Saudi Stroke Standards

Door to needle time Purpose To ensure that timely intravenous thrombolytic therapy is delivered to those stroke patients who can benefit from it. To ensure that intravenous thrombolytic therapy is delivered in an evidence-based manner by qualified staff in appropriately equipped facilities. Rationale Evidence shows that intravenous thrombolytic therapy (recombinant tissue plasminogen activator [rt PA]) is beneficial for selected patients with ischemic stroke. It should be delivered in well-equipped centers/hospitals with adequate expertise and infrastructure for monitoring, rapid assessment and investigation of acute stroke patients. Standards 1. All adult patients with suspected ischemic stroke must have immediate assessment and investigations to establish a diagnosis, rule out stroke mimics, determine eligibility for reperfusion therapy within 24 hours (IV thrombolysis within 4.5 hours; mechanical thrombectomy within 24 hours) from last time patient known to be normal. 2. All hospitals capable of administrating thrombolysis should have an evidence-based driven protocol outlining indications, contraindication, post thrombolysis care, and complication management. 3. Laboratory investigation should be conducted as part of the initial evaluation which includes: random glucose, coagulation status (INR, aPTT), complete blood count (CBC), electrolyte and creatinine. IV r-tPA should not be delayed due to pending lab results unless there is a clinical suspicion of a contraindication such as (patient on warfarin or a history of leukaemia with possible low platelets). 4. If clinically indicated additional investigations such as Cardiac enzymes, ECG and chest X ray should be considered. 5. Point of care testing is recommended for Glucose, Direct Oral Anti-Coagulants (DOACs) and INR. 6. All patients with suspected acute stroke should get brain imaging with CT or MRI as soon as possible. 7. Within 4.5 hours of the onset of stroke symptoms, all eligible patients with disabling ischemic stroke should receive intravenous Alteplase. 8. For patients considered for mechanical thrombectomy, a noninvasive craniocervical vascular study is recommended, however, it should not delay IV thrombolysis if indicated. R-tPA and TNK are the only thrombolytic agents currently approved for IV thrombolysis. 9. All patient who had reperfusion therapy should be admitted to a stroke unit for at least 24 hours QM 4.2.7 Mechanical Thrombectomy (MT) Purpose To quickly identify ischemic stroke patients with large vessel occlusion (LVO) appropriate for recanalization procedure. To quickly recanalize an occluded cerebral large vessel by quickly activating the interventional neuroradiology team. Rationale  Timely mechanical thrombectomy is associated with improved patient outcomes for large vessel occlusion11.  Emergency assessment of suspected stroke patients upon arrival in ED can facilitate timely mechanical thrombectomy. Standards 1. All hospitals will develop a protocol for identifying ischemic stroke patients with LVO. 2. All ischemic stroke patients presenting within 24 hours will be screened for LVO. 3. All hospitals will develop a protocol to treat appropriate patients with LVO or to transfer them as soon as possible to a MT capable center/hospital. 4. All ambulances are encouraged to have a screening protocol for LVO (NIHSS of 11 or more, or another scale such as C-STAT etc.) and transfer them to a MT capable center/hospital. QM