to clearly guide practice. At the same time, this is an area where clinicians often seek guidance from stroke specialists. Blood pressure recommendations emphasize caution and diligence in monitoring and treating extremely high blood pressure in the first hours after stroke onset.
People with lived experience discussed the value of healthcare providers providing information about the scan process. They discussed how being in hospital can be frightening, and that a CT or MRI may be new for the individual and so support, validation of feelings, and information can help the person get through this experience.
People with lived experience also talked about the value of having someone present to help explain to the person with stroke and their family or informal caregivers what is occurring during the acute phase, from an intervention and experiential perspective. They shared that fears, stress, and anxiety can affect their ability to understand information in the moment and can make it harder to ask the right questions. Having someone to provide this type of support and navigation would be helpful. People with lived experience also identified that mental health support is an important part of care, starting right in the emergency department.
To ensure people experiencing a stroke receive timely stroke assessments, interventions and management, interdisciplinary teams need to have the infrastructure and resources required. These may include the following components established at a systems level.
- Local protocols to ensure all patients with stroke have rapid access to CT with CTA of the extracranial and intracranial vessels completed at the same time as the initial brain imaging.
- Protocols for “code stroke” activation of the stroke team and diagnostic services prompted by receiving pre-notification by paramedics of an incoming suspected stroke patient.
- Protocols to prioritize suspected patients with stroke in triage queues at emergency departments and diagnostic suites to ensure timely access to diagnostic service, thrombolysis and EVT (where applicable), and priority transport to the nearest acute treatment capable centre.
- Agreements to ensure patients initially managed in rural hospitals without neurovascular imaging capability have timely access to CTA with imaging of the extracranial and intracranial vessels at partnering hospitals.
- Protocols and standing orders to guide initial blood work and other clinical investigations.
- Local protocols, especially in rural and remote locations, for rapid access to clinicians experienced in interpretation of diagnostic imaging, including access through telemedicine technology.
- Repatriation protocols in place to enable the patient to be transferred back to the originating hospital after acute treatments when appropriate.
- Availability of physicians and other healthcare professionals with stroke expertise across provinces and regions, including provincial and regional recruitment and retention strategies to increase accessibility of acute stroke services for all Canadians.
- Proportion of people with acute stroke who are pronounced dead by EMS or in the emergency department.
- Median time from patient with suspected stroke’s arrival to hospital to first non-contrast CT head or brain MRI imaging scan.
- Median time from patient with suspected stroke’s arrival to hospital to first CTA or MRA of extracranial and intracranial vessels.
- Proportion of patients with stroke who receive a CT or MRI scan in <15 minutes from hospital arrival. Applies to patients arriving <6 hours from last known well time, and without contraindications to thrombolysis.
- Proportion of all patients with stroke who receive a brain CT/CTA within 12 hours of hospital arrival. (Note, Accreditation Canada indicator states on ‘same day of arrival’)
- Proportion of patients with carotid territory stroke syndrome who have carotid imaging in the ED or outpatient carotid imaging.
- Proportion of people with acute stroke who receive a virtual care consult to a stroke expert at another site.
- Virtual stroke care: Time to initiation of virtual acute stroke consult from:
- stroke symptom onset (last time patient was known to be normal)
- arrival in emergency department
- completion of the CT scan
- Proportion of patients managed with Telestroke where the Telestroke consultant’s note is found in the patient’s chart.
- Proportion of patients with acute stroke screening in the emergency department or inpatient unit for dysphagia within 12 hours of arrival to hospital.
Patient-oriented outcome and experience indicators
- Emergency department activities are addressed in Section 4. Include the diagnostic evaluation, consideration of treatment options, and initiation of treatment which should be completed in <60 minutes. The goal is a target 90th percentile for door-to-needle time of 60 minutes (upper limit); and a target median door-to-needle time of 30 minutes or less [Kamal et al., CJNS 2015]. Note: The goal is to transfer admitted patients with stroke within four hours of arrival where possible; however, many hospitals operate at full capacity and patients may have to remain in the emergency department after they are admitted to inpatient care while waiting for an inpatient bed.
- Data may be obtained from laboratory reports or patient chart.
- CT and CTA imaging time should be based on time of first slice by the scanner. Specify in the results which type of scan (CT or CTA, separately or combined) was measured and reported.
- Stratify analysis for patients who arrive within 3.5 hours of stroke symptom onset and those who arrive within 4.5, 6, and 24 hours from stroke symptom onset.
- Performance measure 1: Applies to patients who may be candidates for acute thrombolysis (i.e., who arrive at hospital within 4.5 hours of stroke symptom onset) and to patients who may be eligible for other time-sensitive interventions.
- Time interval measurements for CT and MRI should be calculated from the time the patient enters the emergency department until the time noted on the actual brain imaging scan.
- For outpatient carotid imaging, a notation should appear in the discharge summary, or in nursing notes, with an indication that the test has actually been requested or requisitioned prior to the patient leaving the hospital.
Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices writing group. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.
Healthcare Provider Information
- Canadian Stroke Best Practices Acute Stroke Management Module Appendix 3,Table 4: Screening and Assessment Tools for Acute Stroke Severity
- Canadian Stroke Best Practices Acute Stroke Management Section 2, Table 2A: Recommended Laboratory Investigations for Acute Stroke and Transient Ischemic Attack
- Heart & Stroke: Virtual Stroke Care Implementation Toolkit
- Canadian Cardiovascular Society Atrial Fibrillation Guidelines
- American College of Chest Physicians (CHEST) Pulmonary Vascular Guidelines and Expert Panel Reports
- Canadian Association of Radiologists Guidelines
- Hypertension Canada: Guidelines
- Stroke Engine
- The Ontario Acute Stroke Best Practice Coordinators and the Ontario Regional Education Group in collaboration with Heart & Stroke: Key Changes to the 2022 Acute Stroke Management Canadian Stroke Best Practice Recommendations
Information for people with lived experience of stroke, including family, friends, and caregivers
Evidence Table and Reference List 4 (Emergency Department Evaluation and Management of Patients with TIA and Acute Stroke)
Evidence Table and Reference List 4B (Emergency Department Evaluation and Management of Patients with TIA and Acute Stroke – Imaging)
Evidence Table and Reference List 4C (Virtual Care)
Standard assessments for patients with suspected acute stroke presenting to the emergency department include a neurological examination, monitoring of vital signs, blood work, imaging and cardiovascular investigations, dysphagia screens, and seizure assessment. It is also important to identify patients with stroke “mimics,” to avoid unnecessary and expensive investigations and inappropriate long-term prevention treatments. Patients presenting with stroke symptoms may ultimately be diagnosed with other conditions such as migraine headache, vertigo, metabolic disturbances, brain tumours, presyncope/syncope, or anxiety (Karliński et al., 2015). To assess stroke severity, the NIHSS is used most widely, is known to have good validity and reliability, and correlates well with stroke outcome. It has also been suggested as the best scale to identify patients with potential LVO who may be eligible for mechanical thrombectomy (Smith et al., 2018).
Immediate access to brain and vascular imaging is required for all patients arriving to hospital with suspected stroke or TIA. A NCCT scan is considered the imaging standard and the most cost-effective method to be used initially to identify acute ischemic stroke and rule out intracranial hemorrhage (Wardlaw et al., (2004). While MRI with diffusion-weighted sequences (DWI) may be more sensitive in detecting early changes associated with ischemia, especially in patients with small infarcts, it may not be immediately available. Using the results from 8 studies, Brazzelli et al. (2009) reported that the sensitivity of MRI was higher compared with CT (99% vs. 33%). Both imaging modalities had good specificity (92% and 100%). If an MRI is available and performed in place of CT, enhanced imaging in the form of DWI, GRE, and FLAIR is indicated. Brunser et al. (2013) included 842 patients admitted to the emergency department with a suspected ischemic stroke. Diffusion-weighted imaging (DWI) examinations were performed for all patients. For patients with a final diagnosis of stroke, the sensitivity of DWI in detecting ischemic stroke was 90% (95% CI 87.9 to 92.6), and specificity was 97% (95% CI 91.8 to 99.0).
Early detection of hemorrhage is essential since the presence of blood in the brain or subarachnoid space is the main contraindication for the administration of antithrombotics, intravenous thrombolytic therapy, and mechanical thrombectomy. Early imaging is particularly important for patients who may be potential candidates for thrombolytic therapy, since there is a narrow therapeutic window for its administration. While an NCCT may be sufficient for patients presenting within 4.5 hours of symptom onset who may be eligible for treatment with intravenous thrombolysis, those presenting with an unknow time of symptom onset require advanced imaging using either penumbral imaging, or MRI with DWI-FLAIR mismatch. In the WAKE-UP trial (Thomalla et al., 2018), MRI with DWI-FLAIR mismatch was used as the primary imaging modality (although MRP data were also used in a subgroup of patients), while the imaging criteria in the EXTEND trial (Ma et al., 2019) required either CTP or perfusion-diffusion MRI to identify potentially eligible patients. In both trials, patients who received treatment with t-PA had better 90-day functional outcome compared to those who received placebo. While CTP imaging has been shown to be more accurate than NCCT, with similar accuracy to CTA in detecting acute ischemic stroke (Shen et al., 2017), its availability is limited, with increased radiation and contrast doses and has the potential for causing treatment delays. The use of CTP for acute patients with stroke should be reserved for centres with well-established protocols and experience in interpreting the results, or the use of quantitative CTP using RAPID software.
Early trials of mechanical thrombectomy, including patients who were last known well within the previous 6 hours, required CTA or MRA diagnosis of LVO as an inclusion criterion (REVASCAT, Jovin et al., 2015; SWIFT PRIME, Saver et al., 2015; ESCAPE, Goyal et al., 2015). In the EXTEND-IA trial, (Campbell et al., 2015), inclusion required a 20% mismatch between core infarct and ischemic penumbra identified using CTP. In trials where the treatment window was extended to 6 to 24 hours since last known well, the imaging criteria were more advanced. The criteria for the DAWN trial (Nogueira et al., 2018) included clinical imaging mismatch defined using both core infarct size and NIHSS score on MR-DWI or CTP-rCBF maps, while DEFUSE-3 (Albers et al., 2018) used target mismatch profile on CTP or MRI (ischemic core volume <70 ml, mismatch ratio ≥1.8 and mismatch volume 15 ml).
Acute Blood Pressure Management
For patients eligible for treatment with intravenous thrombolysis, reductions in blood pressure may be indicated when elevations are extreme (e.g., systolic blood pressure [SBP] ≥220 mm Hg or diastolic blood pressure [DBP] ≥120 mm Hg); however, trials including patients with these levels of extreme hypertension have not been published. In the blood pressure arm of the ENCHANTED Trial, Anderson et al. (2019) included 2,227 patients ≥18 years who were eligible to receive t-PA within 4.5 hours of stroke onset, with a SBP ≤150 mmHg and who were able to begin intensive treatment for hypertension within 6 hours. Patients were randomized to an intensive SBP lowering group, with target SBP of 130–140 mmHg achieved within 60 minutes of randomization, which was to be maintained for ≥72 hours, or hospital discharge, or death; or to guideline-recommended BP lowering group with target SBP < 180 mmHg, after commencement of thrombolysis treatment. Although mean SBP over 24 hours was significantly lower in the intensive group (144·3 vs. 149·8 mm Hg), the percentage of patients who experienced death or disability at 90 days did not differ significantly between groups (46·5% vs. 48·0%, adj OR=0·94, 95% CI 0·78–1·14, p=0·55). Significantly fewer patients in the intensive groups had an ICH (14.8% vs. 18.7%, OR= 0·75, 0·60–0·94).
Yuan et al. (2020) recruited 483 patients with acute severe stroke (excluding those who received intravenous thrombolysis or mechanical thrombectomy), and elevated blood pressure in the Controlling Hypertension After Severe Cerebrovascular Event (CHASE) Trial. Patients were randomized to receive an individualized blood pressure lowering group (with 10–15% reduction in SBP from admission level, achieved within 2 hours and sustained for 1 week) or standard blood pressure lowering group (with a target SBP of <200 mm Hg in acute ischemic stroke group, sustained for 1 week). During the first 24 hours, the mean SBP was 144.0 mm Hg in the individualized treatment group and 148.2 mm Hg in the standard treatment group. The odds of a poor outcome (mRS 3-5 or all-cause death, at 90 days) were not reduced significantly in the individualized group (71.1% vs. 73.4%, with adjustment for age, sex, and baseline Glasgow Coma Scale score: OR=0.89, 95% CI 0.47 to 1.19; p=0.222); however, individualized blood pressure lowering treatment had a significant effect on reducing the neurological deficits at hospital discharge as evaluated by NIHSS (β estimate=0.13; 95%CI -0.2 to -0.03; p= 0.009).
An ECG) should be performed immediately to identify arrhythmias for all patients with stroke and TIA presenting to the emergency department. Atrial fibrillation (AF) is commonly diagnosed post-stroke and is of particular concern due to its role in forming emboli. Sposato et al. (2015) included the results from 11 studies in which cardiac monitoring was initiated in the emergency department. An estimated 7.7% of patients without a history of AF were newly diagnosed.
Baseline hyperglycemia has been identified as independent predictor of poor stroke outcome and may be a marker of increased stroke severity. The presence of hyperglycemia may be of particular concern among patients without a history of premorbid diabetes. Using patient data from the ECASS II trial, Yong & Kaste (2008) examined the association between stroke outcomes and four patterns of serum glucose over the initial 24-hour period post stroke. Among 161 patients with pre-morbid diabetes, the odds of poor outcome were not increased significantly for patients with persistent hyperglycemia, or among patients with hyperglycemia at 24 hours, compared with patients with persistent normoglycemia. However, among 587 non-diabetics, patients with persistent hyperglycemia experienced significantly worse outcomes compared to those with persistent normoglycemia. The odds of a good functional outcome at 30 days, minimal disability at 90 days, or neurological improvement over 7 days were significantly reduced compared with patients with persistent normoglycemia, while the odds of 90-day mortality and parenchymal hemorrhage were increased significantly. Since initial hyperglycemia has been associated with poor stroke outcome, several trials have evaluated the potential benefit of tight blood glucose control early following stroke, with null results. In the Stroke Hyperglycemia Insulin Network Effort (SHINE) trial, 1,151 patients ≥18 years with hyperglycemia following acute ischemic stroke were recruited (Johnston et al., 2019). Patients were randomized to receive intensive or standard glucose-lowering treatment during hospital stay. Patients in the intensive treatment group received a continuous intravenous insulin infusion as needed to maintain a blood glucose concentration of 4.44-7.22 mmol/L. Patients in the standard treatment group received insulin on a sliding scale to maintain a blood glucose concentration of 4.44-9.93 mmol/L. The trial was halted prematurely due to futility. While mean blood glucose level was significantly lower in the intensive group during treatment (6.6 vs. 9.9 mmol/L), there was no significant increase in the odds of a favourable outcome at 90 days (20.5% of patients in the intensive groups had a favourable outcome at 90 days vs. 21.6% in the standard group [adj RR=0.97, 95% CI 0.87 to 1.08, p=0.55]). A significantly higher percentage of patients in the intensive group experienced severe hypoglycemia (2.2% vs. 0%, p<0.01). Similar findings were reported in the GIST-UK trial (Gray et al., 2007) in which 899 patients were randomized to receive variable-dose-insulin glucose potassium insulin (GKI) to maintain blood glucose concentration between 4-7mmol/L or saline (control) as a continuous intravenous infusion for 24 hours. For patients in the control group, if capillary glucose >17 mmol/L, insulin therapy could be started at the discretion of the treating physician. Treatment with GKI was not associated with a significant reduction in 90-day mortality (OR= 1.14; 95% CI 0.86 to 1.51; p=0.37) or the avoidance of severe disability (OR= 0.96; 95% CI 0.70 to 1.32). Rescue dextrose was given to 15.7% of GKI-treated patients for asymptomatic prolonged hypoglycemia. The trial was stopped prematurely due to slow enrollment.
Additional Management Considerations
Chest x-ray: Saber et al. (2016) reviewed data from 615 patients included in the Interventional Management of Stroke III (IMS-III) trial who had a chest radiograph. Patients with a chest radiograph that was completed before intravenous thrombolysis treatment had a significantly longer mean door-to-needle times than those who had x-rays completed after thrombolysis treatment (75.8 vs. 58.3 minutes, p=0.0001). Chest radiograph before thrombolysis was an independent predictor of door-to-needle time ≥60 minutes (OR=2.78, 95% CI 1.97–3.92).
Swallowing assessment: In the T3 trial (Middleton et al., 2019) evaluating the benefit of nursing protocols aimed at prompt identification and treatment of patients with fever, hyperglycemia, and dysphagia, over 85% of patients in both the intervention and control group remained NPO until screened. Over 80% received a swallow screen or assessment within 24 hours of emergency department admission.
Urethral catheters: Data from 11,093 patients with acute stroke included in the HeadPoST trial, which examined the effect of head position (flat vs. elevated) on stroke outcome, were used to evaluate the use of indwelling urinary catheter (IUC). Ouyang et al. (2020) compared the outcomes of the 12% of patients who received an IUC with the remainder who did not. Those with an IUC had a greater likelihood of a poor outcome (76.6% vs. 34.7%; p < 0.0001). IUC was an independent predictor of a poor outcome (OR=1.40, 95% CI 1.13–1.74). Those with IUC had a greater likelihood of a UTI (1.5% vs. 0.6%; p= 0.0002), although IUC was not an independent predictor of UTI after multiple adjustment (OR=1.13, 95% CI: 0.59–2.18).
Supplemental oxygen: Roffe et al. (2017) recruited 8,003 adults with acute stroke within 24 hours of hospital admission, with no clear indications for or contraindications to oxygen treatment. Participants were randomized 1:1:1 to receive continuous oxygen for 72 hours, nocturnal oxygen (21:00 to 07:00 hours) for 3 nights, or control (oxygen only if clinically indicated). Oxygen was given via nasal tubes at 3 L/min if baseline oxygen saturation was 93% or less and at 2 L/min if oxygen saturation was >93%. Oxygen supplementation did not significantly improve functional outcome at 90 days. There were no significant differences between groups (2 oxygen groups combined vs. control and continuous oxygen vs. nocturnal oxygen) for any of the 7- or 90-day outcomes (neurological improvement, mortality, or disability).
Virtual Acute Care
Telestroke can be used to increase access to thrombolytic treatment at facilities that lack 24 hour, 7 day a week on-site stroke expertise, using two-way audiovisual equipment to carry out a detailed stroke examination, combined with a system to reliably transmit CT scan results. The safety, feasibility, and efficacy of the “spoke and hub” model, which connects a tertiary stroke centre to one or more distant primary care centres, has been established in many studies conducted in Europe and North America (LaMonte et al., 2003; Wiborg et al., 2003; Schwamm et al., 2004; Audebert et al., 2005; Waite et al., 2006; Vaishnav et al., 2008; Legris et al., 2016). In some of these studies, although minor technical difficulties were reported, the number of patients treated with t-PA increased at the stroke sites where telestroke systems were implemented and the symptom onset-to-treatment time decreased. The outcomes for 153,272 patients treated at hospitals with and without telestroke capacity following admission for acute ischemic stroke in the United States were compared (Wilcock et al., 2021). The frequency of reperfusion therapies received was significantly higher at telestroke hospitals (6.8% vs 6.0%; difference, 0.78 percentage points; 95% CI 0.54-1.03, p < .001). The risks of receiving thrombolysis and thrombectomy were both significantly higher at telestroke hospitals (RR=1.12, 95% CI 1.08 to 1.17 and RR=1.42, 95% CI 1.25 to 1.62, respectively). Both 7- and 30-day mortality was significantly lower in the telestroke hospitals (7-day: 6.03% vs. 6.33%; RR=0.95, 95% CI 0.92 to 0.99, 30-day:13.1% vs 13.6%; RR=0.96, 95% CI 0.94 to 0.99). In Ontario, Porter et al. (2018) conducted an audit to determine whether the safety outcomes of 214 patients treated using the Ontario Telestroke Program with intravenous thrombolysis over a two-year period were compared with those of 1,885 patients treated at regional stroke centres, district stroke centres, and non-designated centres. The administration of t-PA using telestroke was not associated with an increased risk of death within 7 or 90 days (adjusted HR=1.29, 95% 0.68- 2.44 and adjusted HR=1.01, 95% CI 0.67-1.50, respectively), nor was its use associated with an increased risk symptomatic intracerebral hemorrhage (ICH) or poor outcome (adjusted HR=0.71, (95% 0.29-1.71 and adjusted HR=0.75, 95% CI 0.46-1.23, respectively). The results from a systematic review also indicate the outcomes of patients treated with t-PA through telemedicine vs. traditional in-hospital care are similar. Zhai et al. (2015) conducted a systematic review & meta-analysis including the results of 8 studies that compared the outcomes of patients treated with t-PA through telemedicine vs. traditional in-hospital care. Telestroke systems were not associated with increased odds of symptomatic ICH (OR=1.08, 95% CI 0.47-2.5, p=0.85) or mortality (OR=0.95, 95% CI 0.82-1.11, p=0.51.
The outcomes and indicators associated with telestroke services provided by videoconferencing and telephone only appear similar. In the Stroke Team Remote Evaluation using a Digital Observation Camera (Stroke DOC) trial, Meyer et al. (2008) randomized 222 patients to receive telestroke using real-time, two-way audio/video or telephone consultations, to assess the patient’s candidacy for t-PA treatment. Consultations were provided by staff at a single hub institution to patients located at 4 remote sites. The number of patients treated with t-PA was similar between groups (28% vs. 23%). Mean times from stroke onset to t-PA were 157 and 143 minutes in the telemedicine and telephone groups respectively (p=0.137). There were no differences between groups (telemedicine vs. telephone) in the occurrence of ICH (7% vs. 8%, p=1.00), good outcome at 90 days, defined as a mRS score of 0-1 (30% vs. 32%, p=1.00), or 90-day mortality after adjustment for baseline NIHSS score (OR=3.4, 95% CI 0.6-19, p=0.168). However, correct treatment decisions were made more often using videoconferencing (98% vs. 82%, p=0.0009). In a follow-up study (Meyer et al., 2012), which assessed six- and twelve-month outcomes, there were no differences between groups in mortality or the proportion experiencing a good outcome at either assessment point.
Sex & Gender Considerations
Based on the results of studies presented in the accompanying evidence tables, examinations of sex differences were largely absent, with two exceptions. Sex was not found to be a significant effect modifier on the primary outcome in the treatment of hypertension in the ENCHANTED trial (Anderson et al. 2019). Sex was also not found to be a significant effect modifier for the outcomes of either reperfusion treatment or 30-day mortality in a study comparing telestroke-enabled hospitals with those without telestroke capacity (Wilcock et al. 2021).