Early Management of Patients With Acute Ischemic Stroke
Key Points
Key Points
Treatment
...eatment...
...l Stroke Management and Systems of Care...
.... Prehospital Syst...
Public health leaders, along with medical...
Such educational programs should be design...
...of the 9-1-1 system by patients or other member...
1.2. EMS Assessment and...
...use of a stroke assessment tool by first a...
...should provide prehospital notificat...
.... EMS Systems...
...stems of stroke care should be developed....
...in coordination with local, regional, and st...
...ents with a positive stroke screen or w...
...V alteplase-capable hospital options exist w...
...rehospital procedures to identify...
...ital Stroke Capabilities...
...ation of stroke centers by an independent e...
.... Hospital Stroke...
...protocol for the emergency evaluation of...
...signation of an acute stroke team that include...
...onent quality improvement initiatives,...
...mended that stroke systems of care be developed s...
...blishing and monitoring target time...
...Telemedicine...
...r sites without in-house imaging interpretation e...
...implemented within a telestroke netw...
...of telemedicine/telestroke resour...
...adiology evaluations of AIS patients can be effect...
...tration of IV alteplase guided by telestroke cons...
...etworks may be reasonable for triag...
...iding alteplase decision-making support...
....7. Organization and Integration...
...caring for stroke patients within a st...
...es within a hospital that may be tra...
...bectomy requires the patient to be at an experi...
...ay be useful for primary stroke centers and other...
...seful for government agencies and third-part...
...blishment of Data Repositori...
...n a stroke data repository is reco...
...ystem Care Quality Improvement Process...
...hcare institutions should organize a multi...
...come measures should include adjustment...
...us quality improvement processes, implemented b...
.... Emergency Evaluation and Treatmen...
...Stroke Scales...
...he use of a stroke severity rating...
...tional Institutes of Health Stroke Scale...
...d and Neck Imaging...
...2.1. Initial Imaging
...ith suspected acute stroke should receive emergenc...
...hould be established so that brain imaging s...
...ontrast CT (NCCT) is effective to exclude ICH b...
...tic resonance (MR) imaging (MRI) is effective to...
...TP or MR angiography (MRA) with diffusion-weighted...
...IV Alteplase Eligibility...
...on of IV alteplase in eligible patien...
...ts eligible for IV alteplase, because be...
...AIS who awake with stroke symptoms...
...hanical Thrombectomy Eligibility–Vesse...
...ients who otherwise meet criteria...
...s with suspected LVO who have not had no...
...th suspected intracranial LVO and no histor...
...n patients who are potential candidates for mechan...
...be reasonable to incorporate collateral flow...
...al Thrombectomy Eligibility–Multim...
...lecting patients with AIS within 6â...
...uating patients with AIS within 6 ho...
...r Diagnostic Tests...
...ly the assessment of blood glucose must preced...
...ine electrocardiographic assessment is recommende...
...ponin assessment is recommended in...
...ess of chest radiographs in the hyperacute str...
...upportive Care and Emergency Treatment...
...Airway, Breathing, and Oxygenation...
...upport and ventilatory assistance are reco...
...ygen should be provided to maintain oxyge...
Supplemental oxygen is NOT recommended...
...yperbaric oxygen (HBO) is NOT recommended for pa...
...Blood Pressu...
...ion and hypovolemia should be correcte...
...ve elevated BP and are otherwise eligible for...
...for whom mechanical thrombectomy is planned a...
...he usefulness of drug-induced hypertension in...
...ons to Treat Arterial Hypertension in Patients w...
...3. Temperature...
...rthermia (temperature >38°C) should be identifi...
...ients with AIS, the benefit of treatment with in...
...lood Glucose...
...glycemia (blood glucose...
...cates that persistent in-hospital hyperglyc...
.... IV Alteplase...
...General Principles...
...ents eligible for IV alteplase, benefit of th...
...tients undergoing fibrinolytic therapy, physicia...
...sks should be discussed during IV altep...
...inicians should be aware that hypoglycemia and...
...om onset of symptoms to treatment...
...Time Windows
...lase (0.9 mg/kg, maximum dose 90 mg over 60 minu...
...lteplase (0.9 mg/kg, maximum dose 90 mg over 60 m...
...lteplase (0.9 mg/kg, maximum dose 90...
...5.3. Mild Str...
...or otherwise eligible patients with mild...
...herwise eligible patients with mild disabling st...
...ligible patients with mild nondisabling stroke...
...wise eligible patients with mild non-...
...Other Specific Circumstances
...for adults presenting with an AIS with know...
...th a hyperdense MCA sign, IV alteplase can be ben...
....5.5. Bleeding R...
...n the extremely low risk of unsuspected abnormal...
...se eligible patients who have previou...
...e eligible patients who have previo...
The efficacy of the IV glycoprotei...
...ould NOT be administered concurrently w...
...pirin should NOT be administered within...
...ould NOT be administered to patients who hav...
...st-alteplase Treatment...
...ld be maintained at
The risk of antithrombotic therapy (other than...
...ent of Symptomatic Intracranial Bleeding...
...4. Management of Orolingual Angioedema Ass...
...lity Recommendations for IV Alteplase in...
...ications...
Within 3 haIVb alteplase (0.9 mg/kg, maximum dose...
...geFor otherwise medically eligible pat...
...–Severe strokeFor severe stroke, IVb alteplase...
...d disabling strokeFor otherwise eli...
...alteplase (0.9 mg/kg, maximum dose...
...“AgeIV alteplase treatment in the 3- t...
...atment should be initiated as quickly as possible...
...ase is recommended in patients wit...
...d glucoseIVb alteplase is recommended i...
CTIV alteplase administration is recommended in th...
...tiplatelet therapy
...V alteplase is recommended for patient...
...lase is recommended for patients taki...
...stage renal diseaseIn patients with e...
...dditional recommendations for treatme...
...4.5 h–AgeFor patients >80 y of age presentin...
...“Diabetes mellitus and prior strokeIn AIS patie...
....5 h–Severe strokeThe benefit of IV altep...
...o 4.5 h–Mild disabling strokeFor oth...
...nknown time of onsetIV alteplase (0.9 mg/kg,...
...reexisting disabil...
...ability does not seem to independently inc...
...with preexisting dementia may benefit from...
...y improvementIVb alteplase treatment is reasona...
...etIVb,d alteplase is reasonable in pa...
...eTreatment with IV alteplase in pa...
Coagulopat...
...alteplase may be reasonable in patie...
...ety and efficacy of IV alteplase for acute str...
...V alteplase may be considered for patie...
...rial punctureThe safety and effica...
...cent major traumaIn AIS patients with recent majo...
...ent major surgeryUse of IV alteplase in...
...nitourinary bleedingReported literature details...
...nstruatio...
...is probably indicated in women who are me...
...e is a history of recent or active vag...
...tential benefits of IV alteplase probably...
...nial cervical dissectionsIV alteplase in AISb,...
...erial dissectionIV alteplase usefulness and...
...ptured intracranial aneurys...
...tients presenting with AIS who are k...
...fulness and risk of IV alteplase in patie...
...racranial vascular malformations
...resenting with AIS who are known to har...
...of the increased risk of ICH in this population...
...MBs
...herwise eligible patients who have...
...erwise eligible patients who have previousl...
...nt tirofiban, eptifibatideThe effic...
...-axial intracranial neoplasmsIV altepl...
...e MIFor patients presenting with conc...
...cent MI...
...senting with AIS and a history of recent...
...r patients presenting with AIS and a his...
...presenting with AIS and a history of recent M...
Acute perica...
...or patients with major AIS likely to produc...
...r patients presenting with moderate AIS lik...
...atrial or ventricular throm...
...th major AIS likely to produce severe...
...tients presenting with moderate AIS...
...er cardiac disea...
...ents with major AIS likely to produce severe disab...
...ients presenting with major AIS likely to prod...
...okeIV alteplase is reasonable for the tre...
...alignancyThe safety and efficacy of IVb...
...gnancy...
...lteplase administration may be considered in preg...
...efficacy of IVb,d alteplase in the ea...
...thalmological conditionsUse of IV...
...diseaseIV alteplase for adults presenting...
Hyperdense MCA signIn patients with a hyperdense M...
...llicit drug useTreating clinicians s...
...mimicsThe risk of symptomatic intracranial...
...ntraindications...
...to 3-h window–Mild nondisabling strokeF...
...h window–Mild nondisabling strokeFor otherwise e...
...remains insufficient evidence to identify a thre...
...eplase should NOT be administered to...
...roke within 3 moUse of IV alteplase...
...re head trauma within 3 moIn AIS patient...
...maGiven the possibility of bleeding complicat...
...anial/intraspinal surgery within 3 moFor...
...cranial hemorrhageIVb,d,e alteplase admini...
...hemorrhageIVb,d,e alteplase is contraindicated...
...nancy or GI bleed within 21 dPatients with...
...lopathyThe safety and efficacy of IV3...
...WHIV alteplase should NOT be administered to pati...
...ors or factor Xa inhibitorsThe use of IV...
...nt AbciximabAbciximab should NOT be adminis...
...oncomitant IV aspirinIV aspirin should...
...tive endocarditisFor patients with AIS and sympto...
...h dissectionIV alteplase in AISb,d,e known...
...acranial neoplasmIV alteplase treatme...
...ss otherwise specified, these eligi...
Table 6. Treatment of AIS: IV Administratio...
...from Jauch et al. Copyright © 2013, America...
...IV Fibrinolytics and Sonothrombolysis...
...t may be reasonable to choose tenecteplase (si...
...eplase administered as a 0.4-mg/kg single I...
...dministration of IV defibrinogenating agents...
...sonothrombolysis as adjuvant therapy wit...
....7. Mechanical Thrombe...
....1. Concomitant With IV Alteplase...
...gible for IV alteplase should recei...
...r consideration for mechanical thrombectomy,...
....2. 0–6 Hours From Onse...
...should receive mechanical thrombectomy...
...t aspiration thrombectomy as first-pass me...
...e benefits are uncertain, the use of mechan...
...though its benefits are uncertain,...
...he benefits are uncertain, the use of mechan...
.... 6 to 24 Hours From Onset
...selected patients with AIS within 6–16 hours of...
...ted patients with AIS within 16–24 h...
....4. Technique...
...of stent retrievers is indicated in preferen...
...goal of the thrombectomy procedure should be re...
...nefit, reperfusion to mTICI grade 2b/3 should be...
...4-hour thrombectomy window evaluati...
...reasonable to select an anesthetic techniq...
...e of a proximal balloon guide catheter or a lar...
...tandem occlusions (both extracranial...
...y and efficacy of IV glycoprotein...
...echnical adjuncts, including intra-a...
...Blood Pressure Management...
In patients who undergo mechanical...
...s who undergo mechanical thrombectomy with...
...Other Endovascular Therapies...
...thrombectomy with stent retrievers is recommended...
...ra-arterial fibrinolysis initiated within...
....9. Antiplatelet Treat...
...stration of aspirin is recommended in...
...enting with minor noncardioembolic...
...acy of the IV glycoprotein IIb/IIIa inhibitors...
...agrelor is NOT recommended over aspir...
...dministration of the IV glycoprotein IIb/IIIa i...
...is NOT recommended as a substitut...
...10. Anticoagul...
...of urgent anticoagulation in patients with s...
...safety and usefulness of short-term anticoagula...
...present, the usefulness of argatroban, dabigatr...
...safety and usefulness of oral factor Xa...
...lation, with the goal of preventing early recu...
...pansion/Hemodilution, Vasodilators, and H...
...modilution by volume expansion is NOT rec...
...nistration of high-dose albumin is NOT rec...
...nistration of vasodilatory agents, such as pe...
...hanically augment cerebral blood flow for...
...Neuroprotective Agen...
...t, pharmacological or nonpharmacological treatme...
...13. Emergency Carotid Endarterectomy/Carotid A...
...f emergent or urgent carotid endarterec...
...ients with unstable neurological status...
....14. Other
...nscranial near-infrared laser therapy is NOT rec...
...ital Management of AIS: General Supportiv...
...1. Stroke Units
...se of comprehensive specialized stroke care (st...
...he use of standardized stroke care order sets i...
...Head Positioning...
The benefit of flat-head positioning e...
...commendations in this section are repea...
4.3. Supplemental...
...pport and ventilatory assistance are re...
...l oxygen should be provided to maintain oxygen s...
...l oxygen is NOT recommended in nonhypoxic patien...
...Recommendation 1 in this section is repeated...
4.4. Blood Press...
...ion and hypovolemia should be corrected to...
...nts with AIS, early treatment of hypertens...
...ts with BP ≥220/120 mm Hg who did not receiv...
...atients with BP
...tions in this section are repeated from...
...Temperature...
...of hyperthermia (temperature >38°C) should...
...AIS, the benefit of treatment with...
Note: Recommendations in this section ar...
.... Glucos...
...ypoglycemia (blood...
...vidence indicates that persistent in-hospital hy...
...Dysphagia...
...screening before the patient begins...
...c evaluation is reasonable for those...
...easonable for dysphagia screening to...
...t well established which instrument...
...ral hygiene protocols to reduce the...
...8. Nutrition
...should be started within 7 days of admission af...
...ents with dysphagia, it is reasonable...
...tional supplements are reasonable to consider fo...
...9. Deep Vein Thrombosis Prophyl...
...bile stroke patients without contraindic...
...he benefit of prophylactic-dose su...
...hylactic anticoagulation is used, the benef...
...c stroke, elastic compression stockings should NO...
...pression Screening...
...tion of a structured depression inventory is...
...nosed with poststroke depression shou...
4.11. Oth...
...ing hospitalization and inpatient r...
...ed to minimize or eliminate skin fric...
...sonable for patients and families with...
...se of prophylactic antibiotics has NOT been shown...
...e placement of indwelling bladder cathet...
....12. Rehabilitatio...
...ommended that early rehabilitation for hospitalize...
...recommended that stroke survivors rec...
...ed that all individuals with stroke be...
...ional assessment by a clinician with exper...
...e effectiveness of fluoxetine or other selecti...
...very early mobilization within 24 hou...
...-Hospital Management of AIS: Treatment of Ac...
...1 Brain Swell...
.... General Recommendati...
...s with large territorial cerebral and cerebell...
...en the risk of swelling and close monitor...
5.1.2. Medical Management
...of osmotic therapy for patients with clinical de...
...ief moderate hyperventilation (Pco...
...r barbiturates in the setting of ischem...
...of a lack of evidence of efficacy an...
5.1.3. Surgical Management-Supraten...
...though the optimal trigger for decomp...
...ts ≤60 years of age who deteriorate n...
...years of age who deteriorate neurologically w...
...urgical Management-Cerebellar Infarctio...
...lostomy is recommended in the trea...
...suboccipital craniectomy with dura...
...en considering decompressive suboccip...
...Seizures...
...seizures after stroke should be tre...
...use of antiseizure drugs is NOT recommend...
...Hospital Institution of Secondary Stro...
....1. Brain Ima...
...ion of recurrent stroke, the use of M...
...RI is reasonable in selected patients as...
...ctiveness of routine brain MRI to guide treatment...
...Vascular Imaging...
...or patients with nondisabling (mRS...
...tion of recurrent stroke, the use of...
...ntracranial vasculature to detect atherosclerotic...
Routine imaging of the intracranial va...
...ectrocardiographic Monitoring...
...onitoring is recommended to screen for at...
...ffectiveness of prolonged cardiac...
....2. Echocardiography
...vention of recurrent stroke, the us...
...chocardiography is reasonable in sele...
...fectiveness of routine echocardiograp...
....4. Glucos...
...AIS, it is reasonable to screen all...
...sts for Secondary Prevention...
The usefulness of screening for thrombophilic s...
...ning of patients with recent ischemic st...
...testing for antiphospholipid antibodies is NOT re...
...outine screening for hyperhomocyst...
...Antithrombotic Treatment...
....1. Noncardioembolic Stroke...
For patients with noncardioembolic AIS, the u...
...y secondary prevention in patients with noncar...
...patients who have a noncardioembolic A...
...ion might be considered in patients who are f...
...atients who have a noncardioembolic AIS while...
...with noncardioembolic ischemic str...
6.6.2. Atrial Fibr...
...ients with an AIS in the setting of atrial fibril...
...atients with a history of ischemic stroke,...
.... Arterial Dissection...
...ts with AIS and extracranial carotid or verteb...
...s with AIS and extracranial carotid or extracra...
...orrhagic Transformation
...patients with AIS and HT, initiation or...
...Carotid Revascularization...
...cularization is indicated for second...
...reatment of Hyperlipidemia...
.... General Principle...
...ients with AIS should be managed according to th...
...lts who are 20 years of age or olde...
...changes in lifestyle and effects o...
...of Lipid-lowering Drugs for Patients with Clin...
...s who are 75 years of age or younger...
...with clinical ASCVD in whom high-...
...at increased ASCVD risk with chronic, stable liv...
...patients with clinical ASCVD, who...
...ients with clinical ASCVD who are judg...
...18 list prices, PCSK9 inhibitors have a low-cost v...
...ts with clinical ASCVD who are on max...
...lder than 75 years of age with clinical ASCVD, it...
...n patients older than 75 years of age who are to...
In patients with clinical ASCVD who...
...cal aASCVD includes acute coronary syndrome, th...
...e 7. Risk StatusHaving trouble viewing...
...8.3 Implementati...
...atient risk discussion is recommended before i...
...h indication for statin therapy, identificati...
...with statin-associated side effects that are not...
...t increased ASCVD risk with severe statin...
6.8.4. Timin...
...ients already taking statins at the time of...
...patients with AIS who qualify for statin treatmen...
...Special Patient Group...
...of childbearing age who are treated with...
...men of childbearing age with hypercho...
...n adults with advanced kidney disease that...
...lts with advanced kidney disease who require...
...Institution of Antihypertensive Medications...
...ing or restarting antihypertensive...
...ng Cessation Intervention...
...with AIS should receive in-hospital initiation o...
For smokers with an AIS, who receive in-hospi...
...iders should strongly advise every pat...
...reasonable to advise patients afte...
...h an AIS, in-hospital initiation of varenicli...
....11. Stroke Education...
...education about stroke is recommended. Patients...