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

...atment...

...ital Stroke Management and Systems of Car...

...1. Prehospital Syst...

...ic health leaders, along with medical...

...tional programs should be designed to speci...

...f the 9-1-1 system by patients or other mem...

...ssessment and Management...

...f a stroke assessment tool by first aid provide...

...should provide prehospital notificati...

.... EMS Systems...

...ional systems of stroke care should be deve...

EMS leaders, in coordination with local, re...

Patients with a positive stroke screen or who...

...eral IV alteplase-capable hospital opt...

...fective prehospital procedures to identify patie...

...Hospital Stroke Capabilities...

...of stroke centers by an independent...

...Hospital Stroke Tea...

...rganized protocol for the emergency evaluat...

...f an acute stroke team that include...

...ent quality improvement initiatives...

...is recommended that stroke systems of care be dev...

...stablishing and monitoring target ti...

...Telemedicine...

...tes without in-house imaging interpretation...

...lemented within a telestroke network, telera...

...e of telemedicine/telestroke resources and syste...

...leradiology evaluations of AIS patients can be e...

...ration of IV alteplase guided by telest...

...estroke networks may be reasonable...

...alteplase decision-making support via telep...

...Organization and Integration of Compo...

...ll hospitals caring for stroke patients withi...

...services within a hospital that may be t...

...hanical thrombectomy requires the pa...

...e useful for primary stroke centers and ot...

...l for government agencies and third-party payers...

1.8. Establishment of Data Repositor...

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

...Stroke System Care Quality Improvement Proces...

...re institutions should organize a multid...

...come measures should include adjustments fo...

...inuous quality improvement processes...


...Emergency Evaluation and Treatmen...

...Stroke Scale...

...troke severity rating scale, preferabl...

Table 1. National Institutes of Health Stroke Sc...

...d and Neck Imaging...

2.2.1. Initial Imagi...

...patients with suspected acute strok...

...should be established so that brain imaging...

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

...netic resonance (MR) imaging (MRI) is effective t...

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

...IV Alteplase Eligibili...

...n of IV alteplase in eligible patients...

...igible for IV alteplase, because benefit o...

...ith AIS who awake with stroke symptoms or have u...

...chanical Thrombectomy Eligibility–Vessel Imaging...

...otherwise meet criteria for mechanica...

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

...with suspected intracranial LVO and no history o...

...ents who are potential candidates for mechanic...

...nable to incorporate collateral flow statu...

....2.4. Mechanical Thrombectomy Eligibil...

...patients with AIS within 6–24 hours of l...

When evaluating patients with AIS withi...

...3. Other Diagnostic...

...the assessment of blood glucose must pre...

...ectrocardiographic assessment is recommended in...

...nin assessment is recommended in patients p...

...chest radiographs in the hyperacute st...


...General Supportive Care and Emergency Treatment...

...Breathing, and Oxygenation...

...ort and ventilatory assistance are recomm...

...l oxygen should be provided to maint...

...xygen is NOT recommended in non-hypox...

...c oxygen (HBO) is NOT recommended for patients...

...lood Pressure...

...n and hypovolemia should be corrected t...

...ho have elevated BP and are otherwise e...

...ients for whom mechanical thrombectomy...

...ss of drug-induced hypertension in patient...

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

3.3. Temperatur...

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

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

...4. Blood Glucos...

...mia (blood glucose...

...ndicates that persistent in-hospital hyperglycemia...

...IV Alteplase...

3.5.1. General Princi...

...eligible for IV alteplase, benefit of therapy is...

...atients undergoing fibrinolytic therapy, ph...

...risks should be discussed during IV alteplase e...

...linicians should be aware that hypoglycemia and...

...time from onset of symptoms to treatm...

...2. Time Window...

...9 mg/kg, maximum dose 90 mg over 60 minutes...

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

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

....5.3. Mild S...

...igible patients with mild but disabling stro...

...e eligible patients with mild disab...

...ligible patients with mild nondisabling stro...

...otherwise eligible patients with mild non-dis...

...ther Specific Circumstanc...

...lase for adults presenting with an AIS wi...

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

.... Bleeding Ris...

...he extremely low risk of unsuspected abnorm...

...ligible patients who have previously had...

...ise eligible patients who have previous...

...f the IV glycoprotein IIb/IIIa inhibi...

...b should NOT be administered concurrently...

...rin should NOT be administered within 90 minutes...

...alteplase should NOT be administered...

...Post-alteplase Treatment

...P should be maintained at

...k of antithrombotic therapy (other...

...anagement of Symptomatic Intracranial Blee...

...Management of Orolingual Angioedema As...

...ty Recommendations for IV Alteplase in P...

...ications

...3 haIVb alteplase (0.9 mg/kg, maximum...

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

...Severe strokeFor severe stroke, IVb alteplas...

...thin 3 h–Mild disabling strokeFor otherwis...

...haIVb,d alteplase (0.9 mg/kg, maxim...

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

...Treatment should be initiated as qui...

...e is recommended in patients with BP...

...lood glucoseIVb alteplase is recommend...

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

...rior antiplatelet thera...

...se is recommended for patients taking antiplat...

...eplase is recommended for patients taking a...

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

...mendations for treatment with IV alteplase for...

...For patients >80 y of age presenting in...

...h–Diabetes mellitus and prior strokeIn AIS pati...

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

...Mild disabling strokeFor otherwise eligi...

...p and unknown time of onsetIV alteplase...

...isting disability...

...isting disability does not seem to independen...

...eexisting dementia may benefit from IVb,d alteplas...

...y improvementIVb alteplase treatment is reasonable...

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

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

Coagulop...

...,d alteplase may be reasonable in patien...

...efficacy of IV alteplase for acut...

...ctureIV alteplase may be considered for...

...rial punctureThe safety and efficacy of admin...

...or traumaIn AIS patients with recent major tr...

...rgeryUse of IV alteplase in carefully s...

...nitourinary bleedingReported literature details a...

Menstruati...

...s probably indicated in women who are menstruating...

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

...otential benefits of IV alteplase...

...cranial cervical dissectionsIV alteplase i...

...arterial dissectionIV alteplase usefulness and...

...ured intracranial aneurysm...

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

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

...acranial vascular malformations...

...or patients presenting with AIS who are k...

...se of the increased risk of ICH in th...

...MBs

...n otherwise eligible patients who ha...

...wise eligible patients who have previous...

...irofiban, eptifibatideThe efficacy of the...

...intracranial neoplasmsIV alteplase treatmen...

...IFor patients presenting with concurrent AIS and...

...ecent...

...nts presenting with AIS and a history o...

For patients presenting with AIS and a hi...

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

Acute pericard...

...h major AIS likely to produce severe disabilit...

...or patients presenting with moderate AIS...

Left atrial or ventricular thr...

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

...patients presenting with moderate AIS li...

...r cardiac diseases...

...r patients with major AIS likely to...

For patients presenting with major AIS...

...okeIV alteplase is reasonable for the treatment of...

...stemic malignancyThe safety and efficacy of...

...gnancy...

...alteplase administration may be considered in p...

...safety and efficacy of IVb,d altepla...

...ological conditionsUse of IV altepl...

Sickle cell diseaseIV alteplase for adults prese...

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

...Treating clinicians should be aware that illicit...

...micsThe risk of symptomatic intracranial...

...traindications...

...o 3-h window–Mild nondisabling strokeFo...

...- to 4.5-h window–Mild nondisabling str...

...insufficient evidence to identify a threshol...

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

...ic stroke within 3 moUse of IV alt...

...ma within 3 moIn AIS patients with r...

...ute head traumaGiven the possibility of bleedi...

...traspinal surgery within 3 moFor patie...

...acranial hemorrhageIVb,d,e alteplase a...

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

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

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

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

...in inhibitors or factor Xa inhibit...

...iximabAbciximab should NOT be administered conc...

...omitant IV aspirinIV aspirin should NOT be admi...

...fective endocarditisFor patients with AIS and sy...

...c arch dissectionIV alteplase in AISb,d,...

...ntra-axial intracranial neoplasmIV alteplase tre...

...ise specified, these eligibility recommendations...

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

...eprinted from Jauch et al. Copyright © 2013, Amer...

...ther IV Fibrinolytics and Sonothrombolys...

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

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

...istration of IV defibrinogenating agen...

...nothrombolysis as adjuvant therapy with IV...

....7. Mechanical Throm...

.... Concomitant With IV Altepla...

...ts eligible for IV alteplase should receive I...

...under consideration for mechanical thrombe...

...7.2. 0–6 Hours From On...

...hould receive mechanical thrombectomy...

...rect aspiration thrombectomy as first-pass mecha...

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

...efits are uncertain, the use of mechani...

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

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

...ients with AIS within 6–16 hours o...

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

...4. Techniqu...

...stent retrievers is indicated in pr...

...l goal of the thrombectomy procedure should be r...

...nsure benefit, reperfusion to mTICI grad...

...hour thrombectomy window evaluation a...

...nable to select an anesthetic technique during EV...

...of a proximal balloon guide catheter or a larg...

...of tandem occlusions (both extracranial and...

...and efficacy of IV glycoprotein IIb/IIIa inhibi...

...alvage technical adjuncts, includin...

...Blood Pressure Manageme...

...who undergo mechanical thrombectomy, i...

...ho undergo mechanical thrombectomy with successful...

...her Endovascular Therapi...

...nical thrombectomy with stent retrievers is re...

...fibrinolysis initiated within 6 ho...

...platelet Treatment

...inistration of aspirin is recommended...

...tients presenting with minor noncardioembolic isc...

The efficacy of the IV glycoprotein...

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

...administration of the IV glycoprotein I...

...rin is NOT recommended as a substitute f...

.... Anticoagulan...

...of urgent anticoagulation in patient...

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

...present, the usefulness of argatroban, dab...

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

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

...xpansion/Hemodilution, Vasodilators, and Hemody...

...volume expansion is NOT recommended f...

...ration of high-dose albumin is NOT...

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

...mechanically augment cerebral blood...

...europrotective Agent...

At present, pharmacological or nonpharmacologi...

...Carotid Endarterectomy/Carotid Angioplasty...

...ulness of emergent or urgent carotid endart...

...patients with unstable neurological s...

...14. Other

Transcranial near-infrared laser therapy...


...pital Management of AIS: General Suppor...

.... Stroke Uni...

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

...standardized stroke care order sets is r...

...ead Positioning

...t of flat-head positioning early afte...

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

4.3. Supplementa...

...upport and ventilatory assistance are recomme...

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

Supplemental oxygen is NOT recommended in...

...mmendation 1 in this section is re...

...lood Pressure...

...ypotension and hypovolemia should be correc...

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

...patients with BP ≥220/120 mm Hg who...

...tients with BP...

...: Recommendations in this section are rep...

...5. Temperatur...

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

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

...ndations in this section are repeat...

....6. Gluc...

...lycemia (blood glucose

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

...7. Dysphagia...

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

...opic evaluation is reasonable for t...

...easonable for dysphagia screening to be pe...

...ot well established which instrument to choose for...

...ng oral hygiene protocols to reduce the risk of...

...8. Nutrition...

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

...h dysphagia, it is reasonable to initial...

Nutritional supplements are reasonable to consi...

4.9. Deep Vein Thrombosis Prophyla...

...roke patients without contraindications,...

...enefit of prophylactic-dose subcutaneous hepa...

...prophylactic anticoagulation is used, the benefit...

...schemic stroke, elastic compression stockin...

...epression Screening...

...dministration of a structured depression inve...

...tients diagnosed with poststroke depress...

....11. Oth...

...lization and inpatient rehabilitation,...

...ded to minimize or eliminate skin friction, to min...

...s reasonable for patients and fami...

...prophylactic antibiotics has NOT b...

...ment of indwelling bladder catheters should NOT be...

....12. Rehabilitat...

...ecommended that early rehabilitation for hospit...

It is recommended that stroke survivors recei...

...ded that all individuals with stroke...

...onal assessment by a clinician with expertise in r...

...iveness of fluoxetine or other select...

...igh-dose, very early mobilization within...


...pital Management of AIS: Treatment...

...rain Swellin...

...1. General Recommendations...

...s with large territorial cerebral and cerebel...

...easures to lessen the risk of swelling an...

...1.2. Medical Mana...

...osmotic therapy for patients with clinic...

...rief moderate hyperventilation (Pco2 tar...

...mia or barbiturates in the setting of ische...

...ck of evidence of efficacy and the poten...

...gical Management-Supratentorial Infarction...

...hough the optimal trigger for decompress...

...atients ≤60 years of age who deteriorate...

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

...gical Management-Cerebellar Infarc...

...culostomy is recommended in the treatment...

...ressive suboccipital craniectomy with dural expans...

...hen considering decompressive suboccipit...

...Seizures

...t seizures after stroke should be treated in a...

...tic use of antiseizure drugs is NOT recommen...


...Institution of Secondary Stroke Prevention...

...rain Imaging...

...on of recurrent stroke, the use of...

...MRI is reasonable in selected patients as pa...

...iveness of routine brain MRI to guid...

...scular Imaging...

...r patients with nondisabling (mRS score...

...prevention of recurrent stroke, the u...

...of the intracranial vasculature to detect at...

...utine imaging of the intracranial vasculatur...

...Electrocardiographic Monitor...

...c monitoring is recommended to scree...

...eness of prolonged cardiac monitoring duri...

...Echocardiography

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

...graphy is reasonable in selected p...

...ctiveness of routine echocardiography to gu...

.... Glucose...

...t is reasonable to screen all patients for diabe...

....5. Other Tests for Secondary Prev...

...ulness of screening for thrombophili...

...ng of patients with recent ischemic stroke f...

...testing for antiphospholipid antibodi...

...g for hyperhomocysteinemia among patie...

...6. Antithrombotic Treat...

...ncardioembolic Stroke...

...atients with noncardioembolic AIS, the use of...

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

...ts who have a noncardioembolic AIS while taking as...

...ulation might be considered in patients who...

...patients who have a noncardioembolic AIS while tak...

...patients with noncardioembolic ischemic...

...2. Atrial Fibrillat...

...most patients with an AIS in the settin...

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

...3. Arterial Dissection...

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

...ents with AIS and extracranial carotid or...

....6.4. Hemorrhagic Transformation

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

.... Carotid Revascularization...

...vascularization is indicated for s...

...Treatment of Hyperlipidemia

...1. General Principles...

...ients with AIS should be managed ac...

...ho are 20 years of age or older and n...

...anges in lifestyle and effects of LDL-...

...e of Lipid-lowering Drugs for Patients with Clini...

...are 75 years of age or younger with clinical...

...nts with clinical ASCVD in whom high-...

...t increased ASCVD risk with chronic, stab...

...patients with clinical ASCVD, who are judged to be...

...n patients with clinical ASCVD who...

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

...n patients with clinical ASCVD who are...

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

...ts older than 75 years of age who are tolerati...

...n patients with clinical ASCVD who ar...

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

...isk StatusHaving trouble viewing table? Expand...

....8.3 Implementat...

A clinician-patient risk discussion is recommen...

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

...nts with statin-associated side effects...

...increased ASCVD risk with severe statin-asso...

....4. Timing...

...s already taking statins at the time...

...ients with AIS who qualify for statin trea...

....8.5 Special Patient Grou...

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

...f childbearing age with hypercholesterolem...

...h advanced kidney disease that req...

...ults with advanced kidney disease who re...

...n of Antihypertensive Medications...

...arting or restarting antihypertens...

...Smoking Cessation Interv...

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

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

...hcare providers should strongly advise ev...

...asonable to advise patients after ischemic str...

...with an AIS, in-hospital initiation of...

6.11. Stroke Educ...

...education about stroke is recommende...