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

...reatment...

...Stroke Management and Systems of Care...

...Prehospital System...

...health leaders, along with medica...

...ch educational programs should be desig...

...vation of the 9-1-1 system by patients or o...

...2. EMS Assessment and Management

...oke assessment tool by first aid provid...

...ould provide prehospital notification to the...

.... EMS Systems...

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

EMS leaders, in coordination with...

...ts with a positive stroke screen or who...

...IV alteplase-capable hospital options...

...prehospital procedures to identify pa...

...Hospital Stroke Capabiliti...

...tion of stroke centers by an independ...

...pital Stroke Teams...

...ized protocol for the emergency evaluation of p...

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

...quality improvement initiatives, which in...

...ommended that stroke systems of care be develo...

...hing and monitoring target time goals for ED d...

1.6. Telemedic...

...sites without in-house imaging int...

...en implemented within a telestroke network, te...

...medicine/telestroke resources and sy...

...troke/teleradiology evaluations of AIS patien...

Administration of IV alteplase gui...

...roke networks may be reasonable for t...

...g alteplase decision-making support via telephon...

...zation and Integration of Components...

...itals caring for stroke patients within a stroke s...

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

...hanical thrombectomy requires the patient to b...

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

...eful for government agencies and third-part...

.... Establishment of Data Repositor...

...a stroke data repository is recommended...

...troke System Care Quality Improvement Process...

...titutions should organize a multidiscip...

...oke outcome measures should include...

...quality improvement processes, impl...


...Evaluation and Treatment...

...1. Stroke Scales

...e use of a stroke severity rating...

...National Institutes of Health Stroke...

.... Head and Neck Ima...

.... Initial Imaging...

...h suspected acute stroke should receive emergency...

...uld be established so that brain imaging studies...

...rast CT (NCCT) is effective to exclude...

...netic resonance (MR) imaging (MRI) is eff...

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

...V Alteplase Eligibili...

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

...igible for IV alteplase, because benefit of the...

...ts with AIS who awake with stroke symptom...

...ical Thrombectomy Eligibility–Vessel Imaging...

...o otherwise meet criteria for mech...

...or patients with suspected LVO who have not had n...

...patients with suspected intracran...

...nts who are potential candidates for mechanical...

...may be reasonable to incorporate co...

...ical Thrombectomy Eligibility–Multimod...

...n selecting patients with AIS within 6...

...ating patients with AIS within 6 hours of...

...Other Diagnostic Tests...

...ent of blood glucose must precede the in...

...eline electrocardiographic assessment i...

...onin assessment is recommended in patients pres...

...sefulness of chest radiographs in the hyper...


...rtive Care and Emergency Treatment...

...y, Breathing, and Oxygenation...

...t and ventilatory assistance are recommend...

...pplemental oxygen should be provide...

...al oxygen is NOT recommended in non-hypo...

Hyperbaric oxygen (HBO) is NOT recommen...

...lood Pressure

...d hypovolemia should be corrected to main...

...tients who have elevated BP and ar...

...whom mechanical thrombectomy is planned and who...

...of drug-induced hypertension in patie...

...s to Treat Arterial Hypertension in Patients w...

...3. Temperatur...

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

...ts with AIS, the benefit of treatment with i...

...4. Blood Glu...

...oglycemia (blood glu...

...ence indicates that persistent in-hospital hypergl...

...5. IV Alteplas...

....5.1. General Principl...

In patients eligible for IV alteplase, be...

...dergoing fibrinolytic therapy, phys...

...potential risks should be discussed dur...

...ing clinicians should be aware that hyp...

...m onset of symptoms to treatment has such a powe...

...Time Windows...

...plase (0.9 mg/kg, maximum dose 90 mg over 60 mi...

...se (0.9 mg/kg, maximum dose 90 mg over 60 min...

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

3.5.3. Mild...

...se eligible patients with mild but disabling stro...

...eligible patients with mild disabling stroke...

...r otherwise eligible patients with m...

...eligible patients with mild non-disabli...

...er Specific Circumstances...

...r adults presenting with an AIS with known sic...

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

....5. Bleeding Risk

...e extremely low risk of unsuspected abn...

...otherwise eligible patients who have prev...

In otherwise eligible patients who have previousl...

The efficacy of the IV glycoprotein...

...uld NOT be administered concurrently with IV altep...

...V aspirin should NOT be administered with...

...lteplase should NOT be administered to pat...

...ost-alteplase Treatment...

...hould be maintained at...

...risk of antithrombotic therapy (ot...

...ble 3. Management of Symptomatic Intracranial Blee...

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

...ity Recommendations for IV Alteplase in Patie...

Indications

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

...For otherwise medically eligible patien...

...Severe strokeFor severe stroke, IVb a...

...h–Mild disabling strokeFor otherwise eligible...

...,d alteplase (0.9 mg/kg, maximum dose 9...

...eIV alteplase treatment in the 3- to 4.5-h t...

...reatment should be initiated as quickly as...

...IV alteplase is recommended in patients w...

...lucoseIVb alteplase is recommended...

...lase administration is recommended in...

...r antiplatelet therapy...

...V alteplase is recommended for patients...

...se is recommended for patients taking a...

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

...ditional recommendations for treatment with...

...h–AgeFor patients >80 y of age presenting in t...

...4.5 h–Diabetes mellitus and prior str...

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

...d disabling strokeFor otherwise eligible patien...

...ke-up and unknown time of onsetIV alteplase (0.9 m...

...sting disability...

...ability does not seem to independently increase th...

...ith preexisting dementia may benefit from IVb,d al...

...improvementIVb alteplase treatment is reasonable...

...onsetIVb,d alteplase is reasonable in pati...

...od glucoseTreatment with IV alteplase in...

...oagulopat...

...eplase may be reasonable in patients...

...safety and efficacy of IV altepla...

...l punctureIV alteplase may be consider...

Arterial punctureThe safety and efficac...

...raumaIn AIS patients with recent majo...

...major surgeryUse of IV alteplase in caref...

...genitourinary bleedingReported literature de...

Menstrua...

...e is probably indicated in women who are mens...

...n there is a history of recent or active...

...e the potential benefits of IV alteplase probably...

...ervical dissectionsIV alteplase in AISb,d known...

...terial dissectionIV alteplase usefulness and...

...tured intracranial aneu...

For patients presenting with AIS who are k...

Usefulness and risk of IV alteplase in p...

...racranial vascular malformati...

...s presenting with AIS who are known to ha...

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

...MBs...

...erwise eligible patients who have previou...

...gible patients who have previously had a high bu...

...omitant tirofiban, eptifibatideThe...

...al intracranial neoplasmsIV altepl...

...r patients presenting with concurrent AIS an...

Recent...

...ients presenting with AIS and a hist...

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

...resenting with AIS and a history of rec...

...e pericarditis...

...ents with major AIS likely to prod...

...senting with moderate AIS likely to produce mild d...

...ial or ventricular thromb...

...ith major AIS likely to produce severe disabi...

...patients presenting with moderate...

...ardiac diseases...

...atients with major AIS likely to produce sever...

...patients presenting with major AIS likel...

Procedural strokeIV alteplase is reasonab...

...lignancyThe safety and efficacy of IVb...

...egnancy...

...ase administration may be considered in...

...afety and efficacy of IVb,d alteplase in the...

...ical conditionsUse of IV alteplase in patients...

...cell diseaseIV alteplase for adults...

...MCA signIn patients with a hyperdense MCA s...

...seTreating clinicians should be aware...

...e risk of symptomatic intracranial hemorrhage in...

Contraindicati...

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

...window–Mild nondisabling strokeFo...

...e remains insufficient evidence to identify...

...alteplase should NOT be administered to a pati...

...stroke within 3 moUse of IV alteplase...

...evere head trauma within 3 moIn AIS pat...

...te head traumaGiven the possibility of bleed...

...cranial/intraspinal surgery within 3 moF...

...of intracranial hemorrhageIVb,d,e alte...

...ubarachnoid hemorrhageIVb,d,e alteplase is c...

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

...he safety and efficacy of IV3 alteplase for acute...

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

...hibitors or factor Xa inhibitorsThe...

...t AbciximabAbciximab should NOT be administered...

Concomitant IV aspirinIV aspirin...

Infective endocarditisFor patients with AIS a...

...arch dissectionIV alteplase in AISb,d,e kn...

Intra-axial intracranial neoplasmIV alt...

...se specified, these eligibility recommenda...

...6. Treatment of AIS: IV Administration of A...

...auch et al. Copyright © 2013, American Heart...

...Fibrinolytics and Sonothrombolysis...

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

...teplase administered as a 0.4-mg/kg single IV...

The administration of IV defibrinogenating agen...

...of sonothrombolysis as adjuvant therapy wit...

....7. Mechanical Thrombectomy

...7.1. Concomitant With IV Al...

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

...tients under consideration for mec...

....2. 0–6 Hours From Onset...

...atients should receive mechanical thr...

...ration thrombectomy as first-pass mechanical throm...

...enefits are uncertain, the use of mechanical thro...

...ts benefits are uncertain, the use...

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

....3. 6 to 24 Hours From...

...selected patients with AIS within 6–16 hours...

...elected patients with AIS within 16–24 h...

.... Technique...

...stent retrievers is indicated in prefer...

...technical goal of the thrombectomy pro...

...it, reperfusion to mTICI grade 2b/3 sh...

...he 6- to 24-hour thrombectomy window eval...

...e to select an anesthetic technique during EVT...

The use of a proximal balloon guide cat...

...f tandem occlusions (both extracranial and intracr...

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

...e technical adjuncts, including intra-arteria...

....5. Blood Pressure Management

...patients who undergo mechanical thrombectomy,...

...patients who undergo mechanical thrombectomy wit...

....8. Other Endovascular Therap...

...hanical thrombectomy with stent retrie...

...rial fibrinolysis initiated within...

...tiplatelet Treatment...

...tion of aspirin is recommended in patients...

...n patients presenting with minor noncardioemboli...

...fficacy of the IV glycoprotein IIb/IIIa i...

...icagrelor is NOT recommended over aspirin for tr...

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

...s NOT recommended as a substitute for acut...

...10. Anticoagulan...

The usefulness of urgent anticoagulation in...

...sefulness of short-term anticoagulation...

...usefulness of argatroban, dabigatran...

...ety and usefulness of oral factor Xa inhibitor...

...oagulation, with the goal of preventi...

...Expansion/Hemodilution, Vasodilators,...

...on by volume expansion is NOT recommended...

...on of high-dose albumin is NOT recom...

...administration of vasodilatory agents, such...

Devices to mechanically augment ce...

3.12. Neuroprotective Age...

...present, pharmacological or nonpharmacolog...

...Emergency Carotid Endarterectomy/C...

...e usefulness of emergent or urgent carot...

...ients with unstable neurological status (eg, st...

....14. Other...

Transcranial near-infrared laser the...


...Management of AIS: General Supportive Care...

...1. Stroke Un...

...use of comprehensive specialized stroke care (...

...f standardized stroke care order sets is recomme...

...Head Positioning...

...fit of flat-head positioning early after...

...endations in this section are repeated fr...

...plemental Oxygen...

...and ventilatory assistance are re...

...lemental oxygen should be provided to mai...

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

...ecommendation 1 in this section is repeate...

...Blood Pressure...

...nsion and hypovolemia should be correc...

In patients with AIS, early treatment...

...n patients with BP ≥220/120 mm Hg who did not re...

...tients with BP...

...: Recommendations in this section...

4.5. Temperat...

...erthermia (temperature >38°C) should be...

...nts with AIS, the benefit of treatment with induce...

...e: Recommendations in this section are repea...

...6. Glucos...

...ycemia (blood glucose...

...vidence indicates that persistent in-...

...7. Dysphag...

...a screening before the patient begins eatin...

...ndoscopic evaluation is reasonable for t...

...s reasonable for dysphagia screening...

...is not well established which instrument...

...plementing oral hygiene protocols to reduce the...

....8. Nutrition...

...diet should be started within 7 day...

...s with dysphagia, it is reasonable to...

...utritional supplements are reasonabl...

...Vein Thrombosis Prophylaxis...

...immobile stroke patients without contra...

...e benefit of prophylactic-dose subcuta...

...actic anticoagulation is used, the benefit of pro...

In ischemic stroke, elastic compression...

....10. Depression Screeni...

...ion of a structured depression inventory i...

...ients diagnosed with poststroke depression sh...

...1. Other...

...zation and inpatient rehabilitation, regular ski...

...ecommended to minimize or eliminate skin...

...le for patients and families with stroke to b...

...se of prophylactic antibiotics has NOT...

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

...2. Rehabilitatio...

...d that early rehabilitation for hospitalized str...

...commended that stroke survivors receive reha...

...mended that all individuals with stroke b...

...functional assessment by a clinician with experti...

...effectiveness of fluoxetine or othe...

...ery early mobilization within 24 hour...


...Management of AIS: Treatment of Acute...

...Brain Swelling

...eral Recommendations...

...th large territorial cerebral and cerebellar inf...

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

....1.2. Medical Management

...therapy for patients with clinical deteriora...

...erate hyperventilation (Pco2 target, 30–...

...barbiturates in the setting of ischemic...

...use of a lack of evidence of efficacy and...

...Surgical Management-Supratentorial Inf...

...optimal trigger for decompressive craniectom...

...nts ≤60 years of age who deteriora...

...n patients >60 years of age who deterior...

...urgical Management-Cerebellar Infa...

...ostomy is recommended in the treatment of obs...

...ressive suboccipital craniectomy with dural ex...

...decompressive suboccipital craniectomy for cere...

...Seizures...

Recurrent seizures after stroke should be...

...c use of antiseizure drugs is NOT recomm...


...ospital Institution of Secondary Stroke Prevention...

.... Brain Imaging

...revention of recurrent stroke, the u...

...reasonable in selected patients as...

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

....2. Vascular I...

For patients with nondisabling (mRS score 0–2) A...

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

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

...utine imaging of the intracranial va...

....1. Electrocardiographic Monito...

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

...effectiveness of prolonged cardiac monitor...

...Echocardiography...

...n of recurrent stroke, the use of ec...

...aphy is reasonable in selected patients as part of...

...effectiveness of routine echocardiography to g...

.... Glucose

...ter AIS, it is reasonable to screen all patients...

...ther Tests for Secondary Prevent...

...ess of screening for thrombophilic...

...ning of patients with recent ischemic...

...e testing for antiphospholipid anti...

...ng for hyperhomocysteinemia among patients w...

...thrombotic Treatment...

6.6.1. Noncardioembolic Stro...

...ients with noncardioembolic AIS, the use of a...

...secondary prevention in patients wit...

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

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

...atients who have a noncardioembolic AIS while...

...nts with noncardioembolic ischemic stroke...

....2. Atrial Fibrillation

...patients with an AIS in the setting of atrial...

...ents with a history of ischemic stroke, a...

...Arterial Dissection...

...ients with AIS and extracranial carotid or ver...

...with AIS and extracranial carotid...

....4. Hemorrhagic Transformation

...h AIS and HT, initiation or continuation of antipl...

....7. Carotid Revascular...

...scularization is indicated for secondary preven...

...eatment of Hyperlipide...

6.8.1. General Pr...

...h AIS should be managed according to the...

...s who are 20 years of age or older...

...ce to changes in lifestyle and effects of L...

...2. Choice of Lipid-lowering Drugs for Patien...

...patients who are 75 years of age or younger wi...

...h clinical ASCVD in whom high-intensi...

...ients at increased ASCVD risk with ch...

...ts with clinical ASCVD, who are judged...

...with clinical ASCVD who are judged to be v...

...d-2018 list prices, PCSK9 inhibitors hav...

...with clinical ASCVD who are on maximall...

...s older than 75 years of age with clinica...

...n patients older than 75 years of age who are...

...ents with clinical ASCVD who are receiving...

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

...7. Risk StatusHaving trouble viewing ta...

...Implementation...

A clinician-patient risk discussion is reco...

...h indication for statin therapy, identification...

...ith statin-associated side effects...

...t increased ASCVD risk with severe stat...

....8.4. Timi...

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

...s with AIS who qualify for statin treatmen...

...Special Patient Group...

...n of childbearing age who are treated with statin...

...men of childbearing age with hypercholes...

...lts with advanced kidney disease that require...

...dults with advanced kidney disease who require d...

...9. Institution of Antihypertensive Medicati...

...tarting antihypertensive therapy during hospita...

...moking Cessation Intervent...

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

...smokers with an AIS, who receive in-ho...

...care providers should strongly advise eve...

...is reasonable to advise patients after...

...s with an AIS, in-hospital initiation o...

....11. Stroke Education...

Patient education about stroke is recommende...