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Assessments to consider when diagnosing acute ischemic stroke

Consider key assessment points for patients with acute ischemic stroke (AIS)

  • Established time last seen normal2
  • Patient history including degree of independence3
  • Blood glucose concentration2*
  • Imaging to examine for intracerebral hemorrhage (to rule out hemorrhagic stroke),* measure infarct core volume, and confirm large vessel occlusion, if suspected2†
  • Blood pressure measurement2
  • Blood coagulation measurements including complete blood count, prothrombin time (PT)/international normalized ratio (INR), and activated partial thromboplastin time (aPTT)2
  • Oxygen saturation2
  • Electrocardiogram2
  • Markers of cardiac ischemia including baseline troponin assessment2

*The American Heart Association/American Stroke Association recommends brain imaging (noncontrast CT in most cases) and assessment of blood glucose precede the initiation of IV alteplase in all patients. Although it is desirable to know the results of the other tests before administering Activase, fibrinolytic therapy should not be delayed while awaiting those results unless: 1) there is clinical suspicion of a bleeding abnormality or thrombocytopenia; 2) the patient has received heparin or warfarin; or 3) the patient has received other anticoagulants (direct thrombin inhibitors or direct factor Xa inhibitors).2
†If patient transport to a mechanical thrombectomy-capable facility is required, notify that facility’s neurointerventionalist and place interfacility patient transport on standby.2,3

Patients with AIS may initially be misdiagnosed7

  • A retrospective chart review found 1 in 5 ischemic strokes was initially misdiagnosed (n=103/465)

Not all disabling deficits may be detected by the NIHSS

  • Although the National Institutes of Health Stroke Scale (NIHSS) is a useful tool for rating the level of neurological deficit due to stroke, it does not measure all deficits, nor does it fully assess the impact of disability on a patient's activities of daily living.2,3,37 Use of the NIHSS should not substitute for a comprehensive neurological examination2,3,37
    • The NIHSS is recommended by the 2019 American Heart Association/American Stroke Association (AHA/ASA) to quantify the degree of neurological deficit with accuracy and reliability2
    • The NIHSS was originally developed for stroke research trials38 
    • Studies indicate that the NIHSS grades lesion-specific deficits unevenly37

Symptoms associated with an increased likelihood of a missed stroke diagnosis7:

  • Headache
  • Nausea/vomiting
  • Dizziness
  • Seizure
  • Syncope
  • Difficulty walking

Posterior strokes may be misdiagnosed more often than anterior strokes7

  • 37% of posterior strokes were initially misdiagnosed versus 16% of anterior strokes

Examine for symptoms of posterior stroke, which may include4,41:

  • Dizziness
  • Diplopia
  • Dysarthria
  • Dysphagia
  • Dystaxia

The Centers for Disease Control and Prevention defines disability as follows39:

  • A “yes” response to at least one of the following limitation categories:
    • Use of an assistive aid (cane, crutches, walker, or wheelchair)
    • Difficulty performing activities of daily living, instrumental activities of daily living, or specified functional activities
    • One or more selected impairments‡
    • Limitation in the ability to work around the house or at a job or business

Consider how individual deficits can be disabling:

  • While the National Institutes of Health Stroke Scale (NIHSS) can rate the level of neurological deficit due to stroke, it may not detect all deficits. So it's important to consider all neurological deficits and differentiate between disabling and non-disabling deficits on a patient-by-patient basis

Consider the following:

  • Is your patient ambulatory? 
  • Are they able to hold a conversation?

Consider asking each patient the following questions:

  • Will you be able to return to work as normal?
  • Will you be able to perform your everyday activities and hobbies?
  • Do you consider any of your symptoms to be disabling? 
  • What is your dominant hand? Will weakness of your hand affect your daily life?
  • Do you think your quality of life will be impacted?

Deficits considered by the American Heart Association/American Stroke Association to be disabling3:

  • Complete hemianopsia
  • Severe aphasia
  • Visual or sensory extinction
  • Any weakness limiting sustained effort against gravity
  • Any deficits that lead to a total NIHSS score >5
  • Any remaining deficit the patient or practitioner considers potentially disabling (clinical judgment is required)
  • For each patient, all neurological deficits present at the time of the treatment decision should be considered in the context of individual risk and benefit, as well as the patient’s baseline functional status2§

‡Selected impairments include: learning disability, mental retardation, other developmental disability, Alzheimer’s disease/senility/dementia, or other emotional/mental disability.38

§Activase clinical trials enrolled patients with a measurable neurological deficit, defined as impairment of language, motor function, cognition, gaze, vision, or neglect2,6

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NEXT: Learn more about Activase as the standard of care for patients with AIS

DID YOU KNOW?

  • More than 1 in 7 ischemic strokes may be misdiagnosed7,8
  • 37% of posterior strokes were initially misdiagnosed, compared with 16% of anterior strokes7
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IMPORTANT SAFETY INFORMATION & INDICATIONS

Indications

Activase® (alteplase) is indicated for the treatment of acute ischemic stroke. Exclude intracranial hemorrhage as the primary cause of stroke signs and symptoms prior to initiation of treatment. Initiate treatment as soon as possible but within 3 hours after symptom onset.

Activase is indicated for use in acute myocardial infarction (AMI) for the reduction of mortality and reduction of the incidence of heart failure.

Limitation of Use: The risk of stroke may outweigh the benefit produced by thrombolytic therapy in patients whose AMI puts them at low risk for death or heart failure.

Activase is indicated for the lysis of acute massive pulmonary embolism (PE), defined as:

  • Acute pulmonary emboli obstructing blood flow to a lobe or multiple lung segments.
  • Acute pulmonary emboli accompanied by unstable hemodynamics, e.g., failure to maintain blood pressure without supportive measures.

Important Safety Information

Contraindications

Do not administer Activase to treat acute ischemic stroke in the following situations in which the risk of bleeding is greater than the potential benefit: current intracranial hemorrhage (ICH); subarachnoid hemorrhage; active internal bleeding; recent (within 3 months) intracranial or intraspinal surgery or serious head trauma; presence of intracranial conditions that may increase the risk of bleeding (e.g., some neoplasms, arteriovenous malformations, or aneurysms); bleeding diathesis; and current severe uncontrolled hypertension.

Do not administer Activase to treat acute myocardial infarction or pulmonary embolism in the following situations in which the risk of bleeding is greater than the potential benefit: active internal bleeding; history of recent stroke; recent (within 3 months) intracranial or intraspinal surgery or serious head trauma; presence of intracranial conditions that may increase the risk of bleeding; bleeding diathesis; and current severe uncontrolled hypertension.

Warnings and Precautions

Bleeding

Activase can cause significant, sometimes fatal internal or external bleeding, especially at arterial and venous puncture sites. Avoid intramuscular injections and trauma to the patient. Perform venipunctures carefully and only as required. Fatal cases of hemorrhage associated with traumatic intubation in patients administered Activase have been reported. Aspirin and heparin have been administered concomitantly with and following infusion with Activase in the management of acute myocardial infarction and pulmonary embolism. The concomitant administration of heparin and aspirin with and following infusions of Activase for the treatment of acute ischemic stroke during the first 24 hours after symptom onset has not been investigated. Because heparin, aspirin, or Activase may cause bleeding complications, carefully monitor for bleeding, especially at arterial puncture sites. Hemorrhage can occur 1 or more days after administration of Activase, while patients are still receiving anticoagulant therapy. If serious bleeding occurs, terminate the Activase infusion, and treat appropriately.

In the following conditions, the risks of bleeding with Activase are increased and should be weighed against the anticipated benefits: recent major surgery or procedure; cerebrovascular disease; recent intracranial hemorrhage; recent gastrointestinal or genitourinary bleeding; recent trauma; hypertension; acute pericarditis; subacute bacterial endocarditis; hemostatic defects including those secondary to severe hepatic or renal disease; significant hepatic dysfunction; pregnancy; diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic conditions; septic thrombophlebitis or occluded AV cannula at seriously infected site; advanced age; and patients currently receiving oral anticoagulants, or any other condition in which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its location.

Hypersensitivity

Hypersensitivity, including urticarial / anaphylactic reactions, have been reported after administration of Activase. Rare fatal outcome for hypersensitivity was reported. Angioedema has been observed during and up to 2 hours after Activase infusion in patients treated for acute ischemic stroke and acute myocardial infarction. In many cases, patients received concomitant angiotensin-converting enzyme inhibitors. Monitor patients treated with Activase during and for several hours after infusion for hypersensitivity. If signs of hypersensitivity occur, e.g. anaphylactoid reaction or angioedema develops, discontinue the Activase infusion and promptly institute appropriate therapy (e.g., antihistamines, intravenous corticosteroids, epinephrine).

Thromboembolism

The use of thrombolytics can increase the risk of thrombo-embolic events in patients with high likelihood of left heart thrombus, such as patients with mitral stenosis or atrial fibrillation. Activase has not been shown to treat adequately underlying deep vein thrombosis in patients with PE. Consider the possible risk of re-embolization due to the lysis of underlying deep venous thrombi in this setting.

Cholesterol Embolization

Cholesterol embolism, sometimes fatal, has been reported rarely in patients treated with thrombolytic agents; the true incidence is unknown. It is associated with invasive vascular procedures (e.g., cardiac catheterization, angiography, vascular surgery) and/or anticoagulant therapy.

Coagulation Tests May be Unreliable during Activase Therapy

Coagulation tests and/or measures of fibrinolytic activity may be unreliable during Activase therapy unless specific precautions are taken to prevent in vitro artifacts. When present in blood at pharmacologic concentrations, Activase remains active under in vitro conditions, which can result in degradation of fibrinogen in blood samples removed for analysis.

Adverse Reactions

The most frequent adverse reaction associated with Activase therapy is bleeding.

Please see the full Prescribing Information for additional Important Safety Information and Instructions for Use.

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