Although hypotension is rare in AIS, it has been associated with worse outcomes when below 100/70 mmHg.³² Hypotension should prompt the clinician to search for causes to explain both the neurologic deficit and the low blood pressure, including aortic dissection, hypo­volemia, or decreased cardiac output from ischemia or dysrhythmia. Persistent hypotension should be treated with volume expansion with crystalloid and dysrhythmia management.³³

Patients with stroke should always be admitted to the hospital to a telemetry-monitored unit. Important measures such as carotid duplex ultrasound, echocardiography, and smoking cessation counseling are all more efficiently addressed in the inpatient setting.

Controversies

The third European Cooperative Acute Stroke Study (ECASS III) trial investigated the use of rTPA in AIS up to 4.5 hours from the onset of symptoms.³⁴ Like NINDS, this trial had as its primary end point an assessment of functional status at 90 days. The investigators found that administration of rTPA within 4.5 hours resulted in better functional outcomes but was associated with a higher risk of symptomatic ICH (2.4%, compared with 0.2% in the placebo group). Furthermore, this trial showed better outcomes in those treated earlier with rTPA. The ultimate conclusion suggested by the authors was that although patients outside the window of 3 hours may still benefit from thrombolysis, earlier therapy is still preferred.³⁴

The NINDS investigators were stroke experts, and questions exist as to whether the results of this group’s findings could be extrapolated to the broad practice of community emergency medicine.³⁵ This is still a controversial issue, although a large validation of the NINDS trial done in Europe specifically included half of its data from centers with little experience in thrombolysis and found similar functional outcomes and rates of ICH.³⁶ Yet Dubinski and Lai cited higher in-hospital mortality (10.1%, compared with 5.8% in the untreated cohort) among patients treated with rTPA in the community than has been reported in prior studies.³⁷

Similar findings were reported in a German study (11.7% vs 4.5% in untreated), which further found that the risk of in-hospital mortality was higher in hospitals performing fewer than five thrombotic treatments per year.³⁸ The implication for the community emergency physician is to reaffirm the importance of early neurologic consultation.

Emergency physician reluctance to use rTPA has been found to be the result both of questions about efficacy and concern for ICH.³⁹ In the NINDS trial, the treatment arm had a symptomatic ICH risk of 6.4%. Even accounting for this higher risk of bleeding, those treated with rTPA had better functional outcomes. Subsequent studies have shown ICH risks similar to that found by the NINDS group.⁴⁰