Management of Suspected Ischemic Stroke Without Imaging

Critical Limitation Without Imaging

Brain imaging is essential to exclude hemorrhage before administering antithrombotic therapy, and without it, differentiation between ischemic and hemorrhagic stroke cannot be made, according to the American Heart Association 1, 2, 3, 4, 5
The American College of Cardiology recommends that brain imaging is necessary to rule out stroke mimics such as brain tumor, abscess, or other non-vascular pathology 3, 4
The administration of rtPA or any anticoagulation is not safe without brain imaging, as stated by the American Heart Association 1, 2
Assessment for early ischemic changes or hemorrhagic transformation risk cannot be done without brain imaging, according to the American Heart Association 1, 8

The American Heart Association recommends assessing and securing airway, breathing, and circulation immediately in patients with suspected ischemic stroke 1, 2
Continuous monitoring of oxygen saturation and provision of supplemental oxygen if saturation falls below 94% is recommended by the American College of Chest Physicians 9
Respiratory compromise is a common issue in hemiparetic patients, with 63% developing hypoxia within 48 hours, according to the American Thoracic Society 1

The American Heart Association recommends checking vital signs at least every 30 minutes during initial evaluation of patients with suspected ischemic stroke 9, 7
Aggressive treatment of hyperthermia (temperature >99.6°F) is associated with improved stroke outcomes, as stated by the American College of Emergency Physicians 9, 7
Continuous monitoring of cardiac rhythm is necessary, as cardiac arrhythmias commonly accompany acute stroke, according to the American College of Cardiology 4, 7

The American Heart Association recommends not routinely treating hypertension unless blood pressure exceeds 220/120 mmHg in patients with suspected ischemic stroke 9
Rapid or excessive blood pressure lowering may exacerbate cerebral ischemia, according to the American College of Cardiology 9
Permissive hypertension is appropriate to maintain cerebral perfusion in patients with suspected ischemic stroke who cannot receive thrombolytics, as stated by the American Heart Association 9

The American College of Cardiology recommends proceeding with all non-imaging diagnostic tests that would normally be obtained in patients with suspected ischemic stroke 6, 4, 9
Blood glucose measurement to rule out hypoglycemia as a stroke mimic is recommended by the American Diabetes Association 9, 7
Complete blood count with platelet count, prothrombin time/INR, and activated partial thromboplastin time are necessary laboratory tests in patients with suspected ischemic stroke, according to the American College of Cardiology 6, 4, 9

The American Heart Association recommends performing standardized neurological assessment using the National Institutes of Health Stroke Scale (NIHSS) to document baseline severity in patients with suspected ischemic stroke 9, 7
Documentation of the exact time the patient was last known to be well is critical for future decision-making if the patient changes their mind about imaging, according to the American College of Emergency Physicians 9, 7

The American Heart Association recommends that without imaging to confirm ischemic stroke and exclude hemorrhage, antiplatelet therapy (aspirin, clopidogrel) and anticoagulation cannot be safely initiated 4, 3
Risk factor counseling and education, as well as smoking cessation counseling if applicable, can be begun in patients with suspected ischemic stroke, according to the American College of Cardiology 6
Planning for outpatient vascular imaging once the patient agrees to diagnostic workup is recommended by the American Heart Association 10, 6

The American College of Chest Physicians recommends positioning the head of bed at 25-30 degrees in patients with suspected ischemic stroke 9, 7
Keeping the patient NPO (nothing by mouth) until swallowing can be assessed is recommended by the American College of Gastroenterology 9
Prophylactic anticonvulsant medications are not recommended and may impair neural recovery in patients with suspected ischemic stroke, according to the American Academy of Neurology 9

The American Heart Association recommends that accepting the patient's refusal of imaging without adequate informed consent discussion is a critical pitfall to avoid 1, 3, 4
Clearly explaining the risks and benefits of imaging, including the potential for life-saving treatments, is necessary, according to the American College of Emergency Physicians 1, 2
The time window for effective treatment is rapidly closing, ideally within 3-4.5 hours for rtPA, and should be clearly explained to the patient, as stated by the American Heart Association 1, 2