Early Management of Patients With Acute Ischemic Stroke
Key Points
Key Points
Treatment
...atment...
...al Stroke Management and Systems of Care...
.... Prehospital Systems...
...health leaders, along with medical professionals...
...al programs should be designed to spe...
...on of the 9-1-1 system by patients or other...
....2. EMS Assessment and Manageme...
...a stroke assessment tool by first...
...should provide prehospital notification to th...
...3. EMS Systems
...l systems of stroke care should be developed. The...
...S leaders, in coordination with local, region...
...h a positive stroke screen or who are strong...
...IV alteplase-capable hospital options...
...e prehospital procedures to identify patien...
.... Hospital Stroke Capabilities...
...on of stroke centers by an independe...
....5. Hospital Stroke T...
...organized protocol for the emergency eva...
...ation of an acute stroke team that...
...quality improvement initiatives, which include ED...
...ecommended that stroke systems of care be deve...
...lishing and monitoring target time...
....6. Telemedic...
...sites without in-house imaging inte...
...implemented within a telestroke netwo...
...edicine/telestroke resources and systems should...
...e/teleradiology evaluations of AIS patients...
...tion of IV alteplase guided by telestroke consu...
...estroke networks may be reasonable for triag...
...plase decision-making support via telephone...
....7. Organization and Integration of Components
...l hospitals caring for stroke patie...
...rvices within a hospital that may be transferr...
...thrombectomy requires the patient to b...
...seful for primary stroke centers and other...
...be useful for government agencies and th...
...blishment of Data Repositories...
...icipation in a stroke data repository is recomme...
...oke System Care Quality Improvement Pro...
...lthcare institutions should organize a multidisci...
...measures should include adjustments for...
...quality improvement processes, imple...
...ency Evaluation and Treatment...
...troke Scales...
...f a stroke severity rating scale, preferably the...
...onal Institutes of Health Stroke Scale (NIHSS)Ha...
...ead and Neck Imaging...
2.2.1. Initial I...
...s with suspected acute stroke should receive e...
...should be established so that brain imaging stu...
...(NCCT) is effective to exclude ICH before...
...sonance (MR) imaging (MRI) is effective to ex...
...A with CTP or MR angiography (MRA) with diffu...
...V Alteplase Eligibility...
...of IV alteplase in eligible patients wi...
...gible for IV alteplase, because benefit of...
...th AIS who awake with stroke symptoms...
...3. Mechanical Thrombectomy Eligibility–Ves...
...tients who otherwise meet criteria for me...
...h suspected LVO who have not had noninvasive...
...atients with suspected intracranial LVO and n...
...who are potential candidates for mechanical th...
...onable to incorporate collateral flow status into...
...Mechanical Thrombectomy Eligibility...
...g patients with AIS within 6–24 hours of la...
...luating patients with AIS within 6 hours of last...
....3. Other Diagnostic...
...assessment of blood glucose must precede the in...
...ectrocardiographic assessment is recommende...
...oponin assessment is recommended in p...
...fulness of chest radiographs in the...
...ortive Care and Emergency Treatment...
3.1. Airway, Breathing, and Oxyge...
...t and ventilatory assistance are recommended for t...
...pplemental oxygen should be provided to maint...
...upplemental oxygen is NOT recommended in non-hy...
...erbaric oxygen (HBO) is NOT recommended for pa...
.... Blood Pressu...
...otension and hypovolemia should be corrected t...
...have elevated BP and are otherwise eligible...
...patients for whom mechanical thrombectomy is...
...of drug-induced hypertension in patients...
...ons to Treat Arterial Hypertension in Patie...
...Temperature...
...rthermia (temperature >38°C) should be identi...
In patients with AIS, the benefit of treatm...
...Blood Gluco...
...lycemia (blood glucos...
...vidence indicates that persistent in-ho...
....5. IV Altepla...
...1. General Princip...
...igible for IV alteplase, benefit of therapy is t...
...patients undergoing fibrinolytic therapy,...
The potential risks should be discus...
...clinicians should be aware that hypoglycem...
...ecause time from onset of symptoms...
...2. Time Windows
...teplase (0.9 mg/kg, maximum dose 90 mg over...
...alteplase (0.9 mg/kg, maximum dose 90 mg over 6...
...eplase (0.9 mg/kg, maximum dose 90 mg...
...5.3. Mild Stroke
...se eligible patients with mild but...
...erwise eligible patients with mild...
...igible patients with mild nondisabling stroke symp...
...wise eligible patients with mild non-disablin...
...5.4. Other Specific Circumstances...
...e for adults presenting with an AIS...
...nts with a hyperdense MCA sign, IV a...
...Bleeding Risk...
...ven the extremely low risk of unsuspected ab...
...se eligible patients who have prev...
In otherwise eligible patients who h...
...of the IV glycoprotein IIb/IIIa inhibit...
Abciximab should NOT be administered concurren...
...spirin should NOT be administered within...
...teplase should NOT be administered to pat...
.... Post-alteplase Treatm...
...ould be maintained...
...risk of antithrombotic therapy (other than IV asp...
...Management of Symptomatic Intracran...
...e 4. Management of Orolingual Angioe...
...Recommendations for IV Alteplase in...
Indications
Within 3 haIVb alteplase (0.9 mg/kg, maxi...
...thin 3 h–AgeFor otherwise medically eligi...
...in 3 h–Severe strokeFor severe stroke, IVb altep...
...n 3 h–Mild disabling strokeFor otherwise...
...“4.5 haIVb,d alteplase (0.9 mg/kg, maxim...
...5 h–AgeIV alteplase treatment in the 3- to...
...ncyTreatment should be initiated a...
...alteplase is recommended in patients...
...d glucoseIVb alteplase is recommende...
...dministration is recommended in the setting of e...
...antiplatelet therap...
...recommended for patients taking ant...
IV alteplase is recommended for pati...
End-stage renal diseaseIn patients wit...
...onal recommendations for treatment...
...eFor patients >80 y of age presenting...
...h–Diabetes mellitus and prior strokeIn AIS...
...vere strokeThe benefit of IV altepla...
3 to 4.5 h–Mild disabling strokeFor other...
...ke-up and unknown time of onsetIV alteplase (0.9...
...reexisting disabili...
...disability does not seem to independe...
...with preexisting dementia may benefi...
...improvementIVb alteplase treatment...
...zure at onsetIVb,d alteplase is reasonable...
...seTreatment with IV alteplase in pati...
Coagulopath...
IVb,d alteplase may be reasonable in...
...e safety and efficacy of IV alteplase for acute...
...nctureIV alteplase may be considered...
...l punctureThe safety and efficacy of administ...
...major traumaIn AIS patients with recent majo...
...surgeryUse of IV alteplase in caref...
...nitourinary bleedingReported literature d...
...enstruation...
...is probably indicated in women who are menstru...
...there is a history of recent or active vag...
...tential benefits of IV alteplase probably outweigh...
...xtracranial cervical dissectionsIV alteplase...
...nial arterial dissectionIV alteplase usefulnes...
...uptured intracranial aneury...
...ents presenting with AIS who are k...
...nd risk of IV alteplase in patient...
...acranial vascular malformat...
...or patients presenting with AIS who a...
...increased risk of ICH in this population of...
...MBs
In otherwise eligible patients who h...
...n otherwise eligible patients who have previousl...
...rofiban, eptifibatideThe efficacy of the...
...intracranial neoplasmsIV alteplase treatmen...
...ents presenting with concurrent AIS and ac...
...cent MI...
...esenting with AIS and a history of recent MI...
...nts presenting with AIS and a history...
...nts presenting with AIS and a histor...
...e pericarditis...
...h major AIS likely to produce severe disabi...
...ents presenting with moderate AIS likely to...
...eft atrial or ventricular thr...
...patients with major AIS likely to produce se...
For patients presenting with moderate AIS likel...
...ardiac diseases...
...ts with major AIS likely to produce se...
...tients presenting with major AIS likel...
...okeIV alteplase is reasonable for the...
...stemic malignancyThe safety and efficacy of...
...gnancy
...ase administration may be considered i...
...fety and efficacy of IVb,d alteplase i...
...cal conditionsUse of IV alteplase in patient...
...aseIV alteplase for adults presenting...
...erdense MCA signIn patients with a hyperden...
...cit drug useTreating clinicians should be aware th...
...oke mimicsThe risk of symptomatic intracrania...
...ntraindications...
...h window–Mild nondisabling strokeFor other...
3- to 4.5-h window–Mild nondisabling strokeFor...
...here remains insufficient evidence to identify a t...
...V alteplase should NOT be administered to a patien...
Ischemic stroke within 3 moUse of IV alte...
...re head trauma within 3 moIn AIS patie...
...te head traumaGiven the possibility of bleedi...
...cranial/intraspinal surgery within 3 mo...
...acranial hemorrhageIVb,d,e alteplase adminis...
...arachnoid hemorrhageIVb,d,e alteplase...
...or GI bleed within 21 dPatients with a structur...
...agulopathyThe safety and efficacy of IV...
...V alteplase should NOT be administered to...
...hibitors or factor Xa inhibitorsTh...
...mitant AbciximabAbciximab should NOT b...
...tant IV aspirinIV aspirin should N...
...ive endocarditisFor patients with AIS and symptoms...
...ch dissectionIV alteplase in AISb,d,e k...
...-axial intracranial neoplasmIV altep...
...specified, these eligibility recomm...
...6. Treatment of AIS: IV Administra...
...d from Jauch et al. Copyright © 2013,...
...er IV Fibrinolytics and Sonothromb...
...onable to choose tenecteplase (single IV bolus of...
...necteplase administered as a 0.4-mg/kg single IV...
...ministration of IV defibrinogenating a...
...of sonothrombolysis as adjuvant therapy wi...
...anical Thrombectomy...
3.7.1. Concomitant With I...
...ble for IV alteplase should receive IV alteplase e...
...under consideration for mechanical throm...
...–6 Hours From Onset...
...s should receive mechanical thrombectomy w...
...piration thrombectomy as first-pas...
...benefits are uncertain, the use of mechanical...
...gh its benefits are uncertain, the use of me...
...he benefits are uncertain, the use of mechanica...
3.7.3. 6 to 24 Hours...
...patients with AIS within 6–16 hours of las...
...ected patients with AIS within 16–24 hours o...
....4. Technique
...rievers is indicated in preference to...
...nical goal of the thrombectomy procedure should...
...o ensure benefit, reperfusion to mTICI grad...
...-hour thrombectomy window evaluatio...
It is reasonable to select an anesthetic techniq...
...of a proximal balloon guide cathet...
...ent of tandem occlusions (both extracranial an...
...fety and efficacy of IV glycoprotein IIb/IIIa...
...technical adjuncts, including intra-arte...
.... Blood Pressure Management...
In patients who undergo mechanical thrombect...
...tients who undergo mechanical thrombectomy with su...
...er Endovascular Therapi...
...echanical thrombectomy with stent retrievers...
...tra-arterial fibrinolysis initiated within 6 hou...
...tiplatelet Treatment...
...dministration of aspirin is recommended in pat...
...ients presenting with minor noncar...
...cy of the IV glycoprotein IIb/IIIa inhibit...
...r is NOT recommended over aspirin for...
...dministration of the IV glycoprotein II...
...T recommended as a substitute for acute stroke tr...
...Anticoagulants...
...efulness of urgent anticoagulation...
...sefulness of short-term anticoagulation for n...
...usefulness of argatroban, dabigatran, or other t...
...and usefulness of oral factor Xa...
...ent anticoagulation, with the goal of prevent...
...Volume Expansion/Hemodilution, Vasodilator...
...by volume expansion is NOT recommen...
...tration of high-dose albumin is NOT recom...
...ion of vasodilatory agents, such as pentoxifylli...
...echanically augment cerebral blood flow for the t...
3.12. Neuroprotective A...
...t present, pharmacological or nonpharmacological t...
...Emergency Carotid Endarterectomy/Carotid Angi...
The usefulness of emergent or urgent carotid enda...
...n patients with unstable neurologi...
...14. Other...
...ranial near-infrared laser therapy is NOT r...
...Management of AIS: General Supportive Care...
...Stroke Units...
...use of comprehensive specialized stroke care...
...f standardized stroke care order s...
...ead Positioning
...benefit of flat-head positioning ea...
...ecommendations in this section are repe...
...plemental Oxygen...
...y support and ventilatory assistance are recommend...
...upplemental oxygen should be provided to...
...mental oxygen is NOT recommended in nonhypoxi...
...: Recommendation 1 in this section is repeated...
...lood Pressure
...hypovolemia should be corrected to maintai...
...s with AIS, early treatment of hyper...
...patients with BP ≥220/120 mm Hg...
In patients with BP
...endations in this section are repeated from Sec...
...Temperature...
...of hyperthermia (temperature >38°C) shoul...
...with AIS, the benefit of treatment wi...
...ecommendations in this section are repeated from...
4.6. Glu...
...mia (blood glucose
Evidence indicates that persistent...
...Dysphagia...
...ing before the patient begins eating, drinking,...
...endoscopic evaluation is reasonable...
...is reasonable for dysphagia screening to be perf...
...not well established which instrument to choose...
...g oral hygiene protocols to reduce...
....8. Nutriti...
...nteral diet should be started within 7 days...
For patients with dysphagia, it is...
...supplements are reasonable to consider for...
...ein Thrombosis Prophylaxis...
...stroke patients without contraindications, interm...
...prophylactic-dose subcutaneous hepa...
...en prophylactic anticoagulation is used, the...
...oke, elastic compression stockings should NOT be...
4.10. Depression Scree...
...istration of a structured depression...
Patients diagnosed with poststroke depres...
....11. Oth...
...alization and inpatient rehabilitation...
...is recommended to minimize or eliminate skin fri...
...reasonable for patients and families with stroke...
...tine use of prophylactic antibiotics...
...lacement of indwelling bladder cath...
.... Rehabilitation...
...ended that early rehabilitation for hos...
...mmended that stroke survivors receive rehab...
...is recommended that all individuals wit...
...assessment by a clinician with expe...
...e effectiveness of fluoxetine or other sel...
...-dose, very early mobilization wit...
...al Management of AIS: Treatment of Acut...
...Brain Swellin...
...General Recommendations...
...with large territorial cerebral and cerebellar...
...sures to lessen the risk of swelling and close...
...Medical Management...
...tic therapy for patients with clinical det...
...of brief moderate hyperventilation (Pco2 target,...
...or barbiturates in the setting of ischemic c...
...of a lack of evidence of efficacy and the...
...Surgical Management-Supratentorial Infarction...
...optimal trigger for decompressive craniectomy is...
...≤60 years of age who deteriorate n...
...atients >60 years of age who deteri...
...4. Surgical Management-Cerebellar Infarc...
...ntriculostomy is recommended in the treatment...
...ressive suboccipital craniectomy with dural expan...
...idering decompressive suboccipital craniectomy fo...
.... Seizures
...current seizures after stroke should be treat...
...se of antiseizure drugs is NOT recommended....
...-Hospital Institution of Secondary Stroke Pr...
...rain Imaging...
...evention of recurrent stroke, the use of MRI is...
...sonable in selected patients as part of a comprehe...
...effectiveness of routine brain MRI to guide tre...
.... Vascular Ima...
...atients with nondisabling (mRS score 0–2...
...evention of recurrent stroke, the use of i...
...intracranial vasculature to detect a...
...ng of the intracranial vasculature to detect ath...
....1. Electrocardiographic Monitor...
...rdiac monitoring is recommended to screen for atr...
...s of prolonged cardiac monitoring...
....3.2. Echocardiography...
...ntion of recurrent stroke, the use of echo...
...rdiography is reasonable in selected pa...
...he effectiveness of routine echocardiog...
...Glucose
...is reasonable to screen all patients for dia...
6.5. Other Tests for Secondary Pr...
...fulness of screening for thrombophilic...
...tine screening of patients with recent isch...
...ine testing for antiphospholipid antibodies is...
...utine screening for hyperhomocystein...
.... Antithrombotic Treatm...
...oncardioembolic Stroke...
...ients with noncardioembolic AIS, the use of an...
...r early secondary prevention in patients with nonc...
...tients who have a noncardioembolic AIS whi...
...agulation might be considered in patients who are...
...ients who have a noncardioembolic AIS while tak...
...patients with noncardioembolic isch...
...Atrial Fibrillation...
...most patients with an AIS in the se...
...patients with a history of ischemic stroke...
...6.3. Arterial Dissection
...with AIS and extracranial carotid or...
...s with AIS and extracranial carotid or extr...
...morrhagic Transformation...
...s with AIS and HT, initiation or continuatio...
.... Carotid Revasculariza...
...larization is indicated for secondary preventio...
...8. Treatment of Hyperlipi...
...eneral Principles...
...tients with AIS should be managed acco...
...ts who are 20 years of age or older and n...
...herence to changes in lifestyle and effects of...
...Lipid-lowering Drugs for Patients with Cl...
...o are 75 years of age or younger with clini...
...ents with clinical ASCVD in whom hig...
...ients at increased ASCVD risk with chr...
...ents with clinical ASCVD, who are judged t...
...patients with clinical ASCVD who are judged to...
...t prices, PCSK9 inhibitors have a low-c...
...tients with clinical ASCVD who are on maximally to...
...ents older than 75 years of age with...
...nts older than 75 years of age who are tole...
...s with clinical ASCVD who are receivi...
...inical aASCVD includes acute coronary syndrome,...
...7. Risk StatusHaving trouble viewing table? Exp...
....8.3 Implementat...
...ient risk discussion is recommended b...
In patients with indication for statin therapy,...
...h statin-associated side effects that...
...patients at increased ASCVD risk with severe...
...8.4. Timi...
...ients already taking statins at the tim...
...h AIS who qualify for statin treatment,...
...Special Patient Gro...
...n of childbearing age who are treated wi...
...ildbearing age with hypercholesterolemi...
...s with advanced kidney disease that...
...ith advanced kidney disease who re...
6.9. Institution of Antihypertensive Medi...
...ng or restarting antihypertensive...
...10. Smoking Cessation Intervention
...kers with AIS should receive in-hospita...
...rs with an AIS, who receive in-hospital initiation...
...ealthcare providers should strongly advise every p...
...able to advise patients after ischemic stroke...
...r smokers with an AIS, in-hospital initiation of v...
...troke Education
...ion about stroke is recommended. Pati...