Ischemic Stroke - Hennepin County Medical Center

Dear Readers: 

As an emergency physician, I know that my practice is more 

successful when I try to evolve with medical advances and partner 

with the outstanding multidisciplinary team at Hennepin. The question 

I and most other clinicians often ask is: how? How can I keep better 

track of medical advances and apply what I’ve learned to my practice? 

How can I better partner with and understand the perspectives of the 

multiple disciplines on each critical care patient’s team? 

Approaches in Critical Care is our attempt to provide an answer 

those questions. In Approaches in Critical Care, you’ll find real-life 

critical care challenges, chosen because of the lessons they offer for 

everyday clinical practice and written to be relevant to multiple critical 

care disciplines, including physician specialists, subspecialists, 

emergency medical services (EMS), nurses, and others. Each issue 

will include a special section for EMS professionals, a profile of a clinician 

who can lend perspective on the topic being highlighted, and 

information on recent news and events. 

The theme of this inaugural issue is ischemic stroke care. Soon we’ll 

begin work our Spring 2009 issue, which will be devoted to trauma 

care. Have you had an interesting recent trauma case from which 

others could learn? If so, consider authoring a case report. For more 

information, see the author’s guidelines on our Web site at 

www.hcmc.org/approaches. Or if you have an idea for improving this 

publication, please contact us. Like good medicine, we hope this 

publication continually evolves with the needs of all the disciplines 

involved in treating the critical care patient. 

Sincerely, 

Michelle H. Biros, MD, MS 

Department of Emergency Medicine 

Hennepin County Medical Center 

®

Contents Volume 1 | Approaches in Critical Care December 2008 

Approaches in Critical Care 

Editor-in-Chief 

Michelle Biros, MD, MS 

Managing Editor 

Linda Zespy 

EMS Perspectives Editor 

Robert Ball, EMT-P 

Graphic Designer 

Karen Olson 

Marketing Director 

Ted Blank 

Patient Care Director, 

Critical Care and 

Emergency Services 

Kendall Hicks, RN 

Patient Care Director, 

Behavioral and 

Rehabilitative Services 

Joanne Hall, RN 

Printer 

Sexton Printing 

Photographers 

Raoul Benavides 

Clinical Reviewer 

Robert Taylor, MD 

Case Reports 

2 Management of middle cerebral stroke with mass effect in the setting 

of heparin-induced thrombocytopenia 

Charles Bruen, MD 

6 Management of an ischemic stroke with delayed clinical deterioration, 

using intra-arterial tPA and angioplasty 

Jeremy Olson, MD 

8 A case of delayed intra-arterial thrombolysis in a cerebrovascular accident 

Lisa M. Hayden, MD 

11 Critical Care Profile 

Adnan Qureshi, MD, Executive Director of the Minnesota 

Stroke Initiative 

13 EMS Perspectives 

History, prehospital assessment, and management of acute stroke 

17 Calendar of Events 

19 News Notes 

To submit an article 

Contact Managing Editor Linda Zespy at approaches@hcmed.org. The editors reserve the right to 

reject editorial or scientific materials for publication in Approaches in Critical Care. The views 

expressed in this journal do not necessarily represent those of Hennepin County Medical Center, its 

editors, or its staff members. 

Copyright 

Copyright 2008 Hennepin County Medical Center. Approaches in Critical Care is published twice per 

year by Hennepin County Medical Center, 701 Park Avenue, Minneapolis, Minnesota 55415. 

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Approaches in Critical Care | December 2008 | 1

Case Reports 

Treating Ischemic Stroke: 

Three Case Reports 

Stroke is the leading cause of disability 

in the U.S. and the third leading 

cause of death. In the last fifteen 

years, the advent of thrombolytic 

drugs such as tissue plasminogen 

activator (tPA) for ischemic strokes 

has increased the range of options 

for treating stroke patients. However, 

because tPA and other options must 

be provided within a specified number 

of hours after symptom onset and 

many complicating factors can occur, 

stroke care remains a challenging 

endeavor. The following case reports 

describe diverse presentations and 

care decisions for three recent 

Minnesota ischemic stroke patients. 

Case One 

Management of middle cerebral 

stroke with mass effect in the 

setting of heparin-induced 

thrombocytopenia 

by Charles Bruen, M.D. 


and Department of Internal Medicine 


Abstract 

The patient presented to the 

Emergency Department with a large 

right middle cerebral artery ischemic 

stroke with an uncertain time of 

onset. Significant edema developed, 

leading to increased intracranial 

pressure (ICP) and a midline shift. 

This development was monitored via 

a ventriculostomy and therapeutically 

treated with cerebral spinal fluid 

(CSF) drainage. The development of 

Type II heparin-induced thrombocytopenia 

(HIT) provided a challenge to 

balance the new need for anti-coagulation 

to prevent reactive thrombosis 

from HIT with risk for hemorrhagic 

conversion of the existing large 

ischemic stroke. Lepirudin was used 

to bridge anticoagulation until platelets 

normalized and eventual warfarin 

anti-coagulation was initiated. 

Case report 

The patient is a 53-year-old Caucasian 

woman with a past medical history 

significant only for fibromyalgia and 

cessation of smoking ten years prior. 

At approximately 3:00 a.m. the day 

before presentation, she developed a 

right-sided headache that woke her 

from sleep. Several years earlier, the 

patient had a similar headache that 

resolved spontaneously. 

The patient took ibuprofen for her 

headache pain but had no relief. By 

morning, her headache had worsened 

to the point that she decided to stay 

home from work. At midday, her husband 

found her confused and disoriented, 

with diarrhea on the floor and 

objects in the home in disarray. Her 

headache worsened all day, and by 8 

p.m. that evening, her husband was 

unsure of the patient’s ability to 

understand what was told to her. By 

the next morning, her husband noticed 

weakness on the left side of her body 

and the EMS system was activated. 

On presentation in the Emergency 

Department, the patient’s blood pressure 

was 95/75, pulse 52, respirations 

20, SpO2 98%. She was afebrile. 

2 | Approaches in Critical Care | December 2008

Case Reports 

The patient was awake, alert, oriented to person, 

place, and time, maintaining her airway, 

and breathing spontaneously. She had 2+ distal 

pulses. She was moving her right arm and 

both legs, but her left arm was held at her 

side. The patient had 5/5 strength in all 

extremities except her left upper; she was 

unable to lift her arm off the cart, was not able 

to grip, and was not able to perceive touch. 

The remaining physical exam was normal. 

Figure One. CT scan 

obtained on presentation to 

the Emergency Department. 

Figure Two. CT scan 

obtained after placing 

ventriculostomy on hospital 

day 3. 

Figure Three. CT scan 

obtained the day prior 

to discharge after 39 

days in the hospital. 

The patient was given one liter of normal 

saline and Dilaudid for pain. A computed tomograph 

(CT) scan of her head without contrast 

was obtained. (See Figure One.) The images 

revealed a well-established hypodensity in the 

distribution of the right middle cerebral artery. 

Also noted was a significant associated 

edema-induced mass effect and approximately 

6-7 mm of right-to-left midline shift and mild 

sub-falcine and uncal herniation. Immediately 

following the patient's return from radiology, 

she was started on Dilantin for seizure prophylaxis; 

5% hypertonic saline was started to prevent 

further midline shift. 

The decision was made not to treat with 

thrombolytics and to treat the edema conservatively 

in the Surgical Intensive Care Unit 

(SICU). The patient was closely followed by 

the neurocritical care and neurosurgery team 

members. Serial CT scans revealed an evolving 

hypodensity with extensive edema. (See 

Figure Two.) Concerns about increased ICP 

prompted the placement of a ventriculostomy. 

The initial ICP was 20 mmHg. Blood pressure 

was controlled with a mean arterial pressure 

(MAP) >70 mmHg and systolic blood pressure 

(sBP) 320 osmols. She was placed 

on deep venous thrombosis prophylaxis 

with heparin. 

Over the next several days in the SICU, 

repeated attempts at clamping the ventriculostomy 

were poorly tolerated by the patient; 

when this was attempted, changes were noted 

in her mental status and her ICP increased to 

25-40 mmHg. Mechanical drainage of CSF 

(averaging 200cc per day) would return the 

ICP to less than 10 mmHg. During the period 

of peak ICP measurements on days three 

through nine, a combination of 3% hypertonic 

saline and CSF drainage was used, with the 

goals of maintaining ICP 60 mmHg, and 

sodium

Case Reports 

She is continent of bowel and bladder. A left 

field cut is easily demonstrated and she has 

obvious left hemi-neglect on sensory testing. 

The patient is articulate and can express herself 

quite clearly but often interrupts others and 

appears to be somewhat disinhibited in social 

situations. The patient is scheduled for longterm 

physical and rehabilitation therapy to 

regain as complete functioning as possible. 

Discussion 

This patient, whose outcome was decidedly better 

than may have been estimated initially, presented 

several difficult management challenges. 

The patient presented with a history and physical 

examination very suggestive of stroke, a 

luxury not always available to the clinician. 

While clinical exam findings are unquestionably 

useful, the diagnosis is usually confirmed 

with imaging. A cranial CT scan without contrast 

is critical to differentiating ischemic from 

hemorrhagic stroke. An ischemic stroke can 

begin to show changes such as a hyperdense 

artery sign, sulcal effacement, loss of graywhite 

interface, mass effect, and acute hypodensity 

as soon as three hours after the event, 

but more often between 6-12 hours. Presence 

of early ischemic changes does not change 

the management with intravenous fibrinolytic 

therapy within the three-hour time window. An 

electrocardiogram helps diagnose atrial fibrillation 

(which account for 60% of cardio-embolic 

strokes) and myocardial infarction. 

Out-of-hospital providers and emergency 

physicians need to document as best as they 

are able the exact time of stroke onset and 

presence of any neurologic deficits, since 

these findings may rapidly progress or resolve 

by the time the patient arrives at the hospital. 

Such information is critical for the decision in 

administration of fibrinolytics. Management of 

blood pressure should use pre-established 

guidelines and will vary depending on whether 

the patient is a candidate for fibrinolytic therapy. 

The sBP shoud be less than 185 mmHg and 

the dBP less than 110 mmHg before giving fibrinolytics 

because of concern for increased 

intracranial hemorrhage risk with higher blood 

pressures. If fibrinolytics are given, strict blood 

pressure control is indicated, with the goal of 

having sBP 120 mmHg, according to the most recent 

American Heart Association guidelines. Aspirin 

given within 48 hours of the stroke onset has 

been shown to have mild efficacy in preventing 

early recurrent stroke but does not improve 

outcomes from the current stroke. Aspirin 

should be held for 24 hours after fibrinolytic 

therapy in case there is an intracranial hemorrhage. 

Improved outcome has not been shown 

for treatment with heparin for ischemic stroke 

in several clinical trials. Recent studies show 

no benefit from heparin, or a small potential 

benefit of heparin, that is counterbalanced by 

an increased risk of hemorrhage. 

In addition to the focal neurologic injury from the 

ischemic stroke itself, cerebral edema that 

develops following the insult can lead to intracranial 

hypertension and further devastating neurologic 

effects. 

The clinical manifestations of increased 

ICP include: 

Depressed level of consciousness 

Headache 

Vomiting 

Cushing's triad (bradycardia, respiratory 

depression, and hypertension) 

Additional focal deficits can be caused by 

ischemic injury or herniation. These manifestations 

are caused either by direct mass effects 

of the increased intracranial volume (e.g. herniation, 

Cushing's triad) or the decrease in 

cerebral blood flow caused by the ICP. 


Case Reports 

In normal adults, ICP is 20mmHg. Cerebral perfusion pressure (CPP) 

is a clinical marker for the adequacy of cerebral 

blood flow. (CPP = MAP - ICP). Cerebral 

blood flow is normally maintained at a relatively 

constant level by vascular autoregulation 

over a wide range of CPP (50-100 mmHg). 

When intracranial hypertension develops, 

cerebral blood flow decreases, leading to 

hypoperfusion and ischemic injury. Therefore 

in the presence of ICP, CPP should be maintained 

between 60-75 mmHg. 

Management of the cerebral edema and associated 

ICP is critical to minimize worsening the 

ischemic deficit. An important early goal in this 

management of ICP is placement of a monitoring 

device that improves insight into the patient's 

condition and can guide the therapies needed 

to maintain adequate CPP and oxygenation. 

Patients should be kept euvolemic and slightly 

hyperosmolar (295-305 mOsm/L). Hypertonic 

saline acutely lowers ICP but is unproven in 

longterm outcomes. Cerebral metabolic 

demand, and consequently cerebral oxygen 

consumption, can be reduced by sedating 

patients. Blood pressure, especially when 

hypertensive, needs to be carefully managed. 

The optimal blood pressure in these patients 

is still a matter of debate. Some argue that 

lowering the sBP will help decrease the ICP 

and improve outcomes. However, others argue 

that inducing systemic hypertension may 

increase cerebral perfusion and is more important. 

Osmotic diuretics such as mannitol can 

be used to draw free water from the cerebral 

tissues back into the vascular space where it 

can be managed by the kidneys. Despite 

occasional use, glucocorticoids have not been 

shown to improve outcomes and may increase 

the risk of infections, so generally should be 

avoided. While hypocapnia (PaCO2 between 

26-30 mmHg), induced through hyperventilation, 

leads to vasoconstriction and a decrease 

in intracranial blood volume in the early 

management of an acute stroke, it is often 

counter to the need to maintain cerebral perfusion 

and is probably best avoided. Prophylactic 

therapy for seizures in the setting of large 

hemispheric stroke is unproven, but sometimes 

still administered. 

Removal of CSF can be immensely useful in 

lowering ICP, and is generally easily done 

through a ventriculostomy draining to gravity. 

The drainage should be done slowly at a rate 

of 1-2 mL/minute in cycles of 2-3 minutes 

draining with a similar period of being 

clamped. This can be repeated until ICP is

Case Reports 

Case Two 

Management of an ischemic stroke with 

delayed clinical deterioration, using intraarterial 

tPA and angioplasty 

by Jeremy Olson, M.D. 



venous limb gangrene (distal ischemic necrosis 

following DVT), cerebral sinus thrombosis, 

and arterial thrombosis; the patient suffered 

none of these complications. 

Enoxaparin should not be substituted for 

unfractionated heparin after HIT develops. 

Anticoagulation with a direct thrombin inhibitor 

such as lepirudin (FDA-approved for preventing 

new thromboses in patients with isolated 

HIT and no clinically evident thromboembolic 

complications) or argatroban would be advised 

in a patient with HIT. 

However, in a setting of stroke and ventriculostomy, 

anticoagulation is risky for hemorrhagic 

complications or hemorrhagic conversion 

of the intracranial lesion. That being the 

case, at the very least it was prudent to discontinue 

all use of heparin and enoxaparin and 

to conduct screening for and daily assessment 

for thromboembolic disease (i.e. lower extremity 

Doppler exams, asymptomatic size and limb 

discomfort, and shortness of breath). Adequate 

anticoagulant levels were documented by prolongation 

of the activated partial thromboplastin 

time (aPTT) between 1.5 and 2.5. Above 

2.5, the risk of bleeding doubles. Only after the 

patient has been fully anticoagulated with a 

thrombin-specific inhibitor and the platelet count 

increases above 100,000/µL should warfarin be 

started. There should be at least a five-day 

overlap with warfarin before the thrombin 

inhibitor is stopped. 

Abstract 

New diagnostic and treatment modalities such 

as computed tomography (CT) perfusion and 

cerebral angiography are extending the time 

window for the treatment of stroke. Ischemic 

tissue, found at any time following the onset of 

symptoms, can be saved and patients with 

stroke symptoms should be emergently evaluated 

for possible brain-saving therapies for 

ischemic, but not-yet-infarcted tissue. This 

case illustrates the usefulness of advanced 

imaging methods in decision-making for a 

patient with symptoms of an uncertain duration 

and clinical progression. 

Case report 

A 61 year-old male with a history of seizure 

disorder, hypertension and glaucoma presented 

to the Emergency Department with left-sided 

hemiparesis. His time of symptom onset was 

unknown. He was last seen normal at 11:45 

p.m. the night before he presented at the emergency 

department. When he woke up at 9:00 

a.m., he felt weak and was unable to get himself 

out of bed without support. His wife activated 

EMS at 11:25 a.m. when he continued to 

worsen. He was brought via ambulance with 

the presumptive diagnosis of ischemic stroke. 

In the Stabilization Room of the Emergency 

Department he was monitored via a cardiac 

monitor, continuous pulse oximeter, and blood 

pressure cuff. He was provided with oxygen 

via nasal cannula. Initial vital signs were BP 

123/69, HR 71, RR 10, O2 saturation 93%, and 

temperature of 36˚ Celsius. His primary survey 

demonstrated an intact airway, spontaneous respirations 

that were unlabored, intact circulation 


Case Reports 

and a Glasgow Coma Score (GCS) of 15. 

Secondary survey was remarkable only in his 

neurologic exam. He was alert and orientated 

to person, place and time. He had a left facial 

droop and dysarthria. There was no gaze preference. 

Strength was 5/5 RUE and RLE, and 

0/5 LUE and LLE. Response to light touch and 

pinprick were mostly absent on left side. 

Scoring on the National Institutes of Health 

(NIH) stroke scale was 13 on presentation. 

Chest x-ray and electrocardiogram (ECG) 

obtained in the Emergency Department were 

normal. The patient was packaged for head 

CT with the acute stroke team present. 

Given the long time period between being last 

seen normal and presentation (>12 hours), the 

patient was initially not considered a candidate 

for intravenous (IV) thrombolytics. He was 

taken for a non-contrast head CT scan to rule 

out hemorrhage. This was negative for an acute 

bleed. He then underwent emergent magnetic 

resonance imaging (MRI) and magnetic resonance 

angiography (MRA) to evaluate the 

extent of the injury. His brain MRI demonstrated 

an acute infarction of the middle cerebral 

artery distribution involving the right insular 

cortex and posterior limb of the right internal 

capsule and right corona radiata, along with 

chronic small vessel ischemic disease. The 

MRA demonstrated occlusion of the right middle 

cerebral artery beyond the proximal M1 segment, 

without distal reconstitution. The neck 

MRA demonstrated 40% stenosis of proximal 

right internal carotid artery. He was felt to be 

beyond the time window of intervention and 

taken to the ICU for further management. 

After arriving in the ICU, he developed a new 

right gaze preference and hemi-neglect. It was 

felt that these likely represented signs of ongoing 

ischemia/infarction and he was emergently 

taken for a CT perfusion study, which revealed 

diminished perfusion over the entire right middle 

cerebral artery (MCA) territory consistent with 

ischemia and a small localized area of infarction 

in the right insula similar to the infarct 

seen on MRI. (See Figure One on page 8.) 

Given these findings, he was felt to have a 

large area of ischemic but not-yet-infarcted 

brain (termed “penumbra.”) He was emergently 

taken to angiography, where he received lowdose 

intra-arterial tPA and angioplasty of the 

M1 lesion. This resulted in TIMI 3 flow and he 

was noted to have antigravity strength on the 

left side and improvement in his dysarthia. 

On hospital day (HD) 2, the patient was ambulating 

with assistance and had 4/5 strength 

proximal and distal in the LUE and LLE. A 

thromboembolic work-up including a transesophageal 

ECG was negative and it was felt 

that his stroke was a result of atherosclerotic 

vascular disease. Risk factors identified were 

his gender and hypertension. His LDL was 84 

and he was considered a candidate for statin 

therapy. On HD 3, his NIH stroke scale score 

was 3 with residual difficulties with speech and 

word finding. He underwent aggressive PT/OT 

and was discharged home on HD 6. 

On follow-up, the patient has persistent mild 

weakness in the left arm and leg along with 

some coordination difficulty. He is otherwise 

at baseline except for his memory and 

activity tolerance. 

Discussion 

This case illustrates that intervention is not limited 

solely to three hours after symptom onset, 

which is the current standard for IV tPA. 

Studies published in late 2008 may alter this 

standard. Because the clock starts when the 

patient was last seen normal, which includes 

cases where the patient wakes up or is found 

symptomatic, this patient was considered to be 

symptomatic for nearly 12 hours. The patient 

had some area of brain that was ischemic for 

nearly 12 hours but the patient also had a 

much larger area of ischemic brain for less 

than 3 hours when he clinically deteriorated in 

the hospital. 

The patient was initially not considered a candidate 

for acute stroke intervention because he 


Case Reports 

Figure One. 

Head CT perfusion study. 

The right upper quadrant 

shows cerebral blood volume 

(CBV), the left lower 

quadrant shows cerebral 

blood flow (CBF), and the 

right lower quadrant 

demonstrates mean transit 

time (MTT). This 

study shows marked 

asymmetry in CBF and 

MTT between the right 

and left middle cerebral 

artery (MCA) distributions. 

The reduction in 

the right MCA territory 

quantitatively meets 

ischemia criteria. The 

CBV is essentially normal 

in the right MCA, which 

suggests that this is 

ischemia rather than 

infarction. 

was beyond 3 hours for the intravenous 

thrombolytic window, beyond 6 hours for the 

standard intra-arterial thrombolytic window 

and beyond 8 hours for the current standard 

mechanical thrombectomy window. The initial 

MRI showed a relatively small area of infarction 

despite significant clinical symptoms. 

The CT perfusion was important in determining 

the presence of salvageable brain tissue and 

his candidacy for treatment despite the late 

time window. 

CT perfusion involves two contrast boluses 

and several timed CT cuts through the 

lentiform nuclei and the supraventricular white 

matter. The images are reconstructed to represent 

quantitative color maps of cerebral blood 

volume, cerebral blood flow and mean transit 

time. Comparison between the right and left 

hemispheres in the cerebral artery distributions 

can differentiate between infarction and 

ischemia, and delineate tissue in watershed 

locations that may still be viable and survive if 

blood flow is restored. In this case, CT perfusion 

was able to differentiate between the 

small area of infarcted brain parenchyma and 

the large area of ischemic tissue that was still 

viable and would respond to restoration of 

blood flow. With the advent of CT perfusion 

scan to differentiate between infarction and 

ischemia, and cerebral angiography with 

numerous adjunct treatment modalities such 

as angioplasty, intra-arterial thrombolytics and 

mechnical thrombectomy devices, the standard 

time window of 0-6 hours may be extended 

to a longer time window in select patients. 

Case Three 

A case of delayed intra-arterial thrombolysis 

in cerebrovascular accident 

by Lisa M. Hayden, M.D. 



Abstract 

Though cerebrovascular accident (CVA) is 

considered a disease of elders, 25% of CVA 

occurs in patients less than 65 years of age. 


Case Reports 

Guidelines regarding early recognition and 

treatment of CVA are well established. Intraarterial 

thrombolysis (IAT) has been shown to 

improve outcomes in a select group of patients 

with thrombosis of the middle cerebral artery 

(MCA). Class I recommendations by the 

American Stroke Association include IAT for 

patients who are not candidates for intravenous 

thrombolysis and who present to a 

stroke center with thrombus in the MCA within 

6 hours of symptom onset. This case involves 

a young patient who underwent delayed IAT 

with a successful outcome. 

Case report 

A 29 year-old male with no significant past 

medical history presented to a local emergency 

department with sudden onset of severe leftsided 

headache, profound right-sided weakness 

and slurred speech about 30 minutes 

after sexual intercourse. A head CT showed no 

evidence of infarction or hemorrhage. The 

patient’s symptoms completely resolved after 

symptomatic treatment of the headache (about 

1-2 hours from onset) and he was discharged 

to home. The patient fell asleep around 4:00 

a.m. feeling normal. He awoke at 10:00 a.m. 

with aphasia and right-sided weakness and 

returned to the hospital. A repeat head CT at 

this time showed small hypodensities in the 

region of his left MCA. He was transferred to a 

stroke center with persistent right-sided facial 

droop and profound weakness of the right 

upper and lower extremities. 

Upon arrival at the stroke center, his vital signs 

were temperature 35.9° Celsius, BP 153/77, 

HR 75, RR 17, and O2 saturation of 100%. An 

emergent CT perfusion showed a large perfusion 

deficit with a small area of infarction in the 

territory of the left MCA, consistent with a large 

area of at-risk but salvageable brain tissue. CT 

angiogram showed a small focal thrombus in 

the proximal segment of the MCA. Emergent 

MRI confirmed a small amount of existing 

stroke in the left MCA distribution. Cerebral 

angiogram by the neurointerventionalist 

revealed an occlusion of the left M1 with a 

string of delayed flow around the thrombus. 

Low-dose intra-arterial alteplase (2 mg) was 

administered directly into the clot approximately 

17 hours after his initial presentation and 

just over 12 hours after he went to sleep feeling 

normal again after the first transient 

ischemic attack (TIA). Intra-arterial thrombolytic 

treatment was chosen over mechanical 

embolectomy despite the late time window 

because a small clot burden was seen that 

would likely respond to the thrombolytic treatment. 

The angiogram showed partial resolution 

of the clot and significant improvement in distal 

perfusion of his left MCA. (See Figure One on 

page 10.) 

Intravenous Integrilin ® was administered to 

prevent vessel reocclusion and facilitate further 

clot lysis. A follow-up angiogram showed a 

spontaneous dissection in the area of the 

thrombus, which was thought to be the cause 

of occlusion. At a later date, the patient underwent 

stenting of his left M1 dissection and is 

currently on aspirin and Plavix ® . Other workups, 

including labs for hypercoaguable disease 

and imaging for cardiac sources of thromboembolism, 

were negative. The remainder of 

the patient’s hospital course was unremarkable 

and at the one-year follow-up, the patient’s 

only remaining deficit was an occasional 

tremor of his right hand at rest. He is back to 

work and otherwise living a normal life. 

Discussion 

American Stroke Association class I recommendations 

for IAT include patients presenting 

within 6 hours of symptom onset with ischemic 

CVA to the MCA, who are not candidates for 

intravenous thrombolysis (IVT). Class I recommendations 

also include IAT by a qualified 

interventionalist at a center with access to 

cerebral angiogram. Preliminary data show 

significant benefit of IAT versus placebo. One 

example is the PROACT II trial, which has 

shown favorable results for IAT use. One 

aspect of this study compared patients who 


Case Reports 

Since this patient suffered a relatively small 

area of already infarcted brain prior to the procedure, 

his risk of suffering a hemorrhage was 

probably significantly lower than one might 

predict based on the treatment time window. 

Figure One. On left, occlusion of left MCA. On right, reperfusion after IAT. 

received IAT within 6 hours of MCA stroke 

symptom onset with a control group that 

received IV heparin. IAT succeeded in arterial 

recanalization of 67% of patients vs. 18% in 

the control group. 

The possible side effect of intracerebral hemorrhage 

(ICH) remains a concern. In this 

PROACT II study, there was an increase in 

symptomatic ICH (10.2% vs. 1.8% at 24 

hours), although there was no significant difference 

in 90-day survival. Less data are available 

comparing IAT to IVT. Further studies of 

IAT for MCA ischemic stroke are needed 

before approval of this treatment by the FDA. 

In this case, the patient presented after the traditionally 

accepted window for both IVT and 

IAT. There is limited research on delayed IAT 

administration, but recent data suggest that 

IAT administration based on imaging and 

symptoms can extend the accepted treatment 

window. One study of intra-arterial urokinase 

administered within 3.5 to 48 hours of symptom 

onset in 13 patients showed symptom 

improvement in 69% of patients at 48 hours 

and 100% of surviving patients at 3 months. 

This patient may have been considered a good 

candidate for delayed IAT because he was 

young, otherwise healthy with few co-morbidities, 

and had a CT perfusion scan and MRI 

scan that showed only a small existing infarction 

with a very large perfusion deficit (i.e. 

large ischemic penumbra.) New data also suggest 

that the risk of symptomatic intracerebral 

hemorrhage related to thrombolysis correlates 

with the size of the infarction prior to treatment. 

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Barnwell SL, et al. Safety and efficacy of delayed intra-arterial 

urokinase therapy with mechanical clot disruption for thromboembolic 

stroke. Am J of Neuroradiol. September 2004; 

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Ciccone A, et al. Debunking 7 myths that hamper the realization 

of randomized controlled trials on intra-arterial thrombolysis 

for acute ischemic stroke. Stroke. Jul 2007; 38: 2191-2195. 

Del Zoppo GJ, Higashida RT, et al. PROACT: A Phase II randomized 

trial of recombinant pro-urokinase by direct arterial 

delivery in acute middle cerebral artery stroke. Stroke. 1998; 

29:4-11. 

Furlan R, Higashida A. Intra-arterial prourokinase for acute 

ischemic stroke. A PROACT II study: a randomized controlled 

trial. JAMA. 1999; 282:2003-2011. 

Lansberg MG, Thijs VN, Bammer R et al. Risk factors of 

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acute stroke. Stroke: A Journal of Cerebral Circulation. 

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Marx, J; Hockberger, R; Walls, R. Rosen's Emergency Medicine: 

Concepts and Clinical Practice. 6th Ed. Elsevier. 2005. 

Martel, N; Lee, J; Wells, PS. Risk for heparin-induced thrombocytopenia 

with unfractionated and low-molecular-weight 

heparin thromboprophylaxis: A meta-analysis. Blood 2005; 

106:2710. 

Napolitano, LM, et al. Heparin-induced thrombocytopenia in 

the critical care setting: Diagnosis and management. Crit Care 

Med 2006; 34:2898. 

Procaccio, F, et al. Guidelines for the treatment of adults with 

severe head trauma (part I). Initial assessment; evaluation and 

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systemic and cerebral monitoring. J Neurosurg Sci March 

2000; 44(1):1-10. 

Procaccio, F; Stocchetti, N; Citerio, G; et al. Guidelines for the 

treatment of adults with severe head trauma (part II). Criteria 

for medical treatment. J Neurosurg Sci March 2000; 44(1):11-18. 

Warkentin, TE; Levine MN; Hirsh, J. Heparin-induced thrombocytopenia 

in patients treated with low-molecular-weight 

heparin or unfractionated heparin. N Engl J Med 1995; 

332(20):1330-1336. 

Zeumer H, Hacke W, Ringelstein EB. Intra-arterial thrombolysis. 

Am. J. Neuroradiol., September 1, 2001; 22:18S - 21S. 


Profiles in Critical Care 

Q and A withQ and A with 

Adnan Qureshi, MD 

“In terms of 

training, 

we now have 

one of the 

largest training 

programs 

in the 

United States 

in the 

subspecialties 

of stroke.” 

In his clinical practice, Adnan 

Qureshi, MD, has witnessed one of 

the most dramatic evolutions in modern 

medical care—the transformation 

of stroke treatment. As an international 

leader in stroke research and policy, 

he has helped fuel that transformation. 

Qureshi is a neurointerventionalist on 

the in-house stroke teams at 

Hennepin County Medical Center and 

the University of Minnesota Medical 

Center, Fairview. He also is an internationally 

renowned speaker and 

author, Executive Director of the 

University-funded Minnesota Stroke 

Initiative, associate head of the department 

of neurology at the University of 

Minnesota, and Executive Director of 

the U’s Zeenat Qureshi Stroke 

Research Center. We interviewed 

Qureshi about his career path and 

the state of stroke care in Minnesota. 

What is a neurointerventionalist? 

How did you train for the specialty? 

A neurointerventionalist is a person 

who has training in both medical 

management of stroke and treating 

stroke with endovascular procedures 

like use of stents, specialized coils, 

and other mechanical treatments. I 

trained in neurology at Emory University 

in Atlanta and did a fellowship at Johns 

Hopkins, then another fellowship in 

endovascular surgery at Millard Fillmore 

Hospital in Buffalo, NY. So that’s the 

training background for neurointerventionalists–beyond 

neurology, I did 

specialty training in stroke, neurocritical 

care, and interventional procedures. 

What led you into that subspecialty? 

Many years ago, when I made the 

decision, it was clear this was the 

specialty that was going to evolve the 

most. When I first started in this specialty, 

there was only diagnosis—but 

not much for treatment. You could 

sense that treatment was coming. It 

would have been sad to miss out on 

something that was going to evolve 

so rapidly and positively, and there 

was an excitement of being part of 

something so dynamic. What has 

been fascinating and professionally 

satisfying is the amount of treatment 

we can do today, including reversing 

stroke. Reversing stroke was 

unheard of not that long ago, but 

today there are treatments that can 

restore blood and function to the brain. 

Why has stroke care evolved 

so rapidly? 

When there’s no treatment, people 

are likely to move faster. Also, the 

evolution of cardiology and trauma 

care has helped stroke care. Cardiology, 

including the use of stents, angioplasty, 

etc., has evolved in a similar way 

to stroke care but over a longer period 

of time. That’s allowed us to evaluate 

new treatments and put them 

into practice more quickly. Trauma 

developed a system to take people 

from the field and bring them to specialized 

hospitals as quickly as possible. 

Those lessons are being applied 

to stroke care. 


Profiles in Critical Care 

You are the Executive Director of the 

Minnesota Stroke Initiative. What is 

this initiative? 

The Minnesota Stroke Initiative is one of the 

largest stroke initiatives in the United States. 

There are three components. The first is education. 

Through the initiative, we’ve worked 

with several media sources like the American 

Heart Association (AHA) to provide educational 

materials in different forms to the public. The 

second aspect is clinical services and training. 

Clinical services include endovascular treatment, 

neurocritical care, stroke units, and 

stroke clinics. In terms of training, we now 

have one of the largest training programs in 

the United States in the subspecialties of 

stroke. A third very important component is 

research. We work with the National Institutes 

of Health (NIH) on research on the epidemiology 

of stroke, which will help identify new risk 

factors and methods of prevention. We also 

work with NIH and AHA to do clinical and basic 

research, developing new therapies for stroke. 

“It’s true that people don’t come to the 

hospital in time, but also hospitals don’t 

react to the need on time...recent 

studies have shed light on those deficits 

in the medical system, so we can’t just 

say it’s about patients not getting to the 

hospital on time.” 

When it comes to stroke care, what does 

Minnesota do well? What could we do better? 

Minnesota now has more specialized stroke 

centers than we used to have. Also, while in 

the past there was somewhat of a shortage of 

teaching programs that provide specialized 

stroke care, now there’s been a realization that 

we need to keep up with the rest of the country. 

As a program [at Hennepin County Medical 

Center and the University of Minnesota 

Medical Center, Fairview], we now would be 

rated in the top ten in the country, and that 

comes from having some of the largest training 

programs and clinical programs. 

As a state, we need to do more work on public 

education. We haven’t done as well as states 

like Florida, New Jersey, and Massachusetts. 

Those states also have defined standards of 

what they want to see in comprehensive and 

primary stroke centers, and here we have none 

of that. It’s a matter of funding at a state level, 

and the state getting behind it legislatively. 

In twenty years, what will stroke care in 

Minnesota look like? 

There will be evolution in three frontiers: 

First, evolution in patients recognizing a stroke 

earlier and coming to the hospital in time. 

Right now, we still have a lack of public recognition 

of what a stroke feels like, that stroke is 

treatable, and you need to go to the hospital 

as soon as possible and not wait until the 

next morning. 

Second, prevention. We will see programs trying 

to detect high-risk groups in the population 

and finding interventions that can target those 

groups and yield the best results. 

Third, treatment. There will be new treatments 

and the treatments will be applicable to a 

broader population. Right now, we have treatments 

only offered to 4% of the population. It’s 

true that people don’t come to the hospital in 

time, but also hospitals don’t react to the need 

on time. Hospitals aren’t currently ready to 

react in an expedient way, 24 hours per day. 

Recent studies have shed light on those deficits 

in the medical system, so we can’t just say 

it’s about patients not getting to the hospital 

on time. 


EMS Perspectives 

__________________________________ 

EMS Perspectives: Acute Stroke 

Paramedics from Hennepin County Medical Center 

transport a potential stroke patient. 

_____________________________________________ 

by Robert Ball, EMT-P, 

Hennepin Emergency Medical Services, Hennepin County Medical Center 

Acute stroke, or cerebral vascular 

accident (CVA), is the third leading 

cause of death in the U.S. Only heart 

disease and cancer (all types combined) 

have a higher mortality. Over 

780,000 new or recurrent strokes occur 

each year or roughly one every 40 

seconds. Stroke is the single largest 

cause of disability with over 4 million 

survivors; about 90 percent of those 

have at least some neurological deficit. 

History: Stroke treatment and EMS 

Historically, emergency medical services 

(EMS) has considered stroke to 

be a “life-threatening condition” but in 

the past it has been a threat that 

could not be mitigated. This tended to 

leave EMS at odds with other health 

care disciplines, as we would often 

find ourselves responding emergently 

to a patient who had an onset of stroke 

symptoms up to 24 hours earlier. 

The concept of stroke as a “brain 

attack” with definitive methods of 

treatment began in the mid-1990s, as 

ischemic stroke patients were treated 

with tPA and other “clot-busting” drugs. 

The limitations were great, however; 

patients with a symptom onset of 

greater than three hours were not 

good candidates for thrombolytics 

because necrotic areas had a higher 

risk of hemorrhage after this point. 

Also, guidelines dictated that treatment 

could not begin without ensuring 

the patient was indeed having an 

ischemic stroke and not a cerebral 

hemorrhage, which could be worsened 

by thrombolytic drugs like tPA. 

The narrow window of opportunity to 

provide an effective treatment made 

EMS a key stakeholder in reducing 

symptom onset to treatment time. 

Even so, the assessment necessary 

in the emergency department to ensure 

the patient was a suitable candidate 

for treatment resulted in a daunting 

challenge for providers, as some 

assessments were time-consuming. 

Since then, treatment for acute stroke 

has become more refined, including 

the use of intra-arterial administration 

of tPA at the site of the thrombus and 

mechanical clot retrieval devices. 

Such refinements in treatment have 

increased the window of treatment 



time from a mere 3 hours from symptom onset 

to 6-12 hours from symptom onset, depending 

on the location of the insult and other factors. 

An effective EMS response to stroke remains 

a key factor in reducing mortality and morbidity 

from stroke. 

What is stroke? 

Stroke is defined as an acute loss of perfusion 

to the vascular territory of the brain, resulting 

in ischemia and a corresponding loss of neurologic 

function. 

The cause of stroke can vary and greatly 

impacts the management of the patient with 

stroke. Approximately 83% of all strokes are 

ischemic and secondary to either a thrombus 

or embolism. The other 17% are secondary to 

an intracerebral hemorrhage and subarachnoid 

hemorrhage. While the prehospital treatment is 

essentially the same for ischemic and hemorrhagic 

stroke patients, understanding the differences 

is important as it will help direct the 

assessment of the patient on arrival at the 

emergency department. 

Similar to stroke, a transient ischemic attack 

(sometimes called a TIA or “mini-stroke”) is 

defined as temporary neurologic dysfunction 

as a result of vascular occlusion. Symptoms 

normally resolve in less than one hour. While 

neurologic function returns to normal after a 

TIA, these events are strong predictors of a 

future stroke. 

We often think of stroke as a disease of elders. 

While it is most prevalent in people over 

65, stroke can occur at any age. Younger victims 

of stroke often have notable risk factors, 

such as smoking, preexisting coagulopathy, 

the use of oral contraceptives, and the use of 

illicit drugs (especially cocaine). Age alone 

does not allow stroke to be ruled out. 

Patients with stroke often present with a sudden 

onset of numbness or weakness of the 

face, arm, or leg, particularly on one side. 

They may have difficulty speaking (expressive 

aphasia/dysphasia), or difficulty understanding 

language (receptive aphasia/dysphasia). Gait 

and vision disturbances also may occur. In 

addition, sudden headache, decreased level of 

consciousness, nausea and vomiting, hypertension, 

or seizure activity may be present. 

The latter signs are more commonly associated 

with hemorrhagic stroke but may occur in 

any patient with acute stroke. 

When assessing the history of a stroke patient, 

determining the time of onset is critical. 

Providers should not only ask the patient but 

bystanders, family members, or first responders 

who may have witnessed the incident. If 

a definitive time of onset cannot be established, 

onset time must be estimated using the 

last time the patient was seen at their neurologic 

baseline. 

In addition to history related to the acute 

symptoms, it is important to obtain other information 

as well. Important factors include: 

Co-morbid conditions (especially diabetes 

or hypertension) 

Prior history (including recent myocardial 

infarction or history of atrial fibrillation) 

Recent stroke or prior TIAs 

Recent surgery 

Bleeding disorders 

Recent trauma 

Document any medications the patient takes. 

Pay particular attention to antihypertensives, 

insulin, or anticoagulants. 



“ Refinements 

in treatment 

have 

increased the 

window of 

treatment 

time from a 

mere 3 hours 

from 

symptom 

onset to 

6-12 hours 

from 

symptom 

onset, 

depending on 

the location 

of the insult.” 

Assessment and prehospital 

management* 

Like trauma and STEMI patients, the 

patient with stroke symptoms needs 

definitive care. While the assessment 

must be thorough, one must weigh 

the benefit of any procedure performed 

at the scene with the risk of 

delaying transport. Many procedures, 

such as IV access, usually can be 

performed en route to the hospital. 

Airway. Neurologic impairment of the 

face and mouth may require airway 

assistance. Depending on the 

patient’s level of consciousness, this 

may be as simple as positioning and 

suctioning secretions as needed. 

Adjuncts for airway management 

should be used as necessary but with 

caution, as the placement of some 

devices (most notably endotracheal 

intubation) may result in increased 

intracranial pressure. 

Breathing. Ventilatory support should 

be provided as necessary. For the 

breathing patient, oxygen should be 

provided. The use of high amounts of 

oxygen in the non-hypoxic patient is 

currently under study and is controversial. 

The American Heart 

Association currently recommends 

supplemental oxygen to allow a SpO2 

of >92%. This is a significant departure 

from many EMS practices that 

aim for 100% O2 saturation. 

Circulation. In most cases, the 

patient with stroke requires little 

actual circulatory support. Advanced 

life support (ALS) providers should 

establish IV access using 0.9% 

saline. D5W should be avoided in the 

patient with stroke. Transport should 

not be delayed for IV access. IV fluid 

administration should be limited to 

KVO or a saline lock should be 

placed. Avoid multiple IV attempts, as 

they will result in increased bleeding 

during treatment. 

What about hypertension? Many 

EMS agencies “treat” acute hypertension 

in the field. This is not recommended 

in the case of acute 

ischemic stroke. In the ischemic 

stroke patient, hypertension may be 

providing additional perfusion to the 

ischemic portion of the brain. 

Reducing systemic blood pressure 

can worsen the stroke in a subset of 

patients. Some treatment protocols in 

the emergency department include 

increasing the blood pressure slightly 

in some patients and avoiding reduction 

of blood pressure unless the systolic 

BP is >220 mmHg and the diastolic 

BP is >110 mmHg. The risks of 

lowering blood pressure in the field 

are higher than any potential benefit. 

Also, aspirin is not a safe medication 

to give during acute stroke without 

first confirming by CT that the stroke 

is ischemic and not hemorrhagic. 

Glucose level. Acute hypoglycemia 

can mimic acute stroke. When 

possible, a glucose level should be 

checked during the initial examination 

of the patient. Hypoglycemia should 

be corrected immediately. 

Neurological assessment. In addition 

to level of consciousness and 

orientation, EMS providers should 

assess the patient’s stroke symptoms 

using the Cincinnati Stroke Scale. 

(See Figure One.) 

Electrocardiogram. An initial ECG 

should be obtained when possible. 

Twelve-lead ECGs should be 

assessed for ischemic changes. 



________________________________________ 

Seventy-two percent of patients who have one abnormal finding 

on these three exam points may be experiencing an acute stroke. 

The patient is considered a possible CVA patient if any of the 

tested signs/symptoms are abnormal. 

The patient may be a candidate for thrombolysis (intravenous tPA) 

if any of the tested signs/symptoms are abnormal and onset of 

signs and symptoms began within 3 hours. Patients with ischemic 

stroke who are outside of the 3-hour window may be candidates 

for intra-arterial tPA or mechanical embolectomy, so timely hospital 

care is essential. 

Reference. Cincinnati Prehospital Stroke Scale (CPSS), Kothari, et al., 

Annals of Emergency Medicine, Volume 33, April 1999. Used with permission. 

_____________________________________________________ 

Figure One. Cincinnati Prehospital Stroke Scale for EMS Providers 

Transport. Even with the treatment window 

being expanded up to 6-12 hours from symptom 

onset, faster treatment is always better. 

Nearly two million brain cells die during each 

minute of a stroke. Rapid and safe transport to 

the closest appropriate facility is a key element 

of prehospital stroke care. Much like trauma 

and cardiac centers, many major hospitals are 

developing a “stroke center” model, which 

allows for rapid, definitive care of the acute 

stroke patient. When patients present with 

stroke in areas where a “stroke center” is not 

available, transport should be initiated to the 

closest facility capable of initial assessment 

and referral to a tertiary care center. In areas 

where ground transport of an acute stroke 

patient will not result in arrival at an appropriate 

hospital within the treatment window, 

aeromedical evacuation should be considered. 

Notification. Like trauma, STEMI, and other 

critical patients, it’s important to notify the 

receiving facility of an inbound patient with 

symptoms of acute stroke. This allows the 

facility to notify staff, reserve the appropriate 

procedure rooms, and prepare the computed 

tomograph (CT) scanner (a head CT is 

required prior to the administration of thrombolytics 

to ensure that the patient does not 

have a cerebral hemorrhage). Because “time 

is brain,” early notification of the receiving hospital 

allows the hospital-based team to prepare 

to reduce the other transitions in care that are 

necessary before treatment is started, such as 

door-to-CT time, door-to-CT-interpretation 

time, and CT-interpretation-to-treatment time. 

Because of their critical role in stroke care, 

EMS providers have an opportunity to provide 

patients with some of the biggest possible 

reductions in the time it takes for patients to 

be treated. This can be most successful with 

rapid response, early identification of acute 

stroke, early rule-out or management of hypoglycemia, 

and rapid transport to the closest 

appropriate facility, along with early notification 

to allow the hospital to mobilize resources. 

EMS providers may not provide definitive 

care, but they make definitive care effective 

in acute stroke. 

_____________________________________ 

* The treatments described summarize current practices in 

emergency care and serve as a guideline for prehospital care. 

EMS providers should defer to their agency’s medical director 

and standing orders if there is a discrepancy between this 

article and the agency’s current practice. 

__________________________________________________ 


Calendar of Events 

Class Descriptions 

Advanced Cardiac Life Support (ACLS) Provider 

This two-day course teaches paramedics, nurses, 

and physicians the essentials of cardiopulmonary 

resuscitation and emergency cardiac care as established 

by American Heart Association guidelines. 

Advanced Cardiac Life Support (ACLS) 

Provider Renewal 

This one-day review course teaches paramedics, 

nurses, and physicians the essentials of 

cardiopulmonary resuscitation and emergency 

cardiac care as established by American Heart 

Association guidelines. 

Advanced Cardiac Life Support (ACLS) 

for Experienced Providers 

This course is designed to provide experienced 

ACLS providers with new information on how to 

assess and manage critical cardiovascular emergencies 

not currently addressed in standard ACLS 

provider renewal courses. The course covers management 

of the standard ACLS core scenarios and 

focuses on four advanced areas of ACLS in 90- 

minute, interactive, small group sessions using a 

case-based format. These four areas are acute 

coronary syndromes, electrolytes, toxicology, and 

environmental emergencies. 

Emergency Medical Technician- 

Basic Course (EMT) 

This course is designed to train individuals to provide 

comprehensive emergency medical care at the 

basic life support level to victims of illness or injury. 

The course is an intensive three weeks of classroom, 

skills session, and clinical time. On completion 

of the course, students are prepared to function 

on a basic life support ambulance service. 

Certification as an EMT requires the successful 

completion of a national standard written and 

practical exam. 

EMT-Refresher Course 

This course is a review of the skills and knowledge 

covered in the EMT-Basic course. Attendance in an 

EMT-Refresher course and successful completion of 

practical testing every two years is required by the 

state to maintain EMT certification. 

Heartsaver AED 

This half-day course presents AHA CPR information 

and skills for the public are interested in learning 

CPR and AED use for adults, children, and infants. 

Upon completion of the course, the participant is 

issued an American Heart Association Heartsaver 

AED course completion card. 

First Responder Refresher 

This 16-hour course is a review of the skills 

and knowledge covered in the 40-hour First 

Responder course. 

Healthcare Provider CPR 

This half-day course presents AHA CPR information 

and skills for the healthcare professional. Upon 

completion of the course, the participant is issued 

an American Heart Association Healthcare Provider 

CPR course completion card. 

Trauma Nursing Core Course (TNCC) 

and Renewal (TNCC-R) 

The TNCC course is a two-day course, developed 

by the Emergency Nurses Association, that provides 

training in trauma management principles for 

registered nurses. 

To register for a course, visit 

www.hcmc.org and click on “Professional 

Education and Training.” For questions or 

additional information, contact Susan 

Altmann in HCMC Medical Education at 

612-873-5681 or susan.altmann@hcmed.org 

unless another contact person is provided. 

Many courses fill quickly; please register 

early to avoid being wait-listed. 


Calendar of Events 

December 2008 

December 8___________________________ 

Advanced Cardiac Life Support (ACLS) Provider 

Renewal 

HCMC, Minneapolis, MN 

January 2009 

January 14____________________________ 

ACLS for Experienced Providers 


January 21 ___________________________ 

Preparedness Practicum 2009 

Earle Brown Heritage Center, Brooklyn Center, MN 

January 21-22_________________________ 

Trauma Nursing Core Course (TNCC) 


January 26-28_________________________ 

EMT Refresher 


February 2009 

February 2____________________________ 

Heartsaver AED 


February 9-11__________________________ 

EMT Refresher 


February 12-13________________________ 

First Responder Refresher 


February 23___________________________ 

ACLS for Experienced Providers 


March 3______________________________ 

ACLS Provider 

Redwood Falls, MN 

March 4______________________________ 

ACLS Provider 


March 5______________________________ 

ACLS Provider 


March 12_____________________________ 

ACLS Provider 


March 13_____________________________ 

ACLS Provider 


March 18-20___________________________ 

EMT Refresher 


March 23-April 10______________________ 

EMT Basic 

Edina H Training Center, Edina, MN 

February 25-27________________________ 

EMT Refresher 


March 2009 

March 2______________________________ 

Healthcare Provider CPR 


Rapid access to Hennepin physicians 

for referrals and consults 

Services available 24/7 

1-800-424-4262 

612-873-4262 


News Notes 

News Notes 

Analysis reveals most 

common barriers to rapid 

stroke treatment 

The overwhelming majority of ischemic 

stroke patients don’t receive the lifesaving, 

disability-preventing drug, 

tPA, says a report published in the 

August 2008 issue of Stroke: Journal 

of the American Heart Association. 

The analysis, which included data on 

more than 15,000 patients at hospitals 

enrolled in the North Carolina 

Stroke Registry, found some of the 

most common reasons patients don’t 

receive tPA are: 

 

 

Patients don’t seek care in time. 

TPA and other clot-busting drugs 

must be given within three hours 

of symptom onset and a CT scan 

must be performed in advance of 

drug administration. More than 

75% of stroke patients do not 

seek care within two hours of 

symptom onset, which would 

provide hospitals with sufficient 

time to conduct the exam and 

testing necessary before tPA may 

be administered. 

Hospitals do not provide rapid 

CT scans. Guidelines from the 

National Institute of Neurological 

Disorders and Stroke (NINDS) 

recommend CT scans be provided 

within 25 minutes of arrival of 

potential stroke patients but hospitals 

typically do not meet this 

goal. Of the 25% of stroke 

patients who arrive at the hospital 

within two hours after symptom 

onset, less than 1/4 receive a CT 

scan within 25 minutes. 

Other findings of the analysis included: 

Patients arriving via ambulance 

were more likely to receive a 

timely CT scan than those who 

self-transported. Approximate half 

of patients used emergency medical 

services to transport. 

Patients receiving care at primary 

stroke centers (a designation 

created by the Joint 

Commission) were more likely to 

receive a timely CT scan. 

The achievement of timely CT 

scans was not related to factors 

such as health insurance status, 

race, time of day, and 

weekend vs. weekday arrival. 

However, women were found to 

be less likely to receive timely CT 

scans than men. 

_____________________________ 

Team releases data on stroke 

treatment times at 2008 

International Stroke Conference 

The stroke team at Hennepin County 

Medical Center has released data 

showing that after their dedicated 

stroke team was implemented, 

ischemic stroke patients were treated 

more frequently with IV tPA and 

received IV tPA more quickly. 

The data were presented by Gustavo 

Rodriguez, MD, at the 2008 

International Stroke Conference in 

New Orleans, LA. According to the 

presentation, during 2005 the following 

interventions were put into place: 


News Notes 

Team releases data on stroke 

treatment times at 2008 International 

Stroke Conference cont. 

 

 

 

 

A 24/7 dedicated stroke responder team, 

which included neurology residents, vascular 

neurology fellows, and neurology staff. 

A dedicated stroke pager for each team 

member and a system that allowed all 

pagers to be activated simultaneously when 

a potential stroke patient was en route. 

24/7 availability of neurology and 

radiology staff members to assist the 

emergency department. 

Protocols developed for evaluation 

and treatment of potential ischemic 

stroke patients. 

Before/after data show significant shifts that 

occurred after the stroke team was in place: 

 

 

In 2004, 9% of potential stroke patients 

received IV tPA. In 2006, that number rose 

to 17% of potential stroke patients, bringing 

the hospital in line with a handful of top 

national performers in tPA administration. 

In 2004, the mean door-to-needle time (e.g. 

the time from patient arrival to commencement 

of IV tPA) was 73 minutes. In 2006, 

that number dropped to 43 minutes. 

However, the number of patients receiving IV 

tPA decreased slightly and the mean door-toneedle 

time increased slightly in 2007, suggesting 

the importance of continued vigilance in 

speed of treatment for stroke patients. 

The presentation is available online for a 

fee. To purchase it and/or other educational 

presentations from the conference, visit 

www.scienceondemand.org and search under 

“2008 International Stroke Conference.” 

_____________________________________ 

Clinical trials underway through the 

NETT Network 

Each year, more than one million Americans 

experience some type of acute devastating 

neurological illness or injury, ranging from 

ischemic stroke, to head and spinal cord 

injuries, to bacterial meningitis. Medical management 

of these problems often is hampered 

because treatments are understudied, based 

on limited evidence, or ineffective. A new network 

of hospitals is launching multi-centered 

clinical trials that will benefit patients with 

neurology illnesses and injuries. 

In 2003, a group of emergency room physicians 

and neurologists from across the U.S. 

met to discuss the problem and formed the 

Neurological Emergencies Treatment Trial 

(NETT) Network. The NETT Network, which 

recently has received funding from the National 

Institute of Neurological Disorders and Stroke, 

is a nationwide effort to improve the outcomes 

of these patients through interventional clinical 

research, focused on the emergent phase of 

patient care. 

The NETT Network aims to conduct simple 

multi-centered clinical trials of potential new 

therapies for a wide range of neurological problems. 

Each research study conducted by the 

NETT will be streamlined, with simple research 

questions that can be answered through the 

collection of a minimal amount of data at the 

patients’ bedside. The NETT Network includes 

academic centers as well as community and 

rural sites in order to enroll patients who are 

cared for in diverse settings. Several Minnesota 

hospitals will be participating and will assist in 

enrolling patients in future clinical research trials. 

For more information, visit nett.umich.edu/nett. 


Want more information 

on stroke care? 

To download additional resources, 

please visit the Approaches in 

Critical Care Web site at 

www.hcmc.org/approaches 

or the Hennepin Stroke Center 

Web site at www.hcmc.org/stroke. 

There, you’ll find: 

 

 

 

 

 

Hennepin’s stroke care protocol. 

Information on ordering a free 

Cincinatti Prehospital Stroke Care 

badge card for EMS professionals. 

Free downloadable information for 

stroke patient education brochures. 

Checklist of recommended 

activities to be performed prior to 

patient transport. 

An electronic version of 

Approaches in Critical Care that 

you can email to colleagues. 

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Ischemic Stroke - Hennepin County Medical Center

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