Early Management of Patients With Acute Ischemic Stroke

Publication Date: October 30, 2019

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

...Treatment...

...1. Pre...

...1.1. Prehospital Sys...

Public health leaders, along with m...

...ducational programs should be design...

...n of the 9-1-1 system by patients or other membe...

...1.2. EMS Ass...

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

...nnel should provide prehospital notificat...

...1.3. EMS S...

...systems of stroke care should be developed. The...

...aders, in coordination with local, reg...

...ts with a positive stroke screen o...

...eral IV alteplase-capable hospital optio...

...ective prehospital procedures to ident...

...1.4. Hosp...

...f stroke centers by an independent external...

...1.5. Hospit...

...d protocol for the emergency evalua...

...ignation of an acute stroke team that include...

...lticomponent quality improvement initi...

It is recommended that stroke systems...

...g and monitoring target time goals for ED door-to-...

...1.6....

...hout in-house imaging interpretatio...

...nted within a telestroke network, teleradi...

...elemedicine/telestroke resources an...

...roke/teleradiology evaluations of A...

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

...works may be reasonable for triaging patients wit...

...oviding alteplase decision-making support via t...

...1.7. Organization and I...

...itals caring for stroke patients w...

...es within a hospital that may be transf...

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

...may be useful for primary stroke centers and othe...

It may be useful for government agenci...

...1.8. Establis...

...ipation in a stroke data repository is recomm...

...1.9. St...

...re institutions should organize a mul...

...come measures should include adjustments...

...nuous quality improvement processes,...


...2.1. St...

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

...e 1. National Institutes of Health Stroke Scale (N...

...2.2.1. Initial Imagi...

...s with suspected acute stroke should receive...

...be established so that brain imagin...

...ncontrast CT (NCCT) is effective to...

...tic resonance (MR) imaging (MRI) is effective to e...

...CTP or MR angiography (MRA) with diffusion-weight...

...tration of IV alteplase in eligible patients with...

...eligible for IV alteplase, because benefit of...

...n patients with AIS who awake with strok...

...2.2.3. Mechanical Thr...

...patients who otherwise meet criteria for mecha...

...th suspected LVO who have not had noninva...

...suspected intracranial LVO and no...

...s who are potential candidates for mechan...

...may be reasonable to incorporate collateral fl...

2.2.4. Mech...

...cting patients with AIS within 6–24...

...en evaluating patients with AIS within 6 hou...

...2.3. Other Dia...

...ment of blood glucose must precede the...

...trocardiographic assessment is recommended in pati...

...in assessment is recommended in patien...

...f chest radiographs in the hyperacute stro...


...3. G...

...3.1. Airway,...

...irway support and ventilatory assistanc...

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

Supplemental oxygen is NOT recommended...

...oxygen (HBO) is NOT recommended for patient...

...3.2. Blood Pressur...

...hypovolemia should be corrected to maintain...

...ents who have elevated BP and are othe...

...tients for whom mechanical thrombectomy is...

...usefulness of drug-induced hypertension in...

...tions to Treat Arterial Hypertensi...

...3.3. Tem...

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

...tients with AIS, the benefit of treatment with...

...3.4. Blood Glucose...

...cemia (blood glucose...

...ence indicates that persistent in-hospi...

...3.5. IV Alteplas...

...3.5....

...igible for IV alteplase, benefit of therapy is ti...

...patients undergoing fibrinolytic therapy,...

The potential risks should be discussed duri...

Treating clinicians should be aware that hypo...

...om onset of symptoms to treatment has such a...

3.5.2...

...e (0.9 mg/kg, maximum dose 90 mg over 60 minutes...

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

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

...herwise eligible patients with mild but disablin...

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

...e eligible patients with mild nondisabling stro...

...rwise eligible patients with mild non-...

3.5.4. Ot...

...teplase for adults presenting with an AIS with kn...

...patients with a hyperdense MCA sign, IV...

...3.5.5. Bleeding Ris...

...extremely low risk of unsuspected...

...otherwise eligible patients who h...

...eligible patients who have previously had a high...

...efficacy of the IV glycoprotein IIb/I...

...ximab should NOT be administered co...

...pirin should NOT be administered within 90 min...

...should NOT be administered to patients who have...

...3.5.6. Post-alte...

BP should be mainta...

...tithrombotic therapy (other than IV a...

...ment of Symptomatic Intracranial Bleedi...

...4. Management of Orolingual Angioedema...

...Eligibility Recommendatio...

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

...3 h–AgeFor otherwise medically eligible pa...

...evere strokeFor severe stroke, IVb...

...n 3 h–Mild disabling strokeFor otherwise eli...

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

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

UrgencyTreatment should be initiated as...

...lteplase is recommended in patients with BP...

...glucoseIVb alteplase is recommended in otherwi...

...dministration is recommended in the setti...

...ntiplatelet therapy...

...lteplase is recommended for patients taking a...

...ase is recommended for patients taking antiplate...

...stage renal diseaseIn patients with end-st...

...Addi...

...h–AgeFor patients >80 y of age pres...

...abetes mellitus and prior strokeIn AIS patients wi...

...4.5 h–Severe strokeThe benefit of IV altepla...

...ild disabling strokeFor otherwise eligible...

...known time of onsetIV alteplase (0.9 mg/kg...

...reexisting disabil...

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

...preexisting dementia may benefit from...

...provementIVb alteplase treatment is reasonabl...

...etIVb,d alteplase is reasonable in patien...

...glucoseTreatment with IV alteplase in...

...agulopath...

...plase may be reasonable in patients who...

...ety and efficacy of IV alteplase for acute...

...tureIV alteplase may be considered...

...eThe safety and efficacy of administering...

...raumaIn AIS patients with recent major t...

...major surgeryUse of IV alteplase in carefully sel...

...genitourinary bleedingReported liter...

...struation

...plase is probably indicated in women who...

...is a history of recent or active vaginal bleedin...

...e potential benefits of IV alteplase pr...

...al cervical dissectionsIV alteplase in AIS...

...anial arterial dissectionIV altepl...

Unruptured intracrania...

...presenting with AIS who are known to harbor a sm...

...efulness and risk of IV alteplase in patient...

...ranial vascular malformations...

...presenting with AIS who are known to har...

...e increased risk of ICH in this populatio...

...MBs...

...ise eligible patients who have previously...

...n otherwise eligible patients who have previ...

...itant tirofiban, eptifibatideThe efficac...

...racranial neoplasmsIV alteplase treatment...

...tients presenting with concurrent AIS and acute MI...

...ecent...

...patients presenting with AIS and a histo...

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

For patients presenting with AIS and a...

...te pericardi...

...nts with major AIS likely to produce s...

...esenting with moderate AIS likely to...

...trial or ventricular thrombus...

For patients with major AIS likely to produce...

...esenting with moderate AIS likely to produce...

...ther cardiac diseases...

...patients with major AIS likely to p...

...s presenting with major AIS likely t...

...okeIV alteplase is reasonable for the...

...alignancyThe safety and efficacy of I...

...egnancy

...,d alteplase administration may be considered in...

...he safety and efficacy of IVb,d altep...

Ophthalmological conditionsUse of...

...kle cell diseaseIV alteplase for adul...

...erdense MCA signIn patients with a hyperde...

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

Stroke mimicsThe risk of symptomatic intra...

...Contrain...

...–Mild nondisabling strokeFor otherwise eligi...

...4.5-h window–Mild nondisabling strokeFor otherwi...

...emains insufficient evidence to identify...

...ase should NOT be administered to a p...

...within 3 moUse of IV alteplase in p...

Severe head trauma within 3 moIn AIS patients...

...aGiven the possibility of bleeding c...

...raspinal surgery within 3 moFor patients...

...story of intracranial hemorrhageIVb,d,e alteplas...

...chnoid hemorrhageIVb,d,e alteplase is con...

...lignancy or GI bleed within 21 dPatien...

...thyThe safety and efficacy of IV3 alteplase...

...HIV alteplase should NOT be administered to patien...

...itors or factor Xa inhibitorsThe use of I...

...mitant AbciximabAbciximab should NOT be ad...

...t IV aspirinIV aspirin should NOT be administ...

...e endocarditisFor patients with AIS and...

...sectionIV alteplase in AISb,d,e known or sus...

...intracranial neoplasmIV alteplase t...

...erwise specified, these eligibility recommendat...

...able 6. Treatment of AIS: IV Admin...

...from Jauch et al. Copyright © 2013, American...

...3.6. Oth...

...be reasonable to choose tenecteplase (single...

...ministered as a 0.4-mg/kg single IV bolus has...

...istration of IV defibrinogenating agents...

...of sonothrombolysis as adjuvant therapy with I...

...3.7. M...

...3.7.1. Concomitant Wit...

...e for IV alteplase should receive IV alteplase...

...under consideration for mechanical thrombectomy,...

...3.7.2....

...hould receive mechanical thrombectomy with...

...on thrombectomy as first-pass mechanical thro...

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

...hough its benefits are uncertain, the use of m...

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

...patients with AIS within 6–16 hou...

...elected patients with AIS within 16–...

...3.7.4. Tec...

...of stent retrievers is indicated i...

...hnical goal of the thrombectomy procedure...

...e benefit, reperfusion to mTICI grade 2b/3...

...hour thrombectomy window evaluation and treat...

...ble to select an anesthetic technique...

...use of a proximal balloon guide c...

...atment of tandem occlusions (both extra...

...fficacy of IV glycoprotein IIb/IIIa inhibito...

...e of salvage technical adjuncts, i...

...3.7.5. Blood Pressure...

...who undergo mechanical thrombectomy, it is reas...

...ho undergo mechanical thrombectomy wit...

...3.8. Other Endova...

...nical thrombectomy with stent retrievers...

...fibrinolysis initiated within 6 h...

...3.9. Antiplatelet Treatme...

...tration of aspirin is recommended in patients...

...presenting with minor noncardioemboli...

...e efficacy of the IV glycoprotein IIb/IIIa inhibit...

...is NOT recommended over aspirin for trea...

...stration of the IV glycoprotein IIb/I...

...in is NOT recommended as a substitute...

...3.10. Anticoagulan...

...efulness of urgent anticoagulation in patients wit...

...ety and usefulness of short-term anticoagulati...

At present, the usefulness of argatrob...

...safety and usefulness of oral factor Xa in...

...anticoagulation, with the goal of preventing...

...3.11....

...emodilution by volume expansion is NO...

...inistration of high-dose albumin is NOT recommen...

...inistration of vasodilatory agents, such as pentox...

...mechanically augment cerebral blood flow for the t...

...3.12. Neuroprotect...

At present, pharmacological or nonpharmacolo...

...3.13. Emergenc...

...ss of emergent or urgent carotid enda...

...with unstable neurological status...

...near-infrared laser therapy is NOT recomm...


...4. In-Hospital...

...4.1...

...of comprehensive specialized stroke car...

...ndardized stroke care order sets is recommended...

...flat-head positioning early after...

...dations in this section are repeated from Sect...

...support and ventilatory assistance are recomm...

...gen should be provided to maintain oxygen sat...

Supplemental oxygen is NOT recommended in nonhy...

...te: Recommendation 1 in this section is...

...4.4. Blood Pres...

...nd hypovolemia should be corrected to maint...

...s with AIS, early treatment of hyp...

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

...patients with BP...

...dations in this section are repeated f...

...4.5. Tempe...

...ces of hyperthermia (temperature >...

...ith AIS, the benefit of treatment with induced h...

...mmendations in this section are repeated from...

...4.6. Glucose...

...poglycemia (blood glu...

...cates that persistent in-hospital hyperglycem...

...4.7. Dyspha...

...ia screening before the patient begins eating,...

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

...easonable for dysphagia screening to be performed...

...not well established which instrument to choo...

...ral hygiene protocols to reduce the...

...4...

...uld be started within 7 days of admis...

...nts with dysphagia, it is reasonable to initially...

...lements are reasonable to consider for pa...

...4.9. Dee...

...ke patients without contraindication...

...nefit of prophylactic-dose subcuta...

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

...c stroke, elastic compression stocki...

...4.10. Depression Scree...

...tration of a structured depression inventory is...

...sed with poststroke depression should be treated...

...ing hospitalization and inpatient rehabilitati...

...mmended to minimize or eliminate skin friction...

...ble for patients and families with stroke to be...

...of prophylactic antibiotics has NOT been shown...

...ne placement of indwelling bladder catheters...

...4.12. Rehab...

...is recommended that early rehabilitation for hos...

...ed that stroke survivors receive rehabilitation at...

...is recommended that all individuals...

...nal assessment by a clinician with expe...

...ess of fluoxetine or other selective serotoni...

...y early mobilization within 24 hour...


...5. In-Hospital Ma...

...5.1 Brain Swellin...

...5.1.1....

...s with large territorial cerebral and cerebella...

...ures to lessen the risk of swelling and close...

...5.1.2. Medical...

...osmotic therapy for patients with clinical deter...

...moderate hyperventilation (Pco2 target,...

...ypothermia or barbiturates in the setti...

...ack of evidence of efficacy and the potential...

5.1....

...timal trigger for decompressive cran...

...nts ≤60 years of age who deteriorate neurologica...

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

5.1.4. Su...

...lostomy is recommended in the treatment...

...compressive suboccipital craniectomy w...

...ring decompressive suboccipital craniectomy...

...5.2. Seiz...

Recurrent seizures after stroke should be treate...

...se of antiseizure drugs is NOT recommen...


...6.1. Brain...

...evention of recurrent stroke, the use of MRI is...

...rain MRI is reasonable in selected patien...

...effectiveness of routine brain MRI to guide...

...6.2. Vasc...

...ents with nondisabling (mRS score 0–2) AIS in th...

...n of recurrent stroke, the use of intracranial v...

...ntracranial vasculature to detect atheroscle...

...imaging of the intracranial vasculatu...

...6.3.1. E...

...diac monitoring is recommended to scree...

...iveness of prolonged cardiac monit...

...6.3.2. Echo...

...prevention of recurrent stroke, th...

...hocardiography is reasonable in selected pat...

...iveness of routine echocardiography to guide treat...

...6.4. Glucose...

..., it is reasonable to screen all pati...

...6....

...ulness of screening for thrombophilic states...

...utine screening of patients with recent ischemic...

...ing for antiphospholipid antibodies...

...outine screening for hyperhomocysteinemia a...

...6.6. Antithromboti...

...6.6.1. Noncardioembol...

...patients with noncardioembolic AIS, the us...

For early secondary prevention in patients with no...

...have a noncardioembolic AIS while taking...

...gulation might be considered in patients who are...

...atients who have a noncardioembolic AIS wh...

...noncardioembolic ischemic stroke, treat...

...6.6.2. Atrial Fibrill...

...s with an AIS in the setting of atria...

...th a history of ischemic stroke, atrial fibrillati...

...6.6....

...with AIS and extracranial carotid or vertebral...

...with AIS and extracranial carotid or extracra...

...6.6.4....

...or patients with AIS and HT, initiation...

...6.7. Carotid R...

...cularization is indicated for secondary pr...

...6.8. Treatment...

...6.8.1. General Princ...

...nts with AIS should be managed according...

...who are 20 years of age or older and no...

...to changes in lifestyle and effects of LDL-C–...

...6.8.2. Choice of L...

...ts who are 75 years of age or youn...

...s with clinical ASCVD in whom high-intensity sta...

...ents at increased ASCVD risk with chronic, stab...

...h clinical ASCVD, who are judged to be ver...

...patients with clinical ASCVD who are judged t...

At mid-2018 list prices, PCSK9 inhibit...

...th clinical ASCVD who are on maximally tolerated...

...atients older than 75 years of age with clinical...

...patients older than 75 years of age who ar...

...with clinical ASCVD who are receiving maximal...

...aASCVD includes acute coronary syndro...

...7. Risk Status For high-i...

...6.8.3 Impl...

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

...patients with indication for statin t...

...th statin-associated side effects that are not sev...

...s at increased ASCVD risk with severe statin...

...6.8.4. Timing...

...atients already taking statins at the time of...

...r patients with AIS who qualify for stat...

...6.8.5 Special Patie...

...of childbearing age who are treated...

...of childbearing age with hypercholesterolemia who...

...lts with advanced kidney disease that requ...

...advanced kidney disease who requi...

...6.9. Institution of...

...tarting antihypertensive therapy during hospita...

...6.10. Smokin...

...kers with AIS should receive in-hospital initiati...

...h an AIS, who receive in-hospital...

...care providers should strongly advise ever...

...able to advise patients after ischemic...

...smokers with an AIS, in-hospital initiati...

...6.11. Stroke...

...n about stroke is recommended. Patients should be...