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In this lesson, we're going to look at the major types of stroke of which you should be familiar. But first, the word stroke is a general term that refers to an acute neurological impairment following an interruption in blood supply to a specific area of tissue within the brain.
Although immediate stroke care is vital for every patient, the point of this particular lesson is about reperfusion therapy for acute ischemic stroke.
There are two major types of stroke:
- Ischemic stroke – this type of stroke accounts for almost 87 percent of all strokes. It's usually caused by an embolism which occludes an artery and affects the subsequent tissue of the brain that that particular artery affected.
- Hemorrhagic stroke – this type of stroke accounts for around 13 percent of all strokes. It occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue which causes damage.
Warning: In cases of suspected or confirmed hemorrhagic stroke, fibrinolytic therapy is contraindicated, and the use of anticoagulants is to be avoided.
Around 795,000 people have a new or recurrent stroke each year in the U.S., which is why stroke remains a leading cause of death in the U.S.
Pro Tip #1: It's important to realize that early recognition and treatment of acute ischemic stroke is vital because IV fibrinolytic treatment should be provided as quickly as possible.
Over the years, there have been significant improvements in stroke care because of the combined efforts between public education, 911 dispatch, early detection by EMS and triage, systematic hospital stroke protocol, and better overall management of stroke units.
There has also been an increase in appropriate fibrinolytic therapies and overall stoke care has definitely improved. In many cases, ACLS providers are well within the scope of being qualified to identify and manage the initial care of patients who are displaying acute stroke symptoms.
In stroke cases, it's important to recognize that while an ECG is helpful, it should not take priority over obtaining a computed tomography, known commonly as a CT scan.
Pro Tip #2: It's also important to remember that no one arrhythmia is specific for or related to stroke. However, an ECG may help identify some evidence of a recent acute myocardial infarction or an arrhythmia such as atrial fibrillation, which could have caused that embolic stroke.
Many stroke patients demonstrate arrhythmias, but if the patient is hemodynamically stable, treatment of such arrhythmias are not usually indicated.
It is generally accepted and recommended to initiate and maintain cardiac monitoring during the first 24 hours of observation in patients who have experienced an acute ischemic stroke in order to detect atrial fibrillation and other potentially life-threatening arrhythmias. This is important because the goal of stroke care is to minimize brain injury and maximize recovery.
Stroke Chain of Survival
The American Heart Association and the American Stroke Association have developed a stroke chain of survival that is similar to the chain of survival for sudden cardiac arrest.
The stroke chain of survival correlates actions to be taken by patients, family members, and healthcare providers in order to maximize stroke recovery.
The established links in the stroke chain of survival are as follows:
- Rapid recognition and reaction to the stroke warning signs.
- Rapid EMS dispatch by calling 911.
- Rapid EMS system transport and pre-arrival notification to the receiving hospital by the EMTs.
- Rapid diagnosis and treatment upon arrival to the appropriate hospital.
Patients with acute ischemic stroke have what is referred to as time-dependent benefit for fibrinolytic therapies, which is similar to patients with a myocardial infarction that demonstrates ST-segment elevation. However, in stroke cases, this time-dependent benefit is much shorter.
Pro Tip #3: It's important to remember that the critical time period for the administration of IV fibrinolytic therapies begins with the onset of symptoms.
The critical time periods from hospital arrival are as follows:
- The immediate general assessment should be within 10 minutes
- The immediate neurological assessment should be performed within 25 minutes
- The acquisition of a CT scan (or CAT scan) of the patient's head should be done within 25 minutes
- The interpretation of the scan should be completed within 45 minutes
- The administration of fibrinolytic therapies should be within 60 minutes from the time of emergency department arrival
- The administration of fibrinolytic therapies may be delivered in as much as 3 to 4.5 hours in some select patients timed from the onset of symptoms
- The administration of endovascular therapy should be within 6 hours in select patients timed from the onset of symptoms
- The admission to a monitored hospital bed should be within 3 hours
