Early Management of Patients With Acute Ischemic Stroke
Key Points
Key Points
Treatment
...reatme...
...ital Stroke Management and Systems of Ca...
...rehospital Systems...
...c health leaders, along with medical professio...
...ch educational programs should be design...
...vation of the 9-1-1 system by patients or...
...S Assessment and Management...
...f a stroke assessment tool by first aid providers...
...should provide prehospital notification to the...
...EMS Systems
...systems of stroke care should be developed....
...in coordination with local, regional,...
...nts with a positive stroke screen or who are str...
...ral IV alteplase-capable hospital options exist wi...
...hospital procedures to identify patie...
...Hospital Stroke Capabilities...
...f stroke centers by an independent e...
...spital Stroke Teams...
...anized protocol for the emergency eva...
...n of an acute stroke team that includes p...
...icomponent quality improvement initiatives,...
...nded that stroke systems of care be d...
...hing and monitoring target time goals for...
....6. Telemedicine...
...tes without in-house imaging interpretat...
...within a telestroke network, teleradiology sys...
...se of telemedicine/telestroke resources and system...
...ke/teleradiology evaluations of AIS patients...
...dministration of IV alteplase guided by telestrok...
...rks may be reasonable for triaging patients wi...
...plase decision-making support via telephone con...
1.7. Organization and Integration of...
...ls caring for stroke patients within a s...
...rvices within a hospital that may b...
...cal thrombectomy requires the patient to be...
...ul for primary stroke centers and other healthc...
...y be useful for government agencies and third-...
...Establishment of Data Repositories
...ation in a stroke data repository is r...
1.9. Stroke System Care Quality Improvement Pr...
...lthcare institutions should organize a mult...
...e outcome measures should include adjust...
...lity improvement processes, implemented...
...ency Evaluation and Treatment...
....1. Stroke Scal...
...oke severity rating scale, preferably the NIHSS, i...
...1. National Institutes of Health Stroke...
...2. Head and Neck Im...
...1. Initial Imaging
All patients with suspected acute st...
...ystems should be established so that...
...ast CT (NCCT) is effective to exclu...
...etic resonance (MR) imaging (MRI) is effecti...
...or MR angiography (MRA) with diffusion-wei...
...V Alteplase Eligibility...
...of IV alteplase in eligible patients without fir...
...eligible for IV alteplase, because benefit o...
...atients with AIS who awake with stroke...
...2.3. Mechanical Thrombectomy Eligibility–Ve...
...ents who otherwise meet criteria for mechanical th...
For patients with suspected LVO who...
In patients with suspected intracra...
...tients who are potential candidates...
...easonable to incorporate collateral flow...
...ical Thrombectomy Eligibility–Multimodal...
...atients with AIS within 6–24 hours of l...
...patients with AIS within 6 hours of last known nor...
...her Diagnostic Tests
...sessment of blood glucose must precede the...
...cardiographic assessment is recomme...
...oponin assessment is recommended in patients pr...
...sefulness of chest radiographs in th...
...Supportive Care and Emergency Treatment...
...y, Breathing, and Oxygenation...
...port and ventilatory assistance are recommend...
Supplemental oxygen should be provid...
...gen is NOT recommended in non-hypoxic patients wit...
Hyperbaric oxygen (HBO) is NOT recommended...
3.2. Blood Pressur...
...ypotension and hypovolemia should be corrected to...
...have elevated BP and are otherwise eligibl...
...for whom mechanical thrombectomy i...
...of drug-induced hypertension in patients with...
...to Treat Arterial Hypertension in Patients w...
3.3. Tempera...
...thermia (temperature >38°C) shoul...
...patients with AIS, the benefit of...
...Blood Glucose...
...poglycemia (blood glu...
...ates that persistent in-hospital hyp...
...IV Alteplase...
...General Principl...
...s eligible for IV alteplase, benefit of...
...undergoing fibrinolytic therapy, physicians should...
...e potential risks should be discussed during IV...
...clinicians should be aware that hypoglycemia and h...
...me from onset of symptoms to treatme...
...5.2. Time Wind...
...0.9 mg/kg, maximum dose 90 mg over...
...V alteplase (0.9 mg/kg, maximum dose 90...
...9 mg/kg, maximum dose 90 mg over 60 minutes with...
....5.3. Mild Stroke...
...igible patients with mild but disabling str...
...erwise eligible patients with mild disabling s...
...wise eligible patients with mild n...
...therwise eligible patients with mi...
...5.4. Other Specific Circumst...
...eplase for adults presenting with an AI...
...ients with a hyperdense MCA sign, IV alt...
...5. Bleeding Ri...
...he extremely low risk of unsuspected abnormal...
...se eligible patients who have previously had a sm...
...eligible patients who have previously ha...
...fficacy of the IV glycoprotein IIb/IIIa inhibit...
...uld NOT be administered concurrently with IV...
...ld NOT be administered within 90 minutes after t...
...ase should NOT be administered to patients...
3.5.6. Post-alteplase Tr...
...P should be maintained...
...thrombotic therapy (other than IV as...
Table 3. Management of Symptomatic Intracrania...
...ble 4. Management of Orolingual An...
...ligibility Recommendations for IV Alteplase in P...
...dication...
...hin 3 haIVb alteplase (0.9 mg/kg, m...
...“AgeFor otherwise medically eligible patients â...
...ere strokeFor severe stroke, IVb alteplase is ind...
...3 h–Mild disabling strokeFor otherwise eligi...
...Vb,d alteplase (0.9 mg/kg, maximum dose 90 mg...
...“AgeIV alteplase treatment in the 3- to 4.5-h ti...
...t should be initiated as quickly as possi...
...V alteplase is recommended in patients with BP...
...seIVb alteplase is recommended in ot...
...alteplase administration is recomm...
...antiplatelet therapy
...is recommended for patients taking ant...
...ase is recommended for patients taking a...
...diseaseIn patients with end-stage renal d...
...itional recommendations for treatm...
...5 h–AgeFor patients >80 y of age pre...
...abetes mellitus and prior strokeIn A...
....5 h–Severe strokeThe benefit of IV alt...
...“Mild disabling strokeFor otherwise eligible pa...
...and unknown time of onsetIV altepla...
...existing disability...
...eexisting disability does not seem to indepen...
...ith preexisting dementia may benefit from IVb,d...
...entIVb alteplase treatment is reasonab...
...izure at onsetIVb,d alteplase is rea...
...ood glucoseTreatment with IV altep...
...ulopathy...
...alteplase may be reasonable in patients who have...
...and efficacy of IV alteplase for ac...
...l punctureIV alteplase may be consid...
...rial punctureThe safety and efficacy...
...traumaIn AIS patients with recent major trauma...
...surgeryUse of IV alteplase in care...
...genitourinary bleedingReported lit...
Menstruatio...
...ase is probably indicated in women...
...a history of recent or active vaginal bleeding...
...ause the potential benefits of IV...
...cranial cervical dissectionsIV alte...
...erial dissectionIV alteplase usefulness a...
...uptured intracranial aneurysm...
...ts presenting with AIS who are known to harbor...
...and risk of IV alteplase in patients wi...
...ranial vascular malformation...
...ients presenting with AIS who are known to harbor...
...of the increased risk of ICH in this population o...
...MBs...
...otherwise eligible patients who have previously h...
...herwise eligible patients who have previously ha...
...mitant tirofiban, eptifibatideThe efficacy of...
...ial intracranial neoplasmsIV altepla...
...ients presenting with concurrent AIS and acut...
...ecent MI...
...ients presenting with AIS and a history of...
...ients presenting with AIS and a hi...
...ents presenting with AIS and a history of recen...
...pericarditis...
...ts with major AIS likely to produce severe...
...r patients presenting with moderate AIS li...
...atrial or ventricular thromb...
...s with major AIS likely to produce seve...
...r patients presenting with moderate AIS likely...
Other cardiac diseases
...ts with major AIS likely to produce...
...patients presenting with major AIS likely to prod...
...edural strokeIV alteplase is reasonable f...
...ystemic malignancyThe safety and efficacy of IVb...
Pregnan...
...plase administration may be considere...
...nd efficacy of IVb,d alteplase in the early postp...
...phthalmological conditionsUse of IV alte...
...ell diseaseIV alteplase for adults...
...MCA signIn patients with a hyperdens...
...drug useTreating clinicians should be...
...troke mimicsThe risk of symptomatic intracr...
...ntraindication...
0- to 3-h window–Mild nondisabli...
...ow–Mild nondisabling strokeFor otherwise eligi...
...ins insufficient evidence to identify a threshold...
...se should NOT be administered to a pa...
...within 3 moUse of IV alteplase in patients presen...
...ad trauma within 3 moIn AIS patients wit...
...head traumaGiven the possibility of b...
...acranial/intraspinal surgery within 3 moF...
...ntracranial hemorrhageIVb,d,e alteplase admini...
...ubarachnoid hemorrhageIVb,d,e alteplase is c...
...ncy or GI bleed within 21 dPatients with a...
...hyThe safety and efficacy of IV3 alteplase f...
...V alteplase should NOT be administered to p...
...bin inhibitors or factor Xa inhibitorsThe use...
...mitant AbciximabAbciximab should NOT be adminis...
... aspirinIV aspirin should NOT be adminis...
...tive endocarditisFor patients with AIS and...
...dissectionIV alteplase in AISb,d,e kno...
...axial intracranial neoplasmIV altepl...
...wise specified, these eligibility...
...eatment of AIS: IV Administration of...
...nted from Jauch et al. Copyright © 2013, Ame...
3.6. Other IV Fibrinolytics and Sonothromboly...
...may be reasonable to choose tenecteplase (single...
...inistered as a 0.4-mg/kg single IV bolus has not b...
...ation of IV defibrinogenating agent...
...thrombolysis as adjuvant therapy with I...
...Mechanical Thrombectomy...
...1. Concomitant With IV Altepla...
...ible for IV alteplase should receive IV...
...nder consideration for mechanical t...
...7.2. 0–6 Hours From...
...uld receive mechanical thrombectomy...
...aspiration thrombectomy as first-p...
...nefits are uncertain, the use of mechan...
Although its benefits are uncertain, the use o...
...lthough the benefits are uncertain, the use of mec...
...to 24 Hours From Onset...
...patients with AIS within 6–16 hours of la...
...ents with AIS within 16–24 hours o...
.... Technique...
...rievers is indicated in preference to...
...ical goal of the thrombectomy procedure sh...
...it, reperfusion to mTICI grade 2b/3 should...
...-hour thrombectomy window evaluation and t...
It is reasonable to select an anesthetic t...
...proximal balloon guide catheter or a large-bore...
...f tandem occlusions (both extracranial and intracr...
...ty and efficacy of IV glycoprotein I...
...echnical adjuncts, including intra-arterial...
...Blood Pressure Managem...
...atients who undergo mechanical thrombectomy,...
...ts who undergo mechanical thrombectomy with succes...
...Other Endovascular Therapie...
...l thrombectomy with stent retrievers is re...
...ibrinolysis initiated within 6 hours of stro...
...tiplatelet Treatment...
...ion of aspirin is recommended in patients with AIS...
...presenting with minor noncardioemb...
...he efficacy of the IV glycoprotein IIb/IIIa inh...
...is NOT recommended over aspirin for t...
...ion of the IV glycoprotein IIb/IIIa inhibitor...
...pirin is NOT recommended as a substitute for acut...
...Anticoagulants...
...lness of urgent anticoagulation in...
...and usefulness of short-term anticoagulation...
At present, the usefulness of arga...
...and usefulness of oral factor Xa inhibit...
...nt anticoagulation, with the goal of preventi...
...Volume Expansion/Hemodilution, Vasod...
...volume expansion is NOT recommended for tr...
...e administration of high-dose albumin is NOT...
...on of vasodilatory agents, such as pe...
...ices to mechanically augment cerebral blood fl...
...uroprotective Agents...
...harmacological or nonpharmacological trea...
...ergency Carotid Endarterectomy/Carotid Ang...
...ulness of emergent or urgent carotid endar...
...ents with unstable neurological status (...
3.14. Other
...ear-infrared laser therapy is NOT recommended for...
...pital Management of AIS: General Supportive Car...
....1. Stroke U...
...ehensive specialized stroke care (stroke units)...
...f standardized stroke care order s...
...ead Positioning...
...fit of flat-head positioning early aft...
...ote: Recommendations in this section are repeate...
...Supplemental Oxygen...
...ort and ventilatory assistance are recommended fo...
...ental oxygen should be provided to maintain oxyg...
...al oxygen is NOT recommended in nonhy...
...ecommendation 1 in this section is repeated fr...
...Blood Pressure
...on and hypovolemia should be corrected to ma...
...patients with AIS, early treatment of hy...
...nts with BP ≥220/120 mm Hg who did not rec...
In patients with...
...ations in this section are repeated from Section 3...
...Temperature...
...rces of hyperthermia (temperature >38°C) shoul...
...ents with AIS, the benefit of treatment with...
...te: Recommendations in this sectio...
.... Glucose...
...ycemia (blood glucos...
...ndicates that persistent in-hospit...
...Dysphagia...
...a screening before the patient begins eating, d...
...doscopic evaluation is reasonable for those patien...
...e for dysphagia screening to be perf...
...s not well established which instrumen...
...al hygiene protocols to reduce the risk...
4.8. Nutri...
...eral diet should be started within 7...
...atients with dysphagia, it is reasonable to ini...
...tional supplements are reasonable to consider f...
...Vein Thrombosis Prophylaxis...
...roke patients without contraindicatio...
...rophylactic-dose subcutaneous heparin (unfraction...
...prophylactic anticoagulation is us...
...mic stroke, elastic compression stockings sh...
....10. Depression Screenin...
...on of a structured depression inventory is reco...
...tients diagnosed with poststroke depression sho...
....11. Other
...hospitalization and inpatient rehabilitatio...
...mmended to minimize or eliminate skin...
...e for patients and families with stroke...
...outine use of prophylactic antibiotics has NOT bee...
...acement of indwelling bladder catheters should NOT...
...Rehabilitation...
...is recommended that early rehabilitation for hos...
...ecommended that stroke survivors receive...
...mended that all individuals with stroke...
...nal assessment by a clinician with...
...veness of fluoxetine or other selective serotoni...
...ose, very early mobilization within 2...
...Hospital Management of AIS: Treatmen...
...ain Swelling...
5.1.1. General Recommendatio...
...ith large territorial cerebral and c...
...easures to lessen the risk of swelling...
...1.2. Medical Manag...
...se of osmotic therapy for patients with clini...
...derate hyperventilation (Pco2 target...
...pothermia or barbiturates in the se...
...ause of a lack of evidence of effic...
...Management-Supratentorial Infarction...
Although the optimal trigger for decompressive c...
...60 years of age who deteriorate neur...
...years of age who deteriorate neurologically withi...
...gical Management-Cerebellar Infarction...
...riculostomy is recommended in the...
...suboccipital craniectomy with dural expansion sho...
...onsidering decompressive suboccipital craniecto...
.... Seizure...
Recurrent seizures after stroke shou...
...ophylactic use of antiseizure drugs is...
...al Institution of Secondary Stroke Prevention...
...1. Brain Imaging...
...ion of recurrent stroke, the use of MRI is rea...
...rain MRI is reasonable in selected patien...
...iveness of routine brain MRI to guide treatm...
...Vascular Imaging...
...nts with nondisabling (mRS score 0...
...ention of recurrent stroke, the use of intra...
...the intracranial vasculature to detect...
...of the intracranial vasculature to detect athero...
...ectrocardiographic Monitoring...
...itoring is recommended to screen for atrial f...
...e effectiveness of prolonged cardiac monitoring du...
....2. Echocardiogra...
...on of recurrent stroke, the use of echo...
Echocardiography is reasonable in selected patien...
...effectiveness of routine echocardiography t...
6.4. Gluco...
...r AIS, it is reasonable to screen all patient...
...Other Tests for Secondary Preven...
...ness of screening for thrombophilic states in p...
...screening of patients with recent is...
...testing for antiphospholipid antibodies...
...tine screening for hyperhomocysteinemi...
...Antithrombotic Treatment...
...oncardioembolic Strok...
...r patients with noncardioembolic AIS, the...
...ndary prevention in patients with noncardio...
...atients who have a noncardioembolic AIS while t...
...coagulation might be considered in pa...
...ts who have a noncardioembolic AIS while taking a...
...th noncardioembolic ischemic stroke, treatmen...
6.6.2. Atrial Fibrillation
...ost patients with an AIS in the setting of atrial...
...ients with a history of ischemic stroke, at...
...6.3. Arterial Dissection...
...nts with AIS and extracranial carotid or...
...patients with AIS and extracranial carotid o...
...emorrhagic Transformation...
...ts with AIS and HT, initiation or contin...
...rotid Revascularization...
...n revascularization is indicated for seco...
...Treatment of Hyperlipidemia...
...General Principles...
...tients with AIS should be managed ac...
...adults who are 20 years of age or older and...
...o changes in lifestyle and effects...
...e of Lipid-lowering Drugs for Patients...
...ts who are 75 years of age or younger...
...th clinical ASCVD in whom high-intensity s...
...ents at increased ASCVD risk with chronic, stabl...
...ents with clinical ASCVD, who are judged to be...
...n patients with clinical ASCVD who...
...prices, PCSK9 inhibitors have a low-cos...
...h clinical ASCVD who are on maximally tolerated st...
In patients older than 75 years of...
...r than 75 years of age who are tolerat...
...ients with clinical ASCVD who are receiving ma...
...linical aASCVD includes acute coronary syn...
...le 7. Risk StatusHaving trouble viewing ta...
...8.3 Implementati...
...clinician-patient risk discussion is...
In patients with indication for stat...
...ith statin-associated side effects that are not...
...tients at increased ASCVD risk with severe stat...
....8.4. Timing...
...lready taking statins at the time of onset of isc...
...tients with AIS who qualify for statin treatm...
...pecial Patient Groups...
...bearing age who are treated with statin...
...aring age with hypercholesterolemia w...
...ults with advanced kidney disease that req...
In adults with advanced kidney disease who...
.... Institution of Antihypertensive Medications...
...ing or restarting antihypertensive therapy...
6.10. Smoking Cessation Intervent...
...th AIS should receive in-hospital initiation...
...rs with an AIS, who receive in-hospital ini...
...providers should strongly advise every patient...
...sonable to advise patients after ischemic st...
...kers with an AIS, in-hospital initiation of var...
...troke Education...
...ent education about stroke is recommende...