Early Management of Patients With Acute Ischemic Stroke
Key Points
Key Points
Treatment
...atment...
...Prehospital Stroke Management and Sys...
1.1. Prehospital Syste...
...health leaders, along with medical prof...
...h educational programs should be design...
...the 9-1-1 system by patients or o...
...ssessment and Management...
...stroke assessment tool by first aid providers, i...
...nel should provide prehospital notification to th...
...EMS Systems...
...l systems of stroke care should be develop...
...MS leaders, in coordination with loca...
...ith a positive stroke screen or who are stron...
...IV alteplase-capable hospital options exist with...
...ective prehospital procedures to identify pat...
...pital Stroke Capabiliti...
...ication of stroke centers by an ind...
1.5. Hospital Stroke Tea...
...d protocol for the emergency evaluation of...
...ignation of an acute stroke team that in...
...ulticomponent quality improvement initiatives,...
...d that stroke systems of care be developed so t...
...ng and monitoring target time goals for...
.... Telemedici...
...thout in-house imaging interpretation e...
...emented within a telestroke network,...
...e of telemedicine/telestroke resou...
...troke/teleradiology evaluations of AIS patient...
...inistration of IV alteplase guided by...
...networks may be reasonable for triaging p...
...ding alteplase decision-making support via tele...
...nization and Integration of Components...
...l hospitals caring for stroke patients within...
...vices within a hospital that may be tra...
...al thrombectomy requires the patien...
...ay be useful for primary stroke centers and ot...
...seful for government agencies and third-party...
....8. Establishment of Data Reposi...
...ipation in a stroke data repository is recomme...
...System Care Quality Improvement Process...
...institutions should organize a multidis...
Stroke outcome measures should include a...
...ous quality improvement processes,...
...ncy Evaluation and Treatment...
2.1. Stroke Scale...
...e use of a stroke severity rating scale, pre...
...ational Institutes of Health Stroke Scale...
...Head and Neck Imagi...
2.2.1. Initial...
...nts with suspected acute stroke shoul...
...stems should be established so that bra...
Noncontrast CT (NCCT) is effective to exclude I...
...nce (MR) imaging (MRI) is effective...
CTA with CTP or MR angiography (MRA) with diffu...
.... IV Alteplase Eligibility...
...nistration of IV alteplase in eligible pa...
...atients eligible for IV alteplase, because b...
...ents with AIS who awake with stroke symptoms or...
...l Thrombectomy EligibilityāVessel...
...o otherwise meet criteria for mech...
...with suspected LVO who have not had noninvasive...
In patients with suspected intracranial LVO...
...are potential candidates for mechanical thrombect...
...be reasonable to incorporate collatera...
...echanical Thrombectomy EligibilityāMultimodal Im...
...electing patients with AIS within 6ā24 hou...
...ating patients with AIS within 6 hours of las...
...3. Other Diagnostic...
...assessment of blood glucose must...
...trocardiographic assessment is recommende...
...nin assessment is recommended in patients pres...
...chest radiographs in the hyperacute stroke settin...
...neral Supportive Care and Emergency Tre...
....1. Airway, Breathing, and Oxyg...
...support and ventilatory assistance a...
...plemental oxygen should be provided to maintain...
...plemental oxygen is NOT recommended in non-hyp...
...gen (HBO) is NOT recommended for patients with...
...Blood Pressure...
Hypotension and hypovolemia should be corre...
...o have elevated BP and are otherwise eli...
...atients for whom mechanical thrombectomy is...
...ulness of drug-induced hypertension...
...ions to Treat Arterial Hypertension in Patie...
...3. Temperatu...
...of hyperthermia (temperature >38Ā°C)...
...ents with AIS, the benefit of treatment with...
...Blood Glucose...
Hypoglycemia (blood glucos...
...icates that persistent in-hospital hyperglycem...
...IV Alteplas...
....1. General Principle...
...ts eligible for IV alteplase, benefit of therap...
...undergoing fibrinolytic therapy, physicians shoul...
...ential risks should be discussed during I...
...clinicians should be aware that hypoglycemia and...
...e time from onset of symptoms to treatment has s...
...Time Windows...
...lase (0.9 mg/kg, maximum dose 90 mg over 60 mi...
...V alteplase (0.9 mg/kg, maximum dose 90 mg over 6...
...ase (0.9 mg/kg, maximum dose 90 mg over 60 minutes...
....3. Mild Str...
...eligible patients with mild but disab...
...r otherwise eligible patients with mild di...
...r otherwise eligible patients with...
For otherwise eligible patients with mild non-dis...
...Other Specific Circumstances...
...for adults presenting with an AIS with kno...
...nts with a hyperdense MCA sign, IV alteplase can b...
3.5.5. Bleeding R...
...the extremely low risk of unsuspected abnorma...
In otherwise eligible patients who have pr...
In otherwise eligible patients who have previous...
...the IV glycoprotein IIb/IIIa inhibitors ti...
...ab should NOT be administered concurrently with...
...uld NOT be administered within 90 minutes after...
...should NOT be administered to pat...
...t-alteplase Treatment...
...ould be maintained at...
...isk of antithrombotic therapy (other than...
...3. Management of Symptomatic Intracranial Bleed...
...gement of Orolingual Angioedema Associ...
...lity Recommendations for IV Alteplase in P...
...ications...
...alteplase (0.9 mg/kg, maximum dose 90 mg o...
...AgeFor otherwise medically eligible pati...
...āSevere strokeFor severe stroke, IVb alt...
...ild disabling strokeFor otherwise eligible p...
...alteplase (0.9 mg/kg, maximum dose 90 mg over...
...geIV alteplase treatment in the 3- to 4...
UrgencyTreatment should be initiated as quickl...
...is recommended in patients with BP...
...b alteplase is recommended in otherwise...
...e administration is recommended in the settin...
...ior antiplatelet therapy
...teplase is recommended for patient...
...lteplase is recommended for patients taking a...
...renal diseaseIn patients with end-stage renal...
...tional recommendations for treatment withĀ IV...
...4.5 hāAgeFor patients >80 y of age...
...iabetes mellitus and prior strokeIn AIS pat...
...evere strokeThe benefit of IV alteplase betwee...
...Mild disabling strokeFor otherwise eligible patie...
...and unknown time of onsetIV alteplase (0.9...
...reexisting disability...
...disability does not seem to independe...
...nts with preexisting dementia may benefit fro...
...y improvementIVb alteplase treatment is reas...
...at onsetIVb,d alteplase is reasonable...
...lood glucoseTreatment with IV alteplase in patien...
...oagulopat...
...teplase may be reasonable in patients who...
...safety and efficacy of IV alteplase for acute str...
...punctureIV alteplase may be considered for pat...
...punctureThe safety and efficacy of administerin...
...ajor traumaIn AIS patients with recen...
...r surgeryUse of IV alteplase in ca...
...nd genitourinary bleedingReported literature...
...struation...
...probably indicated in women who are...
When there is a history of recent or...
...ential benefits of IV alteplase prob...
...nial cervical dissectionsIV alteplase in AISb,d...
...racranial arterial dissectionIV alteplase...
...tured intracranial aneurysm...
...s presenting with AIS who are known to harbor a...
...sefulness and risk of IV alteplase...
...al vascular malformations...
...s presenting with AIS who are known to...
...ecause of the increased risk of IC...
...MBs
...otherwise eligible patients who have previousl...
...igible patients who have previously had a high b...
...ncomitant tirofiban, eptifibatideThe efficacy of t...
...acranial neoplasmsIV alteplase treatment i...
...tients presenting with concurrent AIS and a...
...ent MI...
For patients presenting with AIS an...
...esenting with AIS and a history of recent MI in...
...ts presenting with AIS and a history of recent...
...cute pericardit...
...th major AIS likely to produce severe disab...
...ts presenting with moderate AIS likely...
...ial or ventricular thrombus...
...r patients with major AIS likely to produce...
...r patients presenting with moderat...
...ardiac diseases...
...ents with major AIS likely to produ...
...ents presenting with major AIS likely to prod...
...trokeIV alteplase is reasonable for...
...malignancyThe safety and efficacy of IVb altepla...
...regnanc...
...alteplase administration may be considered in...
...and efficacy of IVb,d alteplase in t...
...thalmological conditionsUse of IV altepl...
...l diseaseIV alteplase for adults presenting with...
...ignIn patients with a hyperdense MCA sign...
...drug useTreating clinicians should be aw...
...risk of symptomatic intracranial he...
...raindications...
...āMild nondisabling strokeFor other...
...indowāMild nondisabling strokeFor otherwi...
...s insufficient evidence to identif...
...CHIV alteplase should NOT be administered to a p...
...emic stroke within 3 moUse of IV altepla...
...uma within 3 moIn AIS patients with recent sever...
...head traumaGiven the possibility of b...
...al/intraspinal surgery within 3 moFor p...
...story of intracranial hemorrhageIVb,d,e...
...achnoid hemorrhageIVb,d,e alteplase is contrai...
...malignancy or GI bleed within 21 dPatients with...
...opathyThe safety and efficacy of IV3 altepla...
...MWHIV alteplase should NOT be administered to...
...hibitors or factor Xa inhibitorsThe...
...oncomitant AbciximabAbciximab should NOT be a...
... aspirinIV aspirin should NOT be administered wit...
...ive endocarditisFor patients with A...
...ic arch dissectionIV alteplase in AISb,d,e...
...ial intracranial neoplasmIV alteplase t...
...ise specified, these eligibility recommen...
...able 6. Treatment of AIS: IV Administrat...
...nted from Jauch et al. Copyright Ā©...
...Other IV Fibrinolytics and Sonothrombolysis...
...nable to choose tenecteplase (sing...
...administered as a 0.4-mg/kg single IV bolus has n...
...tration of IV defibrinogenating agents or IV fib...
...use of sonothrombolysis as adjuvan...
3.7. Mechanical Thrombectomy
...oncomitant With IV Altep...
...ble for IV alteplase should receive IV alte...
...patients under consideration for mechanica...
....2. 0ā6 Hours From O...
...atients should receive mechanical thromb...
...aspiration thrombectomy as first-pass...
...benefits are uncertain, the use of mechanica...
...efits are uncertain, the use of mechanica...
...benefits are uncertain, the use of...
.... 6 to 24 Hours From On...
...ted patients with AIS within 6ā16 hour...
...elected patients with AIS within 16ā24 hou...
3.7.4. Techni...
...se of stent retrievers is indicated in p...
...hnical goal of the thrombectomy procedure s...
...enefit, reperfusion to mTICI grade 2b/3 sh...
...e 6- to 24-hour thrombectomy window ev...
...s reasonable to select an anesthetic technique dur...
...roximal balloon guide catheter or...
...tment of tandem occlusions (both extracranial and...
...fficacy of IV glycoprotein IIb/IIIa inhibitors...
...technical adjuncts, including intra-ar...
...7.5. Blood Pressure Ma...
...patients who undergo mechanical thrombectomy, it...
...undergo mechanical thrombectomy with succe...
...Other Endovascular Therapies...
...chanical thrombectomy with stent retrie...
...al fibrinolysis initiated within 6 hours of st...
.... Antiplatelet Treatment...
...tration of aspirin is recommended in pa...
In patients presenting with minor noncardioem...
...efficacy of the IV glycoprotein IIb...
...lor is NOT recommended over aspiri...
...tration of the IV glycoprotein IIb/IIIa inhibitor...
...NOT recommended as a substitute for acute str...
.... Anticoagulants...
...ulness of urgent anticoagulation in patients w...
...fety and usefulness of short-term anticoagu...
...esent, the usefulness of argatroban, dabigatran,...
...and usefulness of oral factor Xa inhibi...
...anticoagulation, with the goal of preventin...
...e Expansion/Hemodilution, Vasodilators, and He...
...on by volume expansion is NOT recommended...
...tion of high-dose albumin is NOT recomm...
...stration of vasodilatory agents, such as pentoxif...
...s to mechanically augment cerebral bloo...
...uroprotective Agents...
...rmacological or nonpharmacological t...
...Emergency Carotid Endarterectomy/Carotid Angi...
...efulness of emergent or urgent carotid endarterect...
...nts with unstable neurological status (eg, stro...
3.14. Other
...nial near-infrared laser therapy is NOT reco...
...anagement of AIS: General Supportive Care...
....1. Stroke Uni...
...of comprehensive specialized stroke care (str...
...he use of standardized stroke care order sets is...
...Head Positionin...
...e benefit of flat-head positioning early after...
...e: Recommendations in this section are...
...Supplemental Oxy...
...pport and ventilatory assistance are recommend...
...gen should be provided to maintain oxyge...
Supplemental oxygen is NOT recommende...
...mendation 1 in this section is repeated from S...
.... Blood Pressur...
...d hypovolemia should be corrected to maintain...
...ients with AIS, early treatment of...
...with BP ā„220/120 mm Hg who did not receive IV a...
...atients with BP
Note: Recommendations in this secti...
.... Temperature
...hyperthermia (temperature >38Ā°C) should be...
...with AIS, the benefit of treatment with induce...
...dations in this section are repeated from Sec...
...6. Glucose...
...oglycemia (blood glucose
...dicates that persistent in-hospital h...
....7. Dysphagia...
...agia screening before the patient begins ea...
...aluation is reasonable for those pati...
...is reasonable for dysphagia screening to be pe...
...well established which instrument to choose for...
...menting oral hygiene protocols to reduce...
....8. Nutritio...
...nteral diet should be started within 7 days of...
...th dysphagia, it is reasonable to initially...
...pplements are reasonable to consider for p...
...9. Deep Vein Thrombosis Prophy...
...stroke patients without contraindications, inter...
...efit of prophylactic-dose subcutaneous hepar...
...phylactic anticoagulation is used, the bene...
...stroke, elastic compression stockings should N...
...0. Depression Screening
...n of a structured depression inventory is recomme...
...ed with poststroke depression should be treat...
4.11. Oth...
...ring hospitalization and inpatient rehab...
...mended to minimize or eliminate skin fric...
...asonable for patients and families wit...
...use of prophylactic antibiotics has NOT been s...
...tine placement of indwelling bladder cathet...
....12. Rehabilitatio...
...mmended that early rehabilitation for...
...s recommended that stroke survivors r...
...recommended that all individuals with s...
...assessment by a clinician with exp...
...effectiveness of fluoxetine or other selecti...
...early mobilization within 24 hours o...
5. In-Hospital Management of AIS: Treatm...
...Brain Swelling...
.... General Recommendat...
...ents with large territorial cerebral a...
...sen the risk of swelling and close mo...
....2. Medical Managem...
...f osmotic therapy for patients with cl...
...f moderate hyperventilation (Pco2 targ...
...r barbiturates in the setting of ischemic cereb...
...ack of evidence of efficacy and the p...
...1.3. Surgical Management-Supratentorial I...
...the optimal trigger for decompressive craniec...
...0 years of age who deteriorate neurologicall...
...0 years of age who deteriorate neurologicall...
...rgical Management-Cerebellar Infarction...
...lostomy is recommended in the treatment of obs...
...boccipital craniectomy with dural expansion shou...
...dering decompressive suboccipital...
...Seizures...
...current seizures after stroke should be treat...
...ic use of antiseizure drugs is NOT recom...
...-Hospital Institution of Secondary Stroke Preventi...
.... Brain Imaging...
...f recurrent stroke, the use of MRI is reasonabl...
...n MRI is reasonable in selected patients as...
...ectiveness of routine brain MRI to guid...
....2. Vascular Imaging
...or patients with nondisabling (mRS score...
...of recurrent stroke, the use of intracrani...
...the intracranial vasculature to detect athero...
...g of the intracranial vasculature to detec...
...rocardiographic Monitoring...
...rdiac monitoring is recommended to s...
...effectiveness of prolonged cardiac...
...3.2. Echocardiograph...
...n of recurrent stroke, the use of ech...
...ography is reasonable in selected pa...
...e effectiveness of routine echocardiog...
.... Glucose...
...is reasonable to screen all patients...
...Other Tests for Secondary Prevention...
...ess of screening for thrombophilic states i...
...ening of patients with recent ischemic...
...ng for antiphospholipid antibodies is...
...reening for hyperhomocysteinemia amon...
...ntithrombotic Treatment
...Noncardioembolic Stroke
...r patients with noncardioembolic AIS...
...secondary prevention in patients with noncardi...
...nts who have a noncardioembolic AIS while taking...
...might be considered in patients who are found...
...or patients who have a noncardioembolic AIS...
...patients with noncardioembolic isc...
...2. Atrial Fibrillation...
For most patients with an AIS in the setting...
...ients with a history of ischemic strok...
...6.3. Arterial Dissecti...
...ith AIS and extracranial carotid or verte...
...ents with AIS and extracranial carotid or extracr...
...morrhagic Transformation...
...s with AIS and HT, initiation or c...
...Carotid Revascularization...
...hen revascularization is indicated f...
...ment of Hyperlipidemia...
...8.1. General Princip...
...S should be managed according to the 2...
...lts who are 20 years of age or older and...
...changes in lifestyle and effects of LDL-Cā...
....8.2. Choice of Lipid-lowering Drugs for Pa...
...who are 75 years of age or younger wit...
In patients with clinical ASCVD in whom hig...
...ncreased ASCVD risk with chronic, s...
...n patients with clinical ASCVD, who are j...
...h clinical ASCVD who are judged to be very high r...
...id-2018 list prices, PCSK9 inhibitors have a low...
...ients with clinical ASCVD who are on max...
...patients older than 75 years of a...
...lder than 75 years of age who are tol...
...with clinical ASCVD who are receiving max...
...CVD includes acute coronary syndrome,...
.... Risk StatusHaving trouble viewing...
...Implementation...
...inician-patient risk discussion is recommended b...
...h indication for statin therapy, iden...
...ents with statin-associated side effec...
...increased ASCVD risk with severe st...
6.8.4. Tim...
...patients already taking statins at the time...
...patients with AIS who qualify for statin...
6.8.5 Special Patient G...
...childbearing age who are treated with stati...
...ldbearing age with hypercholesterolemia w...
...ith advanced kidney disease that requi...
In adults with advanced kidney dis...
...nstitution of Antihypertensive Medications...
...g or restarting antihypertensive th...
...moking Cessation Intervention...
...S should receive in-hospital initi...
...mokers with an AIS, who receive in-hospi...
...ders should strongly advise every patie...
...sonable to advise patients after ischemic stroke t...
...an AIS, in-hospital initiation of...
....11. Stroke Education
...ent education about stroke is recommended....