Early Management of Patients With Acute Ischemic Stroke
Key Points
Key Points
Treatment
...reatment...
1. Prehospital Stroke Management a...
....1. Prehospital Systems
...c health leaders, along with medical...
...ducational programs should be designed to spec...
...the 9-1-1 system by patients or other m...
...ssessment and Management...
...e use of a stroke assessment tool by first...
...personnel should provide prehospital notifi...
.... EMS Syste...
...nal systems of stroke care should be d...
..., in coordination with local, regional,...
...a positive stroke screen or who are strongly sus...
...l IV alteplase-capable hospital options exist wi...
...ective prehospital procedures to identify...
...spital Stroke Capabilities...
...tification of stroke centers by an independent...
...5. Hospital Stroke Tea...
...tocol for the emergency evaluation of pat...
...f an acute stroke team that includes physici...
...ent quality improvement initiatives...
...mended that stroke systems of care be dev...
...ng and monitoring target time goals for ED...
.... Telemedicine...
...ites without in-house imaging interpretatio...
...n implemented within a telestroke network...
...telemedicine/telestroke resources and systems sh...
...adiology evaluations of AIS patients...
...inistration of IV alteplase guided by...
...estroke networks may be reasonable...
...g alteplase decision-making support...
...tion and Integration of Components...
...ring for stroke patients within a s...
...ferent services within a hospital that may be tr...
...echanical thrombectomy requires the patient...
...useful for primary stroke centers and other healt...
...ful for government agencies and third-party pay...
...shment of Data Repositories...
...a stroke data repository is recommended to pro...
1.9. Stroke System Care Quality Imp...
...itutions should organize a multidis...
...oke outcome measures should includ...
...tinuous quality improvement processes, implemente...
...mergency Evaluation and Treatment...
....1. Stroke S...
...roke severity rating scale, preferably t...
...ional Institutes of Health Stroke Scale (NIHSS)...
...Head and Neck Imaging...
....2.1. Initial Im...
...with suspected acute stroke should rec...
...e established so that brain imagin...
...(NCCT) is effective to exclude ICH before IV alt...
...resonance (MR) imaging (MRI) is effectiv...
...TP or MR angiography (MRA) with diffusio...
...2.2. IV Alteplase Eligi...
...dministration of IV alteplase in eligible patie...
...tients eligible for IV alteplase, b...
...atients with AIS who awake with stroke sy...
...echanical Thrombectomy Eligibility...
For patients who otherwise meet criteria for me...
...with suspected LVO who have not had noninvas...
...ith suspected intracranial LVO and no history of r...
...ients who are potential candidates for mechanica...
...e reasonable to incorporate collateral...
...chanical Thrombectomy Eligibility–Mul...
...ng patients with AIS within 6–24 hours o...
...valuating patients with AIS within 6 h...
...Other Diagnostic Te...
...nly the assessment of blood glucose must pr...
...e electrocardiographic assessment is recom...
...ine troponin assessment is recommended in patie...
...lness of chest radiographs in the hyp...
...pportive Care and Emergency Treatment...
...Breathing, and Oxygenation...
...port and ventilatory assistance are recom...
...tal oxygen should be provided to maintain oxygen...
Supplemental oxygen is NOT recommended in non-hy...
...ic oxygen (HBO) is NOT recommended for...
...Blood Pressure...
...on and hypovolemia should be corrected...
...ts who have elevated BP and are othe...
...patients for whom mechanical thrombecto...
...e usefulness of drug-induced hypertens...
...Options to Treat Arterial Hypertension in Patient...
...Temperature
...thermia (temperature >38°C) should be identifie...
...th AIS, the benefit of treatment with ind...
...4. Blood Gluc...
...mia (blood glucose...
...cates that persistent in-hospital hy...
...IV Alteplas...
3.5.1. General Principle...
...eligible for IV alteplase, benefit of...
...atients undergoing fibrinolytic therapy, physici...
...he potential risks should be discu...
...ating clinicians should be aware that hypoglycemi...
...se time from onset of symptoms to treatment has su...
3.5.2. Time W...
...plase (0.9 mg/kg, maximum dose 90 mg over 60 minut...
...0.9 mg/kg, maximum dose 90 mg over 60 minutes...
...teplase (0.9 mg/kg, maximum dose 90...
3.5.3. Mild Str...
...otherwise eligible patients with mi...
...r otherwise eligible patients with mild d...
...otherwise eligible patients with mil...
...ligible patients with mild non-disa...
...er Specific Circumstances...
...adults presenting with an AIS with...
...patients with a hyperdense MCA sign, IV alteplase...
....5. Bleeding Risk...
...tremely low risk of unsuspected abnormal...
...otherwise eligible patients who have previously...
...erwise eligible patients who have previously ha...
...ficacy of the IV glycoprotein IIb/IIIa...
...mab should NOT be administered concurre...
...uld NOT be administered within 90 minutes after th...
...V alteplase should NOT be administ...
...5.6. Post-alteplase Treatment...
...should be maintained at...
...ithrombotic therapy (other than IV aspir...
...Management of Symptomatic Intracrani...
...Management of Orolingual Angioedema Associ...
...ility Recommendations for IV Alteplase in...
Indicatio...
...3 haIVb alteplase (0.9 mg/kg, maximum...
...ithin 3 h–AgeFor otherwise medically eligible pa...
...evere strokeFor severe stroke, IVb alteplase...
...d disabling strokeFor otherwise eligible patie...
....5 haIVb,d alteplase (0.9 mg/kg, maximum dose 90...
...“AgeIV alteplase treatment in the 3- to...
...cyTreatment should be initiated as qui...
...alteplase is recommended in patients wit...
...lucoseIVb alteplase is recommended in othe...
CTIV alteplase administration is recommended in t...
...or antiplatelet therapy...
...ase is recommended for patients takin...
...eplase is recommended for patients taking ant...
...renal diseaseIn patients with end-...
...mmendations for treatment with IV al...
...o 4.5 h–AgeFor patients >80 y of age presenti...
...iabetes mellitus and prior strokeIn AIS patients...
...to 4.5 h–Severe strokeThe benefit of IV alte...
...–Mild disabling strokeFor otherwi...
...own time of onsetIV alteplase (0.9 mg/k...
...xisting disability...
...sability does not seem to independently...
...th preexisting dementia may benefit from I...
...arly improvementIVb alteplase treatment is re...
...nsetIVb,d alteplase is reasonable in patients...
...eatment with IV alteplase in patients with A...
...agulopathy
...alteplase may be reasonable in patient...
...afety and efficacy of IV alteplase...
...ureIV alteplase may be considered for patient...
...ureThe safety and efficacy of administering IVb,d...
...t major traumaIn AIS patients with recent...
...major surgeryUse of IV alteplase in ca...
GI and genitourinary bleedingReported lit...
...truation...
...se is probably indicated in women who are...
...is a history of recent or active vaginal bleeding...
...se the potential benefits of IV alteplase pr...
...ranial cervical dissectionsIV alteplase in A...
...arterial dissectionIV alteplase usefu...
...intracranial aneurysm...
...presenting with AIS who are known to harbor a smal...
...efulness and risk of IV alteplase in patie...
...l vascular malformations...
...atients presenting with AIS who are k...
...the increased risk of ICH in this population...
...MBs
...otherwise eligible patients who have previousl...
...igible patients who have previously had a...
...ofiban, eptifibatideThe efficacy of th...
Extra-axial intracranial neoplasmsIV alteplas...
...MIFor patients presenting with concurren...
...ent MI...
...nts presenting with AIS and a history of recent MI...
...r patients presenting with AIS and a history of...
...ents presenting with AIS and a history of recent...
...e pericarditis...
...tients with major AIS likely to produc...
...presenting with moderate AIS likely to produce mi...
...t atrial or ventricular t...
...atients with major AIS likely to produce sev...
...presenting with moderate AIS likely to produc...
...cardiac diseases...
...atients with major AIS likely to produce sev...
...tients presenting with major AIS likely t...
...al strokeIV alteplase is reasonabl...
...emic malignancyThe safety and efficacy of IVb al...
...regnan...
...alteplase administration may be co...
...nd efficacy of IVb,d alteplase in the early postpa...
...lmological conditionsUse of IV alteplase...
...easeIV alteplase for adults presenting with an AIS...
...MCA signIn patients with a hyperde...
...Treating clinicians should be aware that illi...
...e risk of symptomatic intracranial hemorrhage in...
...ontraindications
...ow–Mild nondisabling strokeFor otherwise...
...4.5-h window–Mild nondisabling strokeFo...
...re remains insufficient evidence to identify a...
ICHIV alteplase should NOT be admin...
...within 3 moUse of IV alteplase in patients pres...
...ad trauma within 3 moIn AIS patients wit...
...te head traumaGiven the possibility...
...cranial/intraspinal surgery within 3 m...
...y of intracranial hemorrhageIVb,d,e alteplas...
...id hemorrhageIVb,d,e alteplase is contrain...
...GI bleed within 21 dPatients with a...
...lopathyThe safety and efficacy of I...
...plase should NOT be administered to...
...bitors or factor Xa inhibitorsThe use of IVb,d,...
...nt AbciximabAbciximab should NOT be...
...ncomitant IV aspirinIV aspirin should NOT be...
...fective endocarditisFor patients with AIS...
...h dissectionIV alteplase in AISb,d,e known or...
...al intracranial neoplasmIV alteplase t...
Unless otherwise specified, these eligibility...
...able 6. Treatment of AIS: IV Administ...
...from Jauch et al. Copyright © 2013, Ameri...
.... Other IV Fibrinolytics and Sono...
...be reasonable to choose tenecteplase (single IV b...
...dministered as a 0.4-mg/kg single IV bolus ha...
...on of IV defibrinogenating agents or IV fibrinol...
...e of sonothrombolysis as adjuvant th...
...Mechanical Thrombecto...
...oncomitant With IV Alteplase...
...e for IV alteplase should receive IV...
...nts under consideration for mechanical...
...2. 0–6 Hours From Onse...
...should receive mechanical thrombectom...
...ation thrombectomy as first-pass m...
Although the benefits are uncertain, the use...
...lthough its benefits are uncertain, the use o...
...ough the benefits are uncertain, the use o...
3.7.3. 6 to 24 Hours From...
...tients with AIS within 6–16 hours...
...selected patients with AIS within 16–24...
....7.4. Techn...
...of stent retrievers is indicated in preference to...
...echnical goal of the thrombectomy p...
...e benefit, reperfusion to mTICI grade 2...
...n the 6- to 24-hour thrombectomy window evaluati...
...is reasonable to select an anestheti...
...oximal balloon guide catheter or a...
...tandem occlusions (both extracrani...
...ty and efficacy of IV glycoprotein IIb/IIIa...
...e technical adjuncts, including intr...
....5. Blood Pressure Mana...
...undergo mechanical thrombectomy, it is reas...
...who undergo mechanical thrombectom...
...ther Endovascular Therapies...
...bectomy with stent retrievers is recomme...
...a-arterial fibrinolysis initiated within 6 hours o...
...9. Antiplatelet Trea...
...ation of aspirin is recommended in patients with...
...ients presenting with minor noncardioemboli...
...acy of the IV glycoprotein IIb/IIIa inhibi...
Ticagrelor is NOT recommended over aspir...
...e administration of the IV glycoprotein IIb/I...
...recommended as a substitute for acute...
3.10. Anticoagula...
...fulness of urgent anticoagulation in pat...
...fety and usefulness of short-term anti...
...resent, the usefulness of argatroban, dabi...
...safety and usefulness of oral factor Xa inhi...
...gent anticoagulation, with the goal of preve...
...lume Expansion/Hemodilution, Vasodil...
...n by volume expansion is NOT recommended for trea...
...nistration of high-dose albumin is NOT recomme...
...he administration of vasodilatory agents, such...
...ices to mechanically augment cerebral blood flow...
....12. Neuroprotective...
At present, pharmacological or nonpharmacological...
...13. Emergency Carotid Endarterectomy...
...ess of emergent or urgent carotid endarterectomy...
...ts with unstable neurological status (eg, stro...
3.14. Oth...
...ranial near-infrared laser therapy is NOT...
...ital Management of AIS: General Supportive...
....1. Stroke Unit...
...e of comprehensive specialized stroke care (str...
...dardized stroke care order sets is recomme...
...ad Positioning...
The benefit of flat-head positioning ear...
...dations in this section are repeated fr...
.... Supplemental Oxyge...
...port and ventilatory assistance are re...
...mental oxygen should be provided to maintain oxyg...
Supplemental oxygen is NOT recommende...
...Recommendation 1 in this section is repeated...
...lood Pressure
Hypotension and hypovolemia should be correct...
...with AIS, early treatment of hypertension is...
...h BP ≥220/120 mm Hg who did not receive I...
...patients with BP...
...ommendations in this section are r...
...5. Temperature...
...ources of hyperthermia (temperatur...
...patients with AIS, the benefit of...
Note: Recommendations in this section are rep...
4.6. Gluc...
...glycemia (blood glucose...
...ndicates that persistent in-hospital hypergly...
...Dysphagia...
...hagia screening before the patient begins ea...
...n endoscopic evaluation is reasonable for those...
...able for dysphagia screening to be performed...
...well established which instrument to choose...
...nting oral hygiene protocols to reduce...
...Nutrition...
...uld be started within 7 days of adm...
...ents with dysphagia, it is reasonable...
...tritional supplements are reasonable to consi...
...9. Deep Vein Thrombosis Prophylaxis...
...oke patients without contraindications, intermi...
...fit of prophylactic-dose subcutaneo...
...tic anticoagulation is used, the benefit of p...
...c stroke, elastic compression stockings shoul...
...pression Screening...
...on of a structured depression inventory is r...
Patients diagnosed with poststroke depression...
....11. Oth...
...alization and inpatient rehabilitatio...
...recommended to minimize or eliminate skin friction...
...nable for patients and families with stroke to b...
...prophylactic antibiotics has NOT been shown to be...
...lacement of indwelling bladder cathet...
....12. Rehabilitation
...mended that early rehabilitation f...
...ecommended that stroke survivors receive rehabil...
...ded that all individuals with stroke be pr...
...functional assessment by a clinician wi...
...ctiveness of fluoxetine or other selective seroton...
...ery early mobilization within 24 hours of str...
...pital Management of AIS: Treatment of Ac...
....1 Brain Swel...
...General Recommendatio...
...nts with large territorial cerebral and cerebell...
...s to lessen the risk of swelling and close monitor...
...2. Medical Manageme...
...e of osmotic therapy for patients...
...ef moderate hyperventilation (Pco2 target,...
...hermia or barbiturates in the setting o...
...e of a lack of evidence of efficacy and the potent...
...gical Management-Supratentorial Infarction...
...imal trigger for decompressive craniectomy i...
...n patients ≤60 years of age who deteriorate neu...
In patients >60 years of age who deteri...
...Management-Cerebellar Infarction...
...is recommended in the treatment of obs...
...essive suboccipital craniectomy with dural ex...
...idering decompressive suboccipital craniec...
.... Seizures
...eizures after stroke should be treated i...
...ctic use of antiseizure drugs is NOT rec...
...spital Institution of Secondary Stroke Preve...
...Brain Imaging...
...prevention of recurrent stroke, the use of...
Brain MRI is reasonable in selected patie...
...ss of routine brain MRI to guide treatment sele...
...Vascular Imaging...
...patients with nondisabling (mRS score 0–2) A...
...n of recurrent stroke, the use of intracrani...
...g of the intracranial vasculature to de...
...ging of the intracranial vasculature to detect a...
...Electrocardiographic Monitor...
...iac monitoring is recommended to sc...
...ss of prolonged cardiac monitoring during hos...
6.3.2. Echocardi...
...ion of recurrent stroke, the use of echocardiog...
...aphy is reasonable in selected pat...
...e effectiveness of routine echocard...
.... Glucose...
...is reasonable to screen all patient...
6.5. Other Tests for Secondary Pr...
The usefulness of screening for thrombophi...
...utine screening of patients with rece...
...ing for antiphospholipid antibodies...
...ning for hyperhomocysteinemia among patien...
...tithrombotic Treatment
...Noncardioembolic Str...
...th noncardioembolic AIS, the use of antiplatelet a...
...dary prevention in patients with noncardio...
For patients who have a noncardioembolic AIS w...
...might be considered in patients wh...
...have a noncardioembolic AIS while taking ant...
...nts with noncardioembolic ischemic stroke...
...2. Atrial Fibrillation...
...st patients with an AIS in the setting of atrial...
...patients with a history of ischemic stroke, at...
...Arterial Dissection...
For patients with AIS and extracranial carotid...
...r patients with AIS and extracranial carotid or ex...
.... Hemorrhagic Transformat...
...th AIS and HT, initiation or continuation...
...id Revascularization...
...n revascularization is indicated for secondary pr...
...eatment of Hyperlipidem...
6.8.1. General Princip...
...S should be managed according to th...
...who are 20 years of age or older and not on lipid...
...ence to changes in lifestyle and effec...
...Choice of Lipid-lowering Drugs for Patients wit...
...nts who are 75 years of age or younger with...
...n patients with clinical ASCVD in whom high-inte...
...ients at increased ASCVD risk with c...
...patients with clinical ASCVD, who are judged to be...
...h clinical ASCVD who are judged to be very...
...list prices, PCSK9 inhibitors have a low-co...
...h clinical ASCVD who are on maximally...
...der than 75 years of age with clinical ASCVD,...
...older than 75 years of age who are to...
...tients with clinical ASCVD who are recei...
...aASCVD includes acute coronary syndro...
...StatusHaving trouble viewing table? Expand...
6.8.3 Implemen...
...clinician-patient risk discussion is recomme...
In patients with indication for statin thera...
...tients with statin-associated side effe...
...at increased ASCVD risk with severe...
6.8.4. Tim...
...s already taking statins at the time o...
...patients with AIS who qualify for st...
....5 Special Patient G...
...omen of childbearing age who are treat...
...hildbearing age with hypercholesterole...
...n adults with advanced kidney disease th...
...advanced kidney disease who requir...
6.9. Institution of Antihypertensiv...
...g or restarting antihypertensive ther...
...oking Cessation Intervention...
...ers with AIS should receive in-hosp...
For smokers with an AIS, who receive in-hospita...
...re providers should strongly advise every...
...asonable to advise patients after ischemic stroke...
...with an AIS, in-hospital initiation of varen...
...Stroke Educati...
...ducation about stroke is recommended...