Early Management of Patients With Acute Ischemic Stroke
Key Points
Key Points
Treatment
...atment...
...ospital Stroke Management and Systems of...
....1. Prehospital Systems
...health leaders, along with medical profes...
...ional programs should be designed to spe...
...ation of the 9-1-1 system by patients or ot...
1.2. EMS Assessment and M...
...troke assessment tool by first aid provid...
...nnel should provide prehospital notificatio...
...3. EMS Systems
...systems of stroke care should be developed...
...MS leaders, in coordination with local, regional,...
...with a positive stroke screen or who...
...several IV alteplase-capable hospita...
...prehospital procedures to identify patients who...
...tal Stroke Capabilities...
...ertification of stroke centers by an ind...
....5. Hospital Stroke Tea...
...ed protocol for the emergency evaluation of patien...
...gnation of an acute stroke team that includes p...
...onent quality improvement initiatives...
...ed that stroke systems of care be develo...
...ablishing and monitoring target time...
.... Telemedici...
...hout in-house imaging interpretation expe...
...mented within a telestroke network, teleradiolog...
...elemedicine/telestroke resources and systems...
...stroke/teleradiology evaluations of...
...ration of IV alteplase guided by telestr...
...lestroke networks may be reasonable f...
...alteplase decision-making support via telephone...
...ion and Integration of Components...
...caring for stroke patients within a stroke...
...ifferent services within a hospital...
...thrombectomy requires the patient to be at...
...be useful for primary stroke centers and ot...
...y be useful for government agencies and t...
...ishment of Data Repositories...
...ation in a stroke data repository is rec...
...em Care Quality Improvement Process...
...institutions should organize a multidisciplinary...
...outcome measures should include adjustments...
...inuous quality improvement processes, implemented...
...cy Evaluation and Treatment...
2.1. Stroke Sc...
...stroke severity rating scale, preferabl...
...al Institutes of Health Stroke Scale...
...d and Neck Imaging...
...2.1. Initial Imagin...
...patients with suspected acute stroke should re...
...e established so that brain imaging studies can be...
...ontrast CT (NCCT) is effective to exclude...
...esonance (MR) imaging (MRI) is effective to e...
...r MR angiography (MRA) with diffusion-w...
.... IV Alteplase Eligibility...
...ministration of IV alteplase in eli...
...ible for IV alteplase, because benefit o...
...h AIS who awake with stroke symptoms...
.... Mechanical Thrombectomy Eligibility–Vesse...
...patients who otherwise meet criteria for mec...
...with suspected LVO who have not had non...
...tients with suspected intracranial LV...
...tients who are potential candidates for mechanica...
...reasonable to incorporate collateral flow sta...
...nical Thrombectomy Eligibility–Multimodal I...
...ecting patients with AIS within 6–24 hours of l...
...patients with AIS within 6 hours of l...
...Other Diagnostic Tests...
...he assessment of blood glucose must...
...trocardiographic assessment is recommended in pa...
Baseline troponin assessment is recommen...
...efulness of chest radiographs in the h...
...eneral Supportive Care and Emergency Treatm...
...Airway, Breathing, and Oxyge...
...ort and ventilatory assistance are recommende...
...plemental oxygen should be provided to...
...al oxygen is NOT recommended in non-hypoxic pati...
...erbaric oxygen (HBO) is NOT recommended for patien...
....2. Blood Pressure
...tension and hypovolemia should be c...
...ve elevated BP and are otherwise e...
...tients for whom mechanical thrombectomy is pla...
...e usefulness of drug-induced hypertension...
...s to Treat Arterial Hypertension in Pat...
...Temperature...
...ces of hyperthermia (temperature >38°C) should b...
...nts with AIS, the benefit of treatment with indu...
3.4. Blood Gluc...
Hypoglycemia (blood glucose...
...e indicates that persistent in-hospital hypergl...
...5. IV Altepl...
....5.1. General Principles...
...eligible for IV alteplase, benefit of therapy...
...ents undergoing fibrinolytic therapy, ph...
...al risks should be discussed durin...
...ing clinicians should be aware tha...
...ecause time from onset of symptoms to treat...
...5.2. Time Windows
...eplase (0.9 mg/kg, maximum dose 90 mg over...
....9 mg/kg, maximum dose 90 mg over 60 minute...
...(0.9 mg/kg, maximum dose 90 mg ove...
...5.3. Mild St...
...otherwise eligible patients with mild...
...herwise eligible patients with mild...
...eligible patients with mild nondi...
For otherwise eligible patients with mild...
...r Specific Circumstances...
...plase for adults presenting with an AIS with kno...
...tients with a hyperdense MCA sign, IV alteplas...
3.5.5. Bleeding Ris...
...ven the extremely low risk of unsuspect...
...n otherwise eligible patients who have previously...
...eligible patients who have previo...
...ficacy of the IV glycoprotein IIb/IIIa inhibito...
...ould NOT be administered concurrently with I...
...d NOT be administered within 90 minutes after the...
...hould NOT be administered to patient...
....5.6. Post-alteplase Treatmen...
...should be maintained at
...he risk of antithrombotic therapy (other than I...
...Management of Symptomatic Intracranial Bleedin...
...gement of Orolingual Angioedema Associa...
...ligibility Recommendations for IV Alte...
Indicatio...
...haIVb alteplase (0.9 mg/kg, maximum dose 90 m...
Within 3 h–AgeFor otherwise medi...
...–Severe strokeFor severe stroke, IVb alteplas...
...“Mild disabling strokeFor otherwise eligible p...
...4.5 haIVb,d alteplase (0.9 mg/kg,...
...5 h–AgeIV alteplase treatment in the 3-...
...ment should be initiated as quickly as...
...teplase is recommended in patients with BP...
...od glucoseIVb alteplase is recommended in ot...
...dministration is recommended in the...
...rior antiplatelet therapy...
...recommended for patients taking antiplatelet drug...
...alteplase is recommended for patients taking anti...
...renal diseaseIn patients with end-sta...
...mendations for treatment with IV a...
....5 h–AgeFor patients >80 y of age presen...
...Diabetes mellitus and prior stroke...
...4.5 h–Severe strokeThe benefit of IV...
...h–Mild disabling strokeFor otherwis...
...nd unknown time of onsetIV alteplase (0.9...
...reexisting disab...
...isting disability does not seem to independently i...
...preexisting dementia may benefit f...
Early improvementIVb alteplase trea...
...izure at onsetIVb,d alteplase is reaso...
...glucoseTreatment with IV alteplase in patients wi...
...agulopathy...
...lteplase may be reasonable in patients who have a...
...and efficacy of IV alteplase for acute...
...ral punctureIV alteplase may be considered for pa...
...l punctureThe safety and efficacy...
...jor traumaIn AIS patients with recent ma...
...geryUse of IV alteplase in carefully sel...
...nd genitourinary bleedingReported li...
...nstruation
...s probably indicated in women who are menstruating...
...is a history of recent or active vaginal bleeding...
...potential benefits of IV alteplase prob...
...racranial cervical dissectionsIV alteplase i...
...ial arterial dissectionIV alteplase...
...tured intracranial aneu...
...presenting with AIS who are known to harbo...
...ess and risk of IV alteplase in patients with...
...cranial vascular malformation...
...ents presenting with AIS who are k...
...the increased risk of ICH in this popula...
...MBs...
...e eligible patients who have previously ha...
...rwise eligible patients who have pre...
...comitant tirofiban, eptifibatideThe e...
...xtra-axial intracranial neoplasmsIV alteplas...
...te MIFor patients presenting with concurr...
...ent MI...
...patients presenting with AIS and a...
...nts presenting with AIS and a history...
...presenting with AIS and a history of recent...
...pericarditis...
...ts with major AIS likely to produce se...
...ts presenting with moderate AIS likely to...
...rial or ventricular thrombus...
...s with major AIS likely to produce sever...
...patients presenting with moderate AIS...
...her cardiac diseases...
...ients with major AIS likely to produce severe disa...
...resenting with major AIS likely to produ...
...ocedural strokeIV alteplase is reasonable for the...
...ystemic malignancyThe safety and effi...
Pregnanc...
...teplase administration may be considered...
...afety and efficacy of IVb,d alteplase in the e...
...al conditionsUse of IV alteplase in...
...le cell diseaseIV alteplase for adults pr...
...se MCA signIn patients with a hyperdense MCA sign,...
...eTreating clinicians should be aware tha...
Stroke mimicsThe risk of symptomatic intracran...
...aindications...
...to 3-h window–Mild nondisabling...
...to 4.5-h window–Mild nondisabling st...
...TThere remains insufficient evidence to...
...IV alteplase should NOT be administered to a...
...oke within 3 moUse of IV alteplase in patients pr...
...ad trauma within 3 moIn AIS patients with...
...aGiven the possibility of bleeding compl...
...cranial/intraspinal surgery within 3 moFor...
...tracranial hemorrhageIVb,d,e alteplase admin...
...id hemorrhageIVb,d,e alteplase is contra...
...GI bleed within 21 dPatients with a structu...
...athyThe safety and efficacy of IV3 alteplase f...
...IV alteplase should NOT be administered to p...
...ombin inhibitors or factor Xa inhibitorsThe use o...
...bciximabAbciximab should NOT be administered...
...IVÂ aspirinIV aspirin should NOT be admini...
...carditisFor patients with AIS and symptoms consis...
...arch dissectionIV alteplase in AISb,d,e known or...
...ntracranial neoplasmIV alteplase tre...
...otherwise specified, these eligibil...
...ble 6. Treatment of AIS: IV Administrati...
...rinted from Jauch et al. Copyright © 2013, Ame...
...Fibrinolytics and Sonothrombolysi...
...y be reasonable to choose tenecteplase (sing...
...plase administered as a 0.4-mg/kg single IV bolu...
...he administration of IV defibrinogen...
...thrombolysis as adjuvant therapy with IV fi...
.... Mechanical Thrombectom...
3.7.1. Concomitant With IV A...
...ents eligible for IV alteplase should receive...
...er consideration for mechanical thrombect...
...€“6 Hours From Onset
...should receive mechanical thrombectomy wit...
...aspiration thrombectomy as first-pass mech...
...efits are uncertain, the use of mechanical throm...
...ts benefits are uncertain, the use of mechanic...
...ugh the benefits are uncertain, the use of mec...
...3. 6 to 24 Hours From Onse...
...lected patients with AIS within 6–16...
...d patients with AIS within 16–24 hours of...
....7.4. Techni...
Use of stent retrievers is indicated in preference...
...e technical goal of the thrombectomy...
...ensure benefit, reperfusion to mTICI...
...o 24-hour thrombectomy window evaluation and tre...
...to select an anesthetic technique during EVT for...
...oximal balloon guide catheter or a large-b...
...tandem occlusions (both extracranial and int...
...nd efficacy of IV glycoprotein IIb/II...
...vage technical adjuncts, including intra-...
...Blood Pressure Management...
...s who undergo mechanical thrombectomy, it is...
...tients who undergo mechanical thrombectomy wi...
...Other Endovascular Therapies...
...cal thrombectomy with stent retrievers is recommen...
...arterial fibrinolysis initiated within 6 hours...
...Antiplatelet Treatment...
...ration of aspirin is recommended in pa...
In patients presenting with minor noncardioembo...
...cy of the IV glycoprotein IIb/IIIa inhibito...
...NOT recommended over aspirin for treatmen...
...ministration of the IV glycoprotein IIb/IIIa inh...
...rin is NOT recommended as a substitute for acute...
3.10. Anticoagu...
...efulness of urgent anticoagulation in pa...
...usefulness of short-term anticoagulation fo...
...nt, the usefulness of argatroban, d...
...ety and usefulness of oral factor Xa inhibit...
...oagulation, with the goal of preventing earl...
...Volume Expansion/Hemodilution, Vaso...
...by volume expansion is NOT recommended f...
...on of high-dose albumin is NOT recomme...
...ation of vasodilatory agents, such as...
...s to mechanically augment cerebral blo...
...Neuroprotective Age...
...ent, pharmacological or nonpharmacological tre...
...gency Carotid Endarterectomy/Carotid A...
...sefulness of emergent or urgent carotid...
...patients with unstable neurological status (eg,...
...4. Other...
...anial near-infrared laser therapy is NO...
4. In-Hospital Management of AIS: General Sup...
4.1. Stroke...
...comprehensive specialized stroke care (str...
...of standardized stroke care order...
....2 Head Positio...
...of flat-head positioning early after...
...mmendations in this section are repeated from...
...pplemental Oxygen...
...and ventilatory assistance are recommended for...
Supplemental oxygen should be provided to ma...
...l oxygen is NOT recommended in nonhypo...
...tion 1 in this section is repeated from Secti...
4.4. Blood Pressu...
...potension and hypovolemia should be...
...atients with AIS, early treatment of hyperten...
...tients with BP ≥220/120 mm Hg wh...
...tients with BP...
...: Recommendations in this section are repe...
4.5. Temperature
...hyperthermia (temperature >38°C) sh...
...atients with AIS, the benefit of treatm...
Note: Recommendations in this section are...
.... Glucose...
...glycemia (blood gluc...
...icates that persistent in-hospital hypergl...
.... Dysphagia...
...phagia screening before the patient begins eating...
...endoscopic evaluation is reasonable for those pat...
It is reasonable for dysphagia screening to be pe...
...ot well established which instrument to choos...
...ng oral hygiene protocols to reduce the risk of...
4.8. Nutri...
...ral diet should be started within 7...
...ients with dysphagia, it is reasonable to ini...
...pplements are reasonable to consider for p...
.... Deep Vein Thrombosis Prophylaxis...
...e stroke patients without contraindications...
...of prophylactic-dose subcutaneous heparin (unfra...
...en prophylactic anticoagulation is...
...mic stroke, elastic compression stockings s...
...epression Screening...
...inistration of a structured depression...
...diagnosed with poststroke depression should...
...11. Other...
...pitalization and inpatient rehabilitation, regu...
...t is recommended to minimize or eliminat...
...is reasonable for patients and families...
...of prophylactic antibiotics has NOT bee...
...ent of indwelling bladder catheters should NOT...
....12. Rehabilita...
...nded that early rehabilitation for hospit...
...d that stroke survivors receive rehabilitati...
...nded that all individuals with stroke be...
...nctional assessment by a clinician with exp...
...fectiveness of fluoxetine or other selectiv...
...h-dose, very early mobilization within 2...
...al Management of AIS: Treatment of Acute Complica...
...rain Swelling...
...1.1. General Recommendations...
...large territorial cerebral and cer...
...en the risk of swelling and close monitoring of th...
5.1.2. Medical Manageme...
...f osmotic therapy for patients with clinical dete...
...moderate hyperventilation (Pco2 target, 3...
...pothermia or barbiturates in the setting of isch...
...a lack of evidence of efficacy and th...
...3. Surgical Management-Supratentorial Infarction...
...gh the optimal trigger for decompressive cran...
...tients ≤60 years of age who deter...
...years of age who deteriorate neurologically w...
...rgical Management-Cerebellar Infarction...
...culostomy is recommended in the treatment of obstr...
...ve suboccipital craniectomy with dural expansi...
...ering decompressive suboccipital craniectom...
.... Seizures...
...zures after stroke should be treat...
...phylactic use of antiseizure drugs is NOT r...
.... In-Hospital Institution of Secondary St...
...Brain Imaging...
...revention of recurrent stroke, the use...
...s reasonable in selected patients as part of a co...
The effectiveness of routine brain MRI...
.... Vascular Imagi...
...atients with nondisabling (mRS score 0â...
...on of recurrent stroke, the use of intr...
...the intracranial vasculature to detect...
...imaging of the intracranial vasculat...
...1. Electrocardiographic Mo...
...nitoring is recommended to screen for atrial...
...effectiveness of prolonged cardiac monitoring duri...
.... Echocardiography...
...tion of recurrent stroke, the use of echocardi...
...phy is reasonable in selected patients as part...
...veness of routine echocardiography to guid...
....4. Glucose...
...r AIS, it is reasonable to screen all patients...
6.5. Other Tests for Secondary Pr...
...lness of screening for thrombophil...
...ng of patients with recent ischemic stroke fo...
...utine testing for antiphospholipid antibod...
...ening for hyperhomocysteinemia among patients...
...ithrombotic Treatment
....6.1. Noncardioemboli...
For patients with noncardioembolic AIS, the use o...
...r early secondary prevention in patients with...
...nts who have a noncardioembolic AI...
...icoagulation might be considered in patient...
...patients who have a noncardioembolic...
In patients with noncardioembolic ische...
...trial Fibrillation...
...nts with an AIS in the setting of atr...
...patients with a history of ischemic stroke,...
...3. Arterial Dissect...
...atients with AIS and extracranial carotid or verte...
...s with AIS and extracranial carotid or extracr...
.... Hemorrhagic Transformation...
For patients with AIS and HT, initiation or cont...
...otid Revascularizatio...
...zation is indicated for secondary...
...reatment of Hyperlipidemia...
.... General Principl...
Patients with AIS should be managed a...
...who are 20 years of age or older and not o...
...changes in lifestyle and effects of LDL-C–...
....8.2. Choice of Lipid-lowering Drug...
...n patients who are 75 years of age...
...atients with clinical ASCVD in whom high-intensity...
...tients at increased ASCVD risk with chronic...
...nts with clinical ASCVD, who are judged to be v...
...patients with clinical ASCVD who are judged...
...018 list prices, PCSK9 inhibitors have a low-cost...
...th clinical ASCVD who are on maxima...
...ents older than 75 years of age with clinic...
In patients older than 75 years of age who...
...patients with clinical ASCVD who are rece...
...aASCVD includes acute coronary syndrome, t...
...sk StatusHaving trouble viewing table? Exp...
....3 Implementation...
...ent risk discussion is recommended bef...
In patients with indication for statin therapy, i...
...with statin-associated side effect...
...atients at increased ASCVD risk with se...
6.8.4. Timin...
...ients already taking statins at the time of onset...
...r patients with AIS who qualify for...
....5 Special Patient Groups...
...en of childbearing age who are treated w...
...of childbearing age with hyperchol...
...ith advanced kidney disease that requires...
...advanced kidney disease who require...
...stitution of Antihypertensive Medications...
...rting or restarting antihypertensive the...
...0. Smoking Cessation Intervention
...with AIS should receive in-hospital initiation...
...ith an AIS, who receive in-hospital initiation o...
...re providers should strongly advise ever...
...easonable to advise patients after i...
...smokers with an AIS, in-hospital initiation of...
6.11. Stroke Educ...
...tion about stroke is recommended. Patient...