Management of Ischemic Stroke: Part 1. Emergency Room Management

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Management of Ischemic Stroke: Part 1. Emergency Room
Christine Lu-Emerson, MD
David Likosky, MD
Alpesh Amin, MD, MBA, FACP
David Tirschwell, MD, MSc
1 Department of Neurology, School of Medicine, University of Washington, Seattle, Washington. 2 Stroke Center, Evergreen Hospital Medical Center, Seattle, Washington. 3 Clinical Faculty, School of Medicine, University of Washington, Seattle, Washington. 4 Department of Medicine, Hospitalist Program, University of California, Irvine, California. 5University of Washington (UW) Medicine Stroke Center, Harborview Medical Center, Seattle, Washington. Disclosure: Nothing to report.

BACKGROUND: Acute ischemic stroke is commonly encountered by the hospitalist. There have been dramatic changes in our ability to care for these patients acutely. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) primary stroke center certification has become progressively more important to institutions nationally and includes many aspects of initial evaluation and treatment.

PURPOSE: Acute treatment involves the rapid assimilation of patient characteristics, laboratory results, and imaging results. There are a growing number of potential acute therapies with a range of risk, benefit, necessary time windows, and specific eligibility criteria.

DATA SOURCES: Primary trials, current guidelines.
CONCLUSIONS: The hospitalist is well-positioned to play a major role in the treatment of stroke patients as well as the systems work that aids in the management of this population. Journal of Hospital Medicine 2010;5:33–40. VC 2010 Society of Hospital Medicine.

KEYWORDS: cerebrovascular disorders, emergency room, guidelines, stroke. Additional Supporting Information may be found in the online version of this article. The term ‘‘stroke’’ is defined by the World Health Organization as ‘‘rapidly developed clinical signs of focal (or global) disturbance of cerebral function lasting more than 24 hours

(unless interrupted by surgery or death), with no apparent
cause other than a vascular origin; it includes patients presenting clinical signs and symptoms suggestive of subarachnoid
hemorrhage (SAH), intracerebral hemorrhage, or cerebral
ischemic necrosis.’’1 Stroke is 1 of the leading causes of death and the number 1 cause of long-term disability in the
United States, with over 700,000 strokes and over 150,000
stroke deaths each year.2
Given the projections of 30,000 hospitalists nationally by
2010 ( and only 12,000
neurologists,3 coupled with an aging population, it is important now that the practicing hospitalist is facile in the treatment of patients with cerebrovascular disease—and it is
likely to become progressively more important over time.
Case Presentation
A 76-year-old right-handed male with a history of hyperlipidemia and myocardial infarction was found at 7 AM with
right-sided paralysis and poor responsiveness on the morning of admission. He seemed to prefer looking to the left
and to understand what was being said to him, but had
great difficulty speaking. When he went to bed at 9 PM, he
was at his neurological baseline. Upon finding him that
morning, his wife called 911.
With increased knowledge regarding the pathophysiology
of stroke, it has become clear that timeliness is of utmost
importance (‘‘time is brain’’) and that acute stroke should be regarded as an acute medical/neurological emergency.
This article reviews the approach in evaluating an acute
stroke patient, management strategies, and treatment
options. Where not otherwise referenced, data to support
our comments come from the recently updated and exhaustive
American Heart Association (AHA)/American Stroke
Association (ASA) ‘‘Guidelines for the Early Management of Adults With Ischemic Stroke’’ and will be referred to herein as the ‘‘Guidelines.’’4 Harborview Medical Center in Seattle is a Joint Commission–certified...
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