Stroke Onset Clarification

Question#: 712

Question:

Regarding the stroke bypass indications: Clearly determined time of symptoms onset or the time the patient was last seen in a usual state of health.

If a patient goes to sleep in his normal state but wake up 8 hours later with stroke signs and symptoms and a LMAS score of ≥4. Can we use the wake-up time as the time of symptoms onset and go to the regional stroke center (not the closest) instead of the nearest Telestroke. Just because a good proportion of our stroke patient have wake-up strokes. I have brought in the past stroke patients to the Civic with this example (wake-up stroke) and the neurologist told me that they will treat the patient as a wake-up stroke for the onset.

Answer:

 There really are two questions here.

1) Time-based criteria for acute stroke treatment - currently it is up to 4.5 hours for TPA (6 hours on prompt cared), 24 hours for EVT. The 4.5 hours (or 6 on the paramedic prompt card), is a hard rule right now. As discussed in the article (below), new imaging modalities are likely to increase eligibility based on imaging findings as opposed to time-based eligibility, which will likely increase eligible patients, including the wake-up strokes he refers to. Lots of discussion being had here. But right now 6 hours is still the number.

2) LVO positive patients who present at the 6-24 hour mark from last known normal (in his case 8 hours). Still no bypass for these yet, but lots of discussion. The slow baby steps are triage these as Level 2's and let receiving facility know they screen LVO positive (LAMS > or equal to 4)

Eventually we might get to a bypass point, but nothing beyond 6 hours yet. If they have a 6-24 h LVO positive stroke, you are welcome to consult with a BHP to discuss most appropriate destination. We have discussed this with the Deputy Chiefs at Quality of Care committee and they are okay with the BHP's being involved in these destination decisions.

In the case that you have outlined, this is a perfect case to patch for, and we likely would recommend to an EVT center if they are stable and the drivetime is reasonable, AND operationally it is feasible on your end. We suggest looping your supervisor in at the time of the call.

For further information, please see the MedicNews article from Associate Medical Director Dr. Froats

https://sway.office.com/RFAZjtLKT6wGDCyr?ref=Link