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History of prior stroke and diabetes mellitus

NIH Stroke Scale >25

Oral anticoagulant use regardless of INR

Age >80 years

INR, international normalized ratio; MCA, middle cerebral artery; NIH, National Institutes of Health; aPTT, activated partial thromboplastin time.

Source: Miller J, Hartwell C, Lewandowski C. 2012, Stroke treatment using intravenous and intra‐arterial tissue plasminogen activator. Curr Treat Options Cardiovasc Med. 2012; 14:273–83. © 2012, Springer Nature.

Some literature suggests that placing the patient supine may increase cerebral perfusion, but it also increases intracranial pressure, and this remains an area of uncertainty and investigation. Obviously, supine positioning is not advised in a patient who has clinical evidence of elevated intracranial pressure. As always, the risk of aspiration must be considered as well [13].

Ultimately, the goals for prehospital care of the stroke patients include rapid evaluation, stabilization, neurologic examination, and expedited transport to an appropriate destination hospital [15]. Early communication to the destination hospital is important. Studies have shown that such notification gives time for the stroke team to arrive in the ED and decreases the time from ED arrival to computed tomography (CT) imaging and increased rates of IV tissue plasminogen activator (tPA) administration [16, 17].