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

...reatme...

...spital Stroke Management and Systems...

...1. Prehospital System...

...eaders, along with medical professionals and...

...ational programs should be designed to...

...ivation of the 9-1-1 system by patien...

...EMS Assessment and Management...

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

...should provide prehospital notification to the rec...

...3. EMS System...

...ems of stroke care should be develop...

...in coordination with local, regional, and state ag...

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

...V alteplase-capable hospital options exist wi...

...ospital procedures to identify patients who...

...ospital Stroke Capabilities...

...ication of stroke centers by an independent extern...

.... Hospital Stroke Teams...

...anized protocol for the emergency evaluation o...

Designation of an acute stroke team that includ...

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

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

...ishing and monitoring target time g...

...6. Telemedicine

...thout in-house imaging interpretation expertise, t...

...ed within a telestroke network, te...

...telemedicine/telestroke resources and systems...

...stroke/teleradiology evaluations of AIS pati...

Administration of IV alteplase guided by t...

...networks may be reasonable for triaging patients...

...ding alteplase decision-making support via te...

....7. Organization and Integration of Components

...caring for stroke patients within a stroke syste...

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

...nical thrombectomy requires the patient to be at...

...for primary stroke centers and other healt...

...ay be useful for government agencies and third-pa...

...blishment of Data Repositories...

...tion in a stroke data repository is...

...stem Care Quality Improvement Process...

...stitutions should organize a multidisciplinary...

Stroke outcome measures should include adjustm...

...us quality improvement processes, imple...


...gency Evaluation and Treatm...

.... Stroke Scal...

...oke severity rating scale, preferably the NIHS...

...1. National Institutes of Health Stroke Scale...

...d and Neck Imaging...

2.2.1. Initial Im...

...nts with suspected acute stroke should receive eme...

...stems should be established so that bra...

...trast CT (NCCT) is effective to exclu...

...esonance (MR) imaging (MRI) is effective to ex...

...MR angiography (MRA) with diffusion-...

...IV Alteplase Eligibility...

...nistration of IV alteplase in eligible p...

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

...nts with AIS who awake with stroke symptoms...

...2.3. Mechanical Thrombectomy Eligibility–...

...otherwise meet criteria for mechanical t...

...ts with suspected LVO who have not had...

...ents with suspected intracranial LVO and no...

...n patients who are potential candidates for mec...

...may be reasonable to incorporate collater...

...chanical Thrombectomy Eligibility–Multimodal...

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

...hen evaluating patients with AIS within 6 ho...

....3. Other Diagnostic...

...essment of blood glucose must precede the initi...

...ne electrocardiographic assessment is re...

...troponin assessment is recommended in patients...

...ss of chest radiographs in the hyperacute strok...


...General Supportive Care and Emergency Trea...

....1. Airway, Breathing, and Oxygenatio...

...t and ventilatory assistance are recommended for...

...ntal oxygen should be provided to mainta...

...ntal oxygen is NOT recommended in n...

...yperbaric oxygen (HBO) is NOT recommen...

...Blood Pressure...

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

...ave elevated BP and are otherwise eligible for tre...

...ients for whom mechanical thrombectomy is pla...

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

...tions to Treat Arterial Hypertension in Patie...

...Temperature...

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

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

.... Blood Glucos...

...oglycemia (blood gluc...

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

.... IV Alteplase...

....1. General Princi...

...patients eligible for IV alteplase,...

...patients undergoing fibrinolytic therapy,...

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

...eating clinicians should be aware that hypogl...

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

...Time Windows...

...teplase (0.9 mg/kg, maximum dose 90 mg ov...

...lteplase (0.9 mg/kg, maximum dose 9...

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

....5.3. Mild Stroke...

...igible patients with mild but disabling stroke sy...

...igible patients with mild disabling st...

...otherwise eligible patients with mild non...

...or otherwise eligible patients wit...

...5.4. Other Specific Circumstanc...

...r adults presenting with an AIS wi...

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

....5.5. Bleeding Ri...

...tremely low risk of unsuspected abnor...

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

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

...y of the IV glycoprotein IIb/IIIa inhibitors...

...hould NOT be administered concurrently...

...in should NOT be administered within 90 minute...

...ould NOT be administered to patients who ha...

...st-alteplase Treatment...

...hould be maintained at

...risk of antithrombotic therapy (other than IV as...

...3. Management of Symptomatic Intracrania...

...Management of Orolingual Angioedema Asso...

...commendations for IV Alteplase in Patients Wit...

...dications

...n 3 haIVb alteplase (0.9 mg/kg, maxi...

...h–AgeFor otherwise medically eligible pati...

...Severe strokeFor severe stroke, IVb altepla...

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

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

....5 h–AgeIV alteplase treatment in the 3...

...cyTreatment should be initiated as quic...

...ase is recommended in patients with BP...

...d glucoseIVb alteplase is recommended...

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

...or antiplatelet therapy...

...se is recommended for patients taking antiplate...

...lase is recommended for patients takin...

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

...commendations for treatment with IV alteplase fo...

...For patients >80 y of age presenting in the 3-...

...h–Diabetes mellitus and prior strokeI...

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

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

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

...eexisting disability...

Preexisting disability does not seem to independe...

...eexisting dementia may benefit from...

...y improvementIVb alteplase treatment is reas...

...izure at onsetIVb,d alteplase is rea...

...glucoseTreatment with IV alteplase in...

...gulopathy...

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

...he safety and efficacy of IV alteplase for...

...l punctureIV alteplase may be considered fo...

...erial punctureThe safety and efficac...

...raumaIn AIS patients with recent major trauma (...

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

...I and genitourinary bleedingReporte...

...struation...

...plase is probably indicated in women wh...

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

...tential benefits of IV alteplase probab...

...acranial cervical dissectionsIV altepl...

...erial dissectionIV alteplase usefulness...

...ptured intracranial aneurysm...

...resenting with AIS who are known to harbor...

...ss and risk of IV alteplase in patients w...

...ial vascular malformations...

...r patients presenting with AIS who are known to...

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

CMB...

In otherwise eligible patients who have previousl...

...ise eligible patients who have pre...

...ncomitant tirofiban, eptifibatideThe efficacy...

...l intracranial neoplasmsIV alteplase trea...

...ute MIFor patients presenting with concurrent...

...ecent MI

...r patients presenting with AIS and a history...

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

...ents presenting with AIS and a history of...

...te pericarditis...

...s with major AIS likely to produce severe disab...

...atients presenting with moderate AIS likely...

...al or ventricular thrombus...

...nts with major AIS likely to produce severe disab...

...resenting with moderate AIS likely...

...cardiac diseases...

...patients with major AIS likely to produce...

...s presenting with major AIS likely to produce sev...

...rocedural strokeIV alteplase is reas...

...gnancyThe safety and efficacy of IVb altepla...

...egnancy...

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

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

...mological conditionsUse of IV alteplase in patie...

...iseaseIV alteplase for adults present...

...CA signIn patients with a hyperdense MCA...

...eTreating clinicians should be aware...

...e mimicsThe risk of symptomatic intracr...

...ntraindicatio...

...window–Mild nondisabling strokeFor otherwis...

...ow–Mild nondisabling strokeFor other...

...insufficient evidence to identify a threshold o...

...e should NOT be administered to a pat...

...mic stroke within 3 moUse of IV alteplas...

...vere head trauma within 3 moIn AIS patients with...

...te head traumaGiven the possibility of bleeding co...

...traspinal surgery within 3 moFor pati...

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

...noid hemorrhageIVb,d,e alteplase is...

...or GI bleed within 21 dPatients with a...

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

...lteplase should NOT be administere...

...inhibitors or factor Xa inhibitorsThe...

...tant AbciximabAbciximab should NOT be admini...

...ant IV aspirinIV aspirin should NO...

...e endocarditisFor patients with AIS and symptoms c...

...tic arch dissectionIV alteplase in AIS...

...al intracranial neoplasmIV alteplase treatment fo...

...otherwise specified, these eligibili...

...ment of AIS: IV Administration of Alt...

...rom Jauch et al. Copyright © 2013,...

...ther IV Fibrinolytics and Sonothrombolysi...

...asonable to choose tenecteplase (single IV bolus...

...ase administered as a 0.4-mg/kg single IV bolus h...

...administration of IV defibrinogenatin...

...sonothrombolysis as adjuvant therapy with...

...hanical Thrombectomy

...oncomitant With IV Alteplase...

...gible for IV alteplase should rece...

...tients under consideration for mechanical thromb...

...–6 Hours From Onset...

...nts should receive mechanical thrombectomy w...

Direct aspiration thrombectomy as first-pass me...

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

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

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

...to 24 Hours From Onset...

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

...selected patients with AIS within 16–24 ho...

....7.4. Techniqu...

...retrievers is indicated in preference to the Mec...

...ical goal of the thrombectomy procedu...

...nefit, reperfusion to mTICI grade 2b/3 should be...

...6- to 24-hour thrombectomy window evaluation and...

...able to select an anesthetic techniq...

...e use of a proximal balloon guide catheter or a la...

Treatment of tandem occlusions (both extracran...

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

...of salvage technical adjuncts, including intra-a...

....7.5. Blood Pressure Managem...

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

...ients who undergo mechanical thrombectomy with su...

...Endovascular Therapies...

...hanical thrombectomy with stent retrie...

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

...platelet Treatment...

...istration of aspirin is recommended in patient...

...patients presenting with minor noncardioembolic...

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

...is NOT recommended over aspirin for treatment of p...

...e administration of the IV glycoprotein...

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

...Anticoagulants...

...of urgent anticoagulation in patients with sev...

...safety and usefulness of short-term...

...t, the usefulness of argatroban, dabigatran, or o...

...and usefulness of oral factor Xa inhibitors...

...nticoagulation, with the goal of prevent...

...pansion/Hemodilution, Vasodilators, and Hem...

...n by volume expansion is NOT recomm...

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

...on of vasodilatory agents, such as p...

...es to mechanically augment cerebral...

...uroprotective Agents...

...present, pharmacological or nonpharmac...

....13. Emergency Carotid Endarterectomy/Ca...

...f emergent or urgent carotid endarterectomy (C...

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

...4. Other...

...nscranial near-infrared laser therapy is...


...Management of AIS: General Supporti...

.... Stroke Units...

...ehensive specialized stroke care (st...

The use of standardized stroke care order sets...

...ad Positioning...

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

...e: Recommendations in this section...

...upplemental Oxygen...

...rt and ventilatory assistance are recommended...

...lemental oxygen should be provided t...

...mental oxygen is NOT recommended in nonhypoxic p...

...ation 1 in this section is repeate...

...4. Blood Pressure...

...otension and hypovolemia should be corrected to...

...with AIS, early treatment of hyper...

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

...patients with...

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

...5. Temperature...

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

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

...mendations in this section are repeated...

...6. Glucose...

...oglycemia (blood gluco...

...indicates that persistent in-hospit...

...Dysphagia...

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

...doscopic evaluation is reasonable for thos...

...for dysphagia screening to be perf...

...established which instrument to choose for eva...

...enting oral hygiene protocols to re...

4.8. Nutritio...

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

...or patients with dysphagia, it is reasonable to...

...pplements are reasonable to consider for p...

...p Vein Thrombosis Prophylaxis...

...immobile stroke patients without contrain...

...prophylactic-dose subcutaneous hepari...

...prophylactic anticoagulation is use...

...emic stroke, elastic compression stockings sho...

4.10. Depression Scre...

...tion of a structured depression invento...

...iagnosed with poststroke depression s...

4.11. Oth...

...g hospitalization and inpatient rehabilitatio...

It is recommended to minimize or eliminate...

...le for patients and families with s...

...f prophylactic antibiotics has NOT been shown to b...

...cement of indwelling bladder catheters...

4.12. Rehabilitat...

...is recommended that early rehabilitation...

...ended that stroke survivors receive rehabilita...

...s recommended that all individuals with st...

...ssessment by a clinician with expertise in rehabil...

...veness of fluoxetine or other sele...

...y early mobilization within 24 hours of stroke...


...n-Hospital Management of AIS: Treatment of Acute...

...rain Swelling...

...1.1. General Recommendations

...atients with large territorial cerebral and cerebe...

...o lessen the risk of swelling and close monit...

....2. Medical Managem...

...smotic therapy for patients with clinical...

...e of brief moderate hyperventilation (Pco2 targe...

...or barbiturates in the setting of ischem...

...e of a lack of evidence of efficacy a...

...urgical Management-Supratentorial Infar...

...ptimal trigger for decompressive craniect...

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

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

...Management-Cerebellar Infarction...

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

...suboccipital craniectomy with dural expansion sho...

...sidering decompressive suboccipital craniectom...

....2. Seizures...

...rent seizures after stroke should be t...

...phylactic use of antiseizure drugs is NOT...


6. In-Hospital Institution of Secondary Str...

6.1. Brain I...

...prevention of recurrent stroke, t...

Brain MRI is reasonable in selected patients...

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

....2. Vascular I...

...patients with nondisabling (mRS score 0...

...evention of recurrent stroke, the use o...

...intracranial vasculature to detect ather...

...imaging of the intracranial vasculatu...

.... Electrocardiographic Monitoring...

Cardiac monitoring is recommended to sc...

...ss of prolonged cardiac monitoring during hospita...

....2. Echocardiogra...

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

...iography is reasonable in selected patients...

...ess of routine echocardiography to guide treatmen...

...4. Glucos...

...it is reasonable to screen all patient...

...Other Tests for Secondary Prev...

...he usefulness of screening for throm...

...ening of patients with recent ischemic stro...

...testing for antiphospholipid antibodies i...

...ning for hyperhomocysteinemia among pa...

...Antithrombotic Treatmen...

6.6.1. Noncardioembolic Stro...

...ents with noncardioembolic AIS, the use o...

...secondary prevention in patients with non...

...who have a noncardioembolic AIS while t...

Anticoagulation might be considered in patients wh...

...atients who have a noncardioemboli...

In patients with noncardioembolic ischemic stroke...

....2. Atrial Fibrillat...

...nts with an AIS in the setting of atrial fibri...

...ts with a history of ischemic stroke, atrial...

...6.3. Arterial Dissection

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

...atients with AIS and extracranial carotid or extr...

....4. Hemorrhagic Transform...

...th AIS and HT, initiation or continuation of anti...

...Carotid Revascularization...

...revascularization is indicated for secondary...

....8. Treatment of Hyperli...

...8.1. General Principle...

...ients with AIS should be managed according to the...

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

...nce to changes in lifestyle and effects o...

...of Lipid-lowering Drugs for Patients wi...

...ho are 75 years of age or younger with cli...

...s with clinical ASCVD in whom high...

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

...clinical ASCVD, who are judged to b...

...ts with clinical ASCVD who are judged to be ve...

...list prices, PCSK9 inhibitors have a low-cost va...

...ith clinical ASCVD who are on maximal...

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

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

...ts with clinical ASCVD who are receiving m...

...SCVD includes acute coronary syndrom...

...Risk StatusHaving trouble viewing tab...

...3 Implementation...

...patient risk discussion is recommended before i...

...ients with indication for statin therapy, ident...

...s with statin-associated side effects tha...

...nts at increased ASCVD risk with s...

....8.4. Timi...

...ients already taking statins at the time of ons...

...tients with AIS who qualify for sta...

....5 Special Patient Groups...

...dbearing age who are treated with statin therap...

...f childbearing age with hypercholesterole...

...with advanced kidney disease that re...

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

...tion of Antihypertensive Medications...

...tarting or restarting antihypertensive...

...Smoking Cessation Intervention

...IS should receive in-hospital initiation of high-...

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

...oviders should strongly advise eve...

...e to advise patients after ischemic st...

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

...Stroke Education...

...ducation about stroke is recommended....