Ischemic strokes

These statements must be true in order to consider tPA administration:
1. Ischemic stroke onset within 3 hours, or in certain causes within 4.5 hours.
2. Measurable deficit on NIH Stroke Scale examination.
3. Patient’s computed tomography (CT) does not show hemorrhage or nonstroke cause of deficit.
4. Patient’s age is >18 years.

Contraindications to thrombolytics (tPA)

Do NOT administer tPA if any of these statements are true:
1. Patient’s symptoms are minor or rapidly improving.
2. Patient had seizure at onset of stroke.
3. Patient has had another stroke or serious head trauma within the past 3 months.
4. Patient had major surgery within the last 14 days.
5. Patient has known history of intracranial hemorrhage.
6. Patient has sustained systolic blood pressure >185 mmHg.
7. Patient has sustained diastolic blood pressure >110 mmHg.
8. Aggressive treatment is necessary to lower the patient’s blood pressure.
9. Patient has symptoms suggestive of subarachnoid hemorrhage.
10. Patient has had gastrointestinal or urinary tract hemorrhage within the last 21 days.
11. Patient has had arterial puncture at noncompressible site within the last 7 days.
12. Patient has received heparin within the last 48 hours and has elevated PTT.
13. Patient’s prothrombin time (PT) is >15 seconds.
14. Patient’s platelet count is <100 000/microliter.
15. Patient’s serum glucose is <50 mg/dL or >400 mg/dL.

Relative contraindications to thrombolytics (tPA)

If either of the following statements is true, use tPA with caution:
1. Patient has a large stroke with NIH Stroke Scale score >22.
2. Patient’s CT shows evidence of large middle cerebral artery (MCA) territory infarction (sulcal effacement or blurring of gray-white junction in greater than 1/3 of MCA territory).

Additional contraindications to thrombolytics (tPA) for 3–4.5 hours

1. Age >80 years
2. History of prior stroke and diabetes
3. Any anticoagulant use prior to admission (even if INR <1.7)
4. NIHSS >25
5. CT findings involving more than 1/3 of the MCA territory (as evidenced by hypodensity, sulcal effacement or mass effect estimated by visual inspection or ABC/2 >100 mL)

Table 16.2. NIH Stroke Scale

1a. Level of consciousness: Alertness and response to stimuli	1. Alert; keenly responsive. 2. Not alert; but arousable by minor stimulation to obey, answer, or respond. 3. Not alert; requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped). 4. Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, and areflexic.
1b. LOC questions:The month and patient’s age	1. Answers both questions correctly. 2. Answers one question correctly. 3. Answers neither question correctly.
1c. LOC commands:Opening and closing eyes, opening and closing non-paretic hand	1. Performs both tasks correctly. 2. Performs one task correctly. 3. Performs neither task correctly.
2. Best gaze:Horizontal eye movements	1. Normal. 2. Partial gaze palsy; gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is not present. 3. Forced deviation, or total gaze paresis not overcome by the oculocephalic maneuver.
3. Visual:Test visual fields to confrontation	1. No visual loss. 2. Partial hemianopia. 3. Complete hemianopia. 4. Bilateral hemianopia (blind including cortical blindness).
4. Facial Palsy:Ask patient to show teeth, open/close eyes	1. Normal symmetrical movements. 2. Minor paralysis (flattened nasolabial fold, asymmetry on smiling). 3. Partial paralysis (total or near-total paralysis of lower face). 4. Complete paralysis of one or both sides (absence of facial movement in the upper and lower face).
5. Motor Arm:Extend arm, test for drift 5a. Left Arm 5b. Right Arm	1. No drift; limb holds 90 (or 45) degrees for full 10 seconds. 2. Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support. 3. Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity. 4. No effort against gravity; limb falls. 5. No movement. UN = Amputation or joint fusion.
6. Motor Leg:Extend leg, test for drift 6a. Left Leg 6b. Right Leg	1. No drift; leg holds 30-degree position for full 5 seconds. 2. Drift; leg falls by the end of the 5-second period but does not hit bed. 3. Some effort against gravity; leg falls to bed by 5 seconds, but has some effort against gravity. 4. No effort against gravity; leg falls to bed immediately. 5. No movement. UN = Amputation or joint fusion.
7. Limb Ataxia:Finger-nose and heel-shin tests	1. Absent. 2. Present in one limb. 3. Present in two limbs. UN = Amputation or joint fusion.
8. Sensory:Sensation to pinprick, withdrawal to noxious stimuli	1. Normal; no sensory loss. 2. Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial pain with pinprick, but patient is aware of being touched. 3. Severe to total sensory loss; patient is not aware of being touched in the face, arm, and leg.
9. Best Language:Patient is asked to describe a standard picture, name objects, read sentences	1. No aphasia; normal. 2. Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. Examiner can identify picture or naming card content from patient’s response. 3. Severe aphasia; all communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener. Examiner cannot identify materials provided from patient response. 4. Mute, global aphasia; no usable speech or auditory comprehension.
10. Dysarthria:Patient reads/repeats words	1. Normal. 2. Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty. 3. Severe dysarthria; patient’s speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric. UN = Intubated or other physical barrier.
11. Extinction and inattention:Extinction to bilateral visual/sensory stimuli	1. No abnormality. 2. Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities. 3. Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space.
Sentences for Best Language Task:	Words for Dysarthria Task:
You know how. Down to earth. I got home from work. Near the table in the dining room. They heard him speak on the radio last night.	MAMA TIP-TOP FIFTY-FIFTY THANKS HUCKLEBERRY BASEBALL PLAYER