Early Management of Patients With Acute Ischemic Stroke

Last updated May 27, 2022

Key Points

Key Points

This pocket guide provides general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Treatment

...T...

...1. Preho...

...1.1....

...alth leaders, along with medical prof...

...nal programs should be designed to spe...

...e 9-1-1 system by patients or other members of t...

...1.2. EMS Assessmen...

The use of a stroke assessment tool by first aid...

...l should provide prehospital notification to the...

...1.3. EMS Systems...

...al systems of stroke care should be...

EMS leaders, in coordination with loc...

...a positive stroke screen or who are stron...

...several IV alteplase-capable hospital op...

...ve prehospital procedures to identify patients...

...1.4. Hos...

...n of stroke centers by an independe...

...1.5. H...

...ized protocol for the emergency eva...

...ation of an acute stroke team that includes phy...

Multicomponent quality improvement initiatives...

...recommended that stroke systems of care be devel...

...stablishing and monitoring target time goals fo...

...1.6. Teleme...

...r sites without in-house imaging interpretation ex...

...emented within a telestroke network, tele...

...medicine/telestroke resources and system...

...elestroke/teleradiology evaluations of AIS patien...

...of IV alteplase guided by telestroke...

...works may be reasonable for triaging patient...

...g alteplase decision-making support...

...1.7. Organiz...

...tals caring for stroke patients within...

...t services within a hospital that may b...

...rombectomy requires the patient to be at an exp...

It may be useful for primary stroke cen...

...ay be useful for government agencies and...

...1.8. Establishment of Data...

...pation in a stroke data repository...

...1.9. Stroke...

...tutions should organize a multidisciplinary qualit...

...e outcome measures should include...

...quality improvement processes, implemente...


...2. Emergen...

2....

...use of a stroke severity rating scale...

...tional Institutes of Health Stroke Scale (...

...2.2. Head and Ne...

...2.2.1. Init...

All patients with suspected acute stroke shou...

...be established so that brain imaging stud...

...trast CT (NCCT) is effective to exclude I...

...etic resonance (MR) imaging (MRI) is...

CTA with CTP or MR angiography (MRA)...

...2.2.2. IV Alt...

...inistration of IV alteplase in eligible patien...

...ible for IV alteplase, because benefit of t...

...s with AIS who awake with stroke sym...

...2.2.3. Mechanical T...

...who otherwise meet criteria for mec...

...th suspected LVO who have not had noninvasive ve...

...tients with suspected intracranial...

...patients who are potential candidates for mecha...

...reasonable to incorporate collateral flow st...

...2.2.4. Me...

...ecting patients with AIS within 6–24 hours of l...

...g patients with AIS within 6 hours of las...

...2.3....

...the assessment of blood glucose must precede the...

...ne electrocardiographic assessment...

...ponin assessment is recommended in pat...

...f chest radiographs in the hyperac...


...3.1. Airway, B...

...irway support and ventilatory assistanc...

...tal oxygen should be provided to maintai...

...xygen is NOT recommended in non-hypoxic patients...

...ic oxygen (HBO) is NOT recommended for patients wi...

...sion and hypovolemia should be corrected to ma...

...nts who have elevated BP and are otherwise...

...ents for whom mechanical thrombectomy is plann...

...e usefulness of drug-induced hypertensi...

...2. Options to Treat Arterial Hypertension in Pat...

...3.3. Te...

...urces of hyperthermia (temperature >38°C) should...

...n patients with AIS, the benefit o...

...3.4. Blood...

...glycemia (blood glucose...

...nce indicates that persistent in-hospital hyperg...

...3.5. IV Altepl...

...3.5.1. General Principles...

...ligible for IV alteplase, benefit o...

...ndergoing fibrinolytic therapy, physicians sho...

...sks should be discussed during IV alteplase elig...

...clinicians should be aware that hypoglycemia and...

...use time from onset of symptoms to...

...3.5.2. Time Win...

...alteplase (0.9 mg/kg, maximum dose 90 mg o...

...se (0.9 mg/kg, maximum dose 90 mg over 6...

IV alteplase (0.9 mg/kg, maximum dose 90 m...

...3.5.3. Mild...

...or otherwise eligible patients with mild...

...igible patients with mild disabling stroke symp...

...se eligible patients with mild nondisablin...

...ligible patients with mild non-dis...

...3.5.4. Other Specif...

...or adults presenting with an AIS with kn...

...nts with a hyperdense MCA sign, IV alteplase can b...

...3.5.5. Bleeding Ris...

...the extremely low risk of unsuspected...

...therwise eligible patients who have prev...

...therwise eligible patients who have previously ha...

...ficacy of the IV glycoprotein IIb/IIIa...

...NOT be administered concurrently wi...

...irin should NOT be administered within 90...

...teplase should NOT be administered to patien...

...3.5.6. Post-alteplas...

BP should be maintai...

...sk of antithrombotic therapy (other than IV aspiri...

...gement of Symptomatic Intracranial Bleeding...

...le 4. Management of Orolingual Angioedema Associa...

...I...

...haIVb alteplase (0.9 mg/kg, maximum d...

...AgeFor otherwise medically eligible...

...h–Severe strokeFor severe stroke, IVb al...

...hin 3 h–Mild disabling strokeFor...

3–4.5 haIVb,d alteplase (0.9 mg/kg, maximum...

...4.5 h–AgeIV alteplase treatment in the 3-...

...tment should be initiated as quickly as possible...

...PIV alteplase is recommended in patients with BP...

...seIVb alteplase is recommended in other...

...se administration is recommended in the setting...

Prior antiplatelet ther...

...e is recommended for patients taking antiplatelet...

...alteplase is recommended for patients taking an...

...d-stage renal diseaseIn patients wit...

...to 4.5 h–AgeFor patients >80 y of...

3 to 4.5 h–Diabetes mellitus and...

...evere strokeThe benefit of IV alteplase between 3...

...to 4.5 h–Mild disabling strokeFor otherwise...

...ake-up and unknown time of onsetIV...

...xisting disability...

...bility does not seem to independently i...

Patients with preexisting dementia may benefit fr...

...ntIVb alteplase treatment is reason...

...izure at onsetIVb,d alteplase is reasonable in...

...ood glucoseTreatment with IV alteplase in p...

...oagulopathy

...lase may be reasonable in patients who have a hi...

...safety and efficacy of IV alteplase f...

...ral punctureIV alteplase may be con...

...l punctureThe safety and efficacy of administering...

...r traumaIn AIS patients with recent major traum...

...jor surgeryUse of IV alteplase in carefully sele...

...tourinary bleedingReported literature detai...

...nstruation...

IV alteplase is probably indicated in women w...

...a history of recent or active vaginal blee...

...tential benefits of IV alteplase probabl...

...al cervical dissectionsIV alteplase in...

...erial dissectionIV alteplase usefulness and hemor...

...ed intracranial aneurysm...

...senting with AIS who are known to harbor a sma...

...s and risk of IV alteplase in pati...

Intracranial vascular malform...

...tients presenting with AIS who are known to harb...

...the increased risk of ICH in this population...

...MBs

In otherwise eligible patients who hav...

...gible patients who have previously had a hig...

...mitant tirofiban, eptifibatideThe efficacy of the...

...racranial neoplasmsIV alteplase treatment...

...cute MIFor patients presenting with concurren...

...ecent MI

...tients presenting with AIS and a history o...

...presenting with AIS and a history of recent MI...

...senting with AIS and a history of recen...

...cute pericardit...

...h major AIS likely to produce severe d...

...ents presenting with moderate AIS likely to p...

...ft atrial or ventricular thrombu...

...or patients with major AIS likely...

...r patients presenting with moderate AIS li...

Other cardiac diseas...

...th major AIS likely to produce severe...

...ients presenting with major AIS likely t...

Procedural strokeIV alteplase is reasonabl...

...ystemic malignancyThe safety and efficacy of IVb...

...egnanc...

...lteplase administration may be consid...

...nd efficacy of IVb,d alteplase in t...

...ogical conditionsUse of IV alteplas...

...ell diseaseIV alteplase for adults presenting wi...

...erdense MCA signIn patients with a hyperdense M...

...t drug useTreating clinicians should be aware...

Stroke mimicsThe risk of symptomatic...

...to 3-h window–Mild nondisabling strokeFor...

3- to 4.5-h window–Mild nondisabling strokeF...

...emains insufficient evidence to identify a...

...alteplase should NOT be administered t...

...chemic stroke within 3 moUse of IV alteplase in pa...

...rauma within 3 moIn AIS patients with re...

...raumaGiven the possibility of bleeding com...

...tracranial/intraspinal surgery within...

...ory of intracranial hemorrhageIVb,d,e altepl...

...barachnoid hemorrhageIVb,d,e alteplas...

...r GI bleed within 21 dPatients with...

...pathyThe safety and efficacy of IV3 alteplase...

...V alteplase should NOT be administered to patients...

...n inhibitors or factor Xa inhibito...

...bciximabAbciximab should NOT be administered...

...IV aspirinIV aspirin should NOT be admini...

...ctive endocarditisFor patients with AIS and...

...dissectionIV alteplase in AISb,d,e known...

...ntracranial neoplasmIV alteplase treatment f...

...less otherwise specified, these eligibility...

...eatment of AIS: IV Administration of Alte...

...printed from Jauch et al. Copyright © 2013, Amer...

3.6. Other...

...may be reasonable to choose tenecteplase...

...inistered as a 0.4-mg/kg single IV bolus...

...e administration of IV defibrinogena...

...f sonothrombolysis as adjuvant therapy with IV f...

...3.7. Mechanical Thrombec...

...le for IV alteplase should receive...

...tients under consideration for mechanical...

...3.7.2. 0...

...ts should receive mechanical thrombectomy wi...

...spiration thrombectomy as first-pass mechanical...

...lthough the benefits are uncertain, the...

...nefits are uncertain, the use of mechanical...

Although the benefits are uncertain, the use of...

...3.7.3. 6 to 24...

...ients with AIS within 6–16 hours of last known n...

...n selected patients with AIS within...

...3.7.4. Technique...

...t retrievers is indicated in preference t...

...al of the thrombectomy procedure sh...

...ensure benefit, reperfusion to mTICI g...

In the 6- to 24-hour thrombectomy w...

...s reasonable to select an anesthetic tech...

...ximal balloon guide catheter or a large-bore di...

...andem occlusions (both extracranial and...

...ty and efficacy of IV glycoprotein I...

...f salvage technical adjuncts, including intra-arte...

...3.7.5. Blood Pr...

...ients who undergo mechanical thrombectomy, it is r...

...undergo mechanical thrombectomy with successf...

...3.8. Other Endo...

...thrombectomy with stent retrievers...

...al fibrinolysis initiated within 6 hours of strok...

...3.9. Antiplatele...

...dministration of aspirin is recommended...

...n patients presenting with minor noncardioembol...

...f the IV glycoprotein IIb/IIIa inhibitors tiro...

Ticagrelor is NOT recommended over asp...

...ration of the IV glycoprotein IIb/IIIa inhib...

...recommended as a substitute for acute s...

...3....

...ulness of urgent anticoagulation in...

...fety and usefulness of short-term anticoagulatio...

...nt, the usefulness of argatroban,...

...afety and usefulness of oral factor Xa inhi...

...anticoagulation, with the goal of prev...

...3.11. Volume Expansion/...

...y volume expansion is NOT recommended for treat...

...he administration of high-dose albumin is...

...ion of vasodilatory agents, such as pentoxifyll...

...to mechanically augment cerebral blood flow for...

...3.12. Neuro...

...t present, pharmacological or nonpharmacologi...

...3.13. Emerge...

...ess of emergent or urgent carotid e...

...tients with unstable neurological status (eg,...

...3.14. Other...

...ranscranial near-infrared laser therapy...


...4. In-Hospita...

...4...

...of comprehensive specialized stroke care (st...

...se of standardized stroke care order set...

...4.2 Head...

The benefit of flat-head positioning early a...

...te: Recommendations in this section are...

...4.3. Suppleme...

...irway support and ventilatory assistance are...

...oxygen should be provided to maintain o...

...l oxygen is NOT recommended in nonhypoxic pat...

...mendation 1 in this section is repeated from...

...4.4....

...ension and hypovolemia should be corre...

...nts with AIS, early treatment of hyperte...

...with BP ≥220/120 mm Hg who did not rece...

...ients with BP...

Note: Recommendations in this section are repeat...

...4.5. Tempera...

...rces of hyperthermia (temperature >38°C...

...ients with AIS, the benefit of tre...

...: Recommendations in this section are repeate...

...4.6. Glucose...

...glycemia (blood glucose...

Evidence indicates that persistent in-hospital hy...

...4.7....

...phagia screening before the patient begi...

...pic evaluation is reasonable for those patients...

...is reasonable for dysphagia screening to...

...l established which instrument to choose for...

...ng oral hygiene protocols to reduce...

...4.8. Nutriti...

...should be started within 7 days of...

...ients with dysphagia, it is reasonable to i...

...onal supplements are reasonable to consider...

...4.9. Deep Vei...

...obile stroke patients without contr...

...prophylactic-dose subcutaneous heparin (unf...

...hen prophylactic anticoagulation is used,...

...ke, elastic compression stockings should NO...

...tion of a structured depression inv...

...ts diagnosed with poststroke depression should be...

...4.11. Other...

...pitalization and inpatient rehabilita...

...ecommended to minimize or eliminate sk...

...is reasonable for patients and families...

...use of prophylactic antibiotics has NOT be...

...ine placement of indwelling bladder catheters...

...4.12. Rehabilitat...

...mended that early rehabilitation for hospitalized...

...ecommended that stroke survivors receive reha...

It is recommended that all individual...

...al assessment by a clinician with expertise in re...

...eness of fluoxetine or other selective se...

High-dose, very early mobilization w...


...5. In-Hospi...

...5.1 Brain Swelling...

...5.1.1. General Re...

...rge territorial cerebral and cerebe...

...lessen the risk of swelling and close monitori...

5.1.2. M...

...tic therapy for patients with clinical deteriorati...

...of brief moderate hyperventilation...

...a or barbiturates in the setting of i...

...lack of evidence of efficacy and the poten...

...5.1.3. Su...

...h the optimal trigger for decompressi...

...ients ≤60 years of age who deteriorate n...

...ts >60 years of age who deteriorate neu...

...culostomy is recommended in the treatment of obst...

...boccipital craniectomy with dural exp...

...considering decompressive suboccipital cranie...

...5.2. Seiz...

...current seizures after stroke should...

...ic use of antiseizure drugs is NOT recommended....


...6. In-Hospital Insti...

...6.1. Brain Imag...

...or prevention of recurrent stroke, the use...

...in MRI is reasonable in selected patients...

...tiveness of routine brain MRI to guide treatme...

...6.2. Vascular I...

...r patients with nondisabling (mRS scor...

...or prevention of recurrent stroke, the use of int...

...ging of the intracranial vasculature to detect ath...

...g of the intracranial vasculature to detect...

...6.3.1. Elect...

...ring is recommended to screen for atrial fibril...

...ness of prolonged cardiac monitoring du...

...6.3.2. Echocardio...

...of recurrent stroke, the use of echocardio...

...hocardiography is reasonable in selected patients...

...ectiveness of routine echocardiography to guid...

...6.4. Glucose...

...is reasonable to screen all patients for diabet...

...6.5. O...

...ulness of screening for thrombophilic state...

...eening of patients with recent ischemic str...

...g for antiphospholipid antibodies...

...utine screening for hyperhomocysteinemia among...

...6.6. Antithrombotic...

...6.6.1. No...

...ents with noncardioembolic AIS, the use of antipl...

...secondary prevention in patients wi...

...who have a noncardioembolic AIS while taking as...

...oagulation might be considered in patients...

...tients who have a noncardioembolic AIS while takin...

...h noncardioembolic ischemic stroke, treatmen...

...s with an AIS in the setting of atrial fi...

...h a history of ischemic stroke, atrial fibr...

...6.6.3. Ar...

...ients with AIS and extracranial caro...

...patients with AIS and extracranial ca...

6.6.4...

...tients with AIS and HT, initiation o...

...6.7. Caroti...

...en revascularization is indicated for...

...6.8.1. General P...

...tients with AIS should be managed accord...

...ho are 20 years of age or older and not on lipi...

...hanges in lifestyle and effects of...

...6.8.2. Ch...

...are 75 years of age or younger with clinical ASCVD...

...patients with clinical ASCVD in whom high-intens...

...at increased ASCVD risk with chronic, stable...

...n patients with clinical ASCVD, who are...

...nts with clinical ASCVD who are ju...

...ist prices, PCSK9 inhibitors have a low-cost v...

...n patients with clinical ASCVD who...

...ients older than 75 years of age with clin...

In patients older than 75 years of age who are t...

...ts with clinical ASCVD who are receivi...

...l aASCVD includes acute coronary syndrome, those...

...tatus For high-intensity...

...6...

...ient risk discussion is recommended before...

...s with indication for statin therapy, identific...

...n patients with statin-associated side effects...

...n patients at increased ASCVD risk wi...

...6.8.4. Timing...

...already taking statins at the time o...

...patients with AIS who qualify for statin treatment...

...6.8.5 Special Pati...

...of childbearing age who are treated with st...

...ldbearing age with hypercholesterolemia who pl...

...lts with advanced kidney disease tha...

...h advanced kidney disease who require dialysis...

...6.9. Institution...

...tarting or restarting antihypertensive therapy...

6.1...

...th AIS should receive in-hospital initiatio...

...r smokers with an AIS, who receive in-hospi...

...are providers should strongly advise every patien...

...le to advise patients after ischemic s...

...ith an AIS, in-hospital initiation...

...6.11. Stroke Edu...

...atient education about stroke is recom...