4. Emergency Department Evaluation and Management of Patients with Transient Ischemic Attack and Acute Stroke

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.

1. 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.
2. 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.
3. 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.
4. 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.
5. Protocols and standing orders to guide initial blood work and other clinical investigations. 
6. Local protocols, especially in rural and remote locations, for rapid access to clinicians experienced in interpretation of diagnostic imaging, including access through telemedicine technology.
7. Repatriation protocols in place to enable the patient to be transferred back to the originating hospital after acute treatments when appropriate. 
8. 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.

System indicators

1. Proportion of people with acute stroke who are pronounced dead by EMS or in the emergency department.

Process indicators

2. Median time from patient with suspected stroke’s arrival to hospital to first non-contrast CT head or brain MRI imaging scan.
3. Median time from patient with suspected stroke’s arrival to hospital to first CTA or MRA of extracranial and intracranial vessels.
4. 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. 
5. 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’)
6. Proportion of patients with carotid territory stroke syndrome who have carotid imaging in the ED or outpatient carotid imaging.
7. Proportion of people with acute stroke who receive a virtual care consult to a stroke expert at another site.
8. Virtual stroke care: Time to initiation of virtual acute stroke consult from:
1. stroke symptom onset (last time patient was known to be normal)
2. arrival in emergency department
3. completion of the CT scan
9. Proportion of patients managed with Telestroke where the Telestroke consultant’s note is found in the patient’s chart.
10. 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

In development

Measurement Notes

1. 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. 
2. Data may be obtained from laboratory reports or patient chart. 
3. 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.
4. 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. 
5. 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.
6. 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. 
7. 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

• Heart & Stroke: Signs of Stroke
• Heart & Stroke: FAST Signs of Stroke
• Heart & Stroke: What is stroke?
• Heart & Stroke: Atrial Fibrillation 
• Heart & Stroke: Virtual Healthcare Checklist
• Heart & Stroke: Acute Stroke Management Infographic
• Stroke Engine

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)

Sex and Gender Considerations Reference List

Initial Assessment 

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).

Neurovascular Imaging

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). 

Cardiovascular Investigations

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. 

Glucose Management

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).