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    ASTRAL Score for Ischemic Stroke

    Predicts 90-day poor outcome in patients with acute ischemic stroke.
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    INSTRUCTIONS

    Use in patients with acute ischemic stroke admitted within 24 hours of stroke onset.
    When to Use
    Pearls/Pitfalls
    Why Use

    Patients with acute ischemic stroke admitted within 24 hours of stroke onset.

    • The ASTRAL Score uses clinical characteristics and laboratory testing to predict the likelihood that a given patient with acute ischemic stroke will have a Modified Rankin Scale result of 3–6 at 90 days after stroke.
    • Developed to predict a dichotomous outcome, not a discrete Modified Rankin Scale score at 90 days.
    • Does not predict mortality or degree of improvement from any form of rehabilitation.
    • Should not be used as a surrogate for stroke severity.
    • Can provide additional information on medium-term functional outcome in patients that have suffered acute ischemic stroke, in addition to clinical judgment based on relevant clinical and laboratory variables.
    • Does not need neuroimaging data to calculate.
    • Can be used to adjust for functional outcome in multivariate models in acute stroke-related research studies.
    • Can serve as a selection criterion for cohorts in acute stroke-related research studies.
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    Advice

    • Acute ischemic stroke is a neurological emergency that is amenable to time-sensitive treatments (e.g. tPA, mechanical thrombectomy) if certain clinical conditions are met.
    • Neurological consultation should be obtained immediately in suspected cases of acute ischemic stroke.
    • Should not be used as a substitute for clinical judgment and is intended for use as an adjunct to medical decision-making.

    Management

    • In cases of suspected ischemic stroke, the following is recommended:
      • STAT neurological consultation.
      • STAT CT head without contrast.
      • STAT laboratory testing (complete blood count, PT/INR/aPTT, basic metabolic panel, type & screen, troponin-I).
      • Consider STAT CT angiogram of the head & neck in cases of suspected large-vessel occlusion (LVO) presenting in the acute setting.

    Critical Actions

    • Intravenous tissue plasminogen activator (IV tPA) is the standard-of-care treatment for adult patients presenting with acute ischemic stroke within 4.5 hours of symptom onset, if no exclusion criteria are met.
    • Mechanical thrombectomy is the standard-of-care treatment for selected adult patients presenting with acute ischemic stroke due to LVO presenting in the acute setting.
    • Note that the appropriateness of patient for endovascular intervention depends on multiple factors, such as time since onset, neuroimaging, baseline functional status, and others.
    • Appropriateness for intravenous thrombolysis or mechanical thrombectomy should be determined by neurological/neurosurgical consultant whenever available.
    Content Contributors
    About the Creator
    Dr. George Ntaios
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    Dr. Patrik Michel
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