Early Management of Patients With Acute Ischemic Stroke
Key Points
Key Points
Treatment
...eatmen...
...tal Stroke Management and Systems of...
...hospital Systems...
...leaders, along with medical professionals...
...l programs should be designed to speci...
...n of the 9-1-1 system by patients or other members...
...sessment and Management...
...of a stroke assessment tool by first aid provider...
...sonnel should provide prehospital not...
...EMS Systems...
...s of stroke care should be develop...
...eaders, in coordination with local, regional, a...
...th a positive stroke screen or who are stron...
...en several IV alteplase-capable hospi...
...hospital procedures to identify patients who are i...
...ital Stroke Capabilities...
...ation of stroke centers by an indepe...
...5. Hospital Stroke Tea...
...rganized protocol for the emergency evaluatio...
...signation of an acute stroke team th...
...lticomponent quality improvement initiatives, wh...
...s recommended that stroke systems of care be de...
...tablishing and monitoring target time...
1.6. Telemedicine
...s without in-house imaging interpretat...
...mented within a telestroke network, teleradi...
...edicine/telestroke resources and systems...
...troke/teleradiology evaluations of AIS patients ca...
...ration of IV alteplase guided by telestrok...
...rks may be reasonable for triaging patients wi...
...plase decision-making support via t...
.... Organization and Integration of Compon...
...caring for stroke patients within...
Different services within a hospital that may be...
...hrombectomy requires the patient t...
...be useful for primary stroke centers...
...e useful for government agencies and third-pa...
...Establishment of Data Repositor...
...icipation in a stroke data repository...
...System Care Quality Improvement P...
...e institutions should organize a m...
Stroke outcome measures should include adjust...
...s quality improvement processes, implemente...
...ncy Evaluation and Treatment...
2.1. Stroke S...
...e of a stroke severity rating scale, preferably...
...able 1. National Institutes of Health Stroke Sca...
...ead and Neck Imaging
...1. Initial Imaging...
...l patients with suspected acute stroke sh...
...e established so that brain imaging...
...CT (NCCT) is effective to exclude ICH bef...
...onance (MR) imaging (MRI) is effecti...
...ith CTP or MR angiography (MRA) with diffusi...
....2. IV Alteplase Eligibility...
...inistration of IV alteplase in elig...
...n patients eligible for IV alteplase,...
...th AIS who awake with stroke symptoms o...
...al Thrombectomy Eligibility–Vessel...
...ients who otherwise meet criteria for mech...
...patients with suspected LVO who have not h...
...with suspected intracranial LVO and n...
In patients who are potential candidates for mec...
...reasonable to incorporate collatera...
...cal Thrombectomy Eligibility–Multimoda...
...cting patients with AIS within 6–24 hours of l...
...evaluating patients with AIS within...
.... Other Diagnostic Tests...
...ssment of blood glucose must precede th...
...cardiographic assessment is recommended in patient...
...troponin assessment is recommended in patie...
Usefulness of chest radiographs in the h...
...l Supportive Care and Emergency Treat...
...Breathing, and Oxygenation...
...upport and ventilatory assistance are recommende...
...pplemental oxygen should be provided to...
...l oxygen is NOT recommended in non-h...
...oxygen (HBO) is NOT recommended for patients wi...
...Blood Pressure...
...nd hypovolemia should be corrected to maintain sy...
...nts who have elevated BP and are otherwise...
...for whom mechanical thrombectomy is planned and...
...usefulness of drug-induced hypertensio...
...s to Treat Arterial Hypertension in Patients with...
....3. Temperature...
...erthermia (temperature >38°C) should b...
...ents with AIS, the benefit of treatment w...
3.4. Blood G...
...cemia (blood glucose...
...ates that persistent in-hospital hypergl...
...5. IV Alteplase...
3.5.1. General Princi...
...ts eligible for IV alteplase, benefit o...
...ients undergoing fibrinolytic therapy...
...l risks should be discussed during IV alteplase...
...clinicians should be aware that hypoglycemia and...
...e from onset of symptoms to treatment has such a p...
3.5.2. Time Windo...
...e (0.9 mg/kg, maximum dose 90 mg over 60 minutes...
....9 mg/kg, maximum dose 90 mg over 60 minutes with...
...(0.9 mg/kg, maximum dose 90 mg over...
....5.3. Mild Strok...
...rwise eligible patients with mild but disabling...
...rwise eligible patients with mild...
...ligible patients with mild nondisabli...
...rwise eligible patients with mild non-disab...
...her Specific Circumstances...
...or adults presenting with an AIS with...
...a hyperdense MCA sign, IV alteplase c...
...5. Bleeding Risk...
...emely low risk of unsuspected abnormal pl...
...otherwise eligible patients who have...
...erwise eligible patients who have...
...icacy of the IV glycoprotein IIb/I...
...ximab should NOT be administered concurrently wi...
...rin should NOT be administered within 90...
...alteplase should NOT be administered to patient...
.... Post-alteplase Treatme...
...ould be maintained at...
The risk of antithrombotic therapy (other than I...
...ment of Symptomatic Intracranial Bleeding Occurri...
...ment of Orolingual Angioedema Associated w...
...igibility Recommendations for IV Alteplase in...
Indicati...
...aIVb alteplase (0.9 mg/kg, maximum dos...
...–AgeFor otherwise medically eligible patients â...
...h–Severe strokeFor severe stroke, IVb alteplas...
...–Mild disabling strokeFor otherwise...
...alteplase (0.9 mg/kg, maximum dose...
...–4.5 h–AgeIV alteplase treatment in th...
...ent should be initiated as quickly...
BPIV alteplase is recommended in patients...
...glucoseIVb alteplase is recommended in otherwise e...
...TIV alteplase administration is re...
...or antiplatelet therapy
...plase is recommended for patients...
...lteplase is recommended for patients taking ant...
...age renal diseaseIn patients with end-stage...
Additional recommendations for tre...
...h–AgeFor patients >80 y of age presen...
...o 4.5 h–Diabetes mellitus and prior strokeIn AI...
...4.5 h–Severe strokeThe benefit of IV...
...“Mild disabling strokeFor otherwise eligi...
...up and unknown time of onsetIV alteplase (0.9...
...eexisting disab...
...disability does not seem to independently inc...
Patients with preexisting dementia may benefi...
...tIVb alteplase treatment is reasonable for...
...etIVb,d alteplase is reasonable in patients w...
...Treatment with IV alteplase in patients with AIS...
...agulopathy...
...ase may be reasonable in patients who have a hi...
...he safety and efficacy of IV alteplase for ac...
...alteplase may be considered for pati...
Arterial punctureThe safety and eff...
...aumaIn AIS patients with recent major trau...
...ajor surgeryUse of IV alteplase in carefully...
...and genitourinary bleedingReported literat...
Menstruati...
...s probably indicated in women who ar...
...history of recent or active vaginal bleeding ca...
...se the potential benefits of IV alteplas...
...acranial cervical dissectionsIV altepla...
...acranial arterial dissectionIV alteplase use...
...ured intracranial aneu...
...or patients presenting with AIS who are...
...isk of IV alteplase in patients wi...
...racranial vascular malformati...
...presenting with AIS who are known...
...of the increased risk of ICH in this populati...
CMB...
...n otherwise eligible patients who have...
...eligible patients who have previously had a h...
...itant tirofiban, eptifibatideThe efficacy...
...acranial neoplasmsIV alteplase treatment is pro...
...IFor patients presenting with concu...
...ecent...
...senting with AIS and a history of re...
...esenting with AIS and a history of...
...r patients presenting with AIS and a hist...
Acute pericarditi...
...tients with major AIS likely to produ...
...patients presenting with moderate...
...atrial or ventricular thrombus
...ith major AIS likely to produce severe disab...
...r patients presenting with moderate AIS...
...cardiac diseases
...s with major AIS likely to produce severe disabi...
...senting with major AIS likely to produce...
...ural strokeIV alteplase is reasona...
...ncyThe safety and efficacy of IVb...
...egnancy...
...plase administration may be considered i...
...y and efficacy of IVb,d alteplase in the early pos...
...lmological conditionsUse of IV alteplase...
...cell diseaseIV alteplase for adults p...
...MCA signIn patients with a hyperdens...
...drug useTreating clinicians should be...
...mimicsThe risk of symptomatic int...
...ontraindicati...
...window–Mild nondisabling strokeFor otherwise eli...
3- to 4.5-h window–Mild nondisabling strokeF...
...mains insufficient evidence to identify a thresho...
...teplase should NOT be administered to...
...troke within 3 moUse of IV alteplase in patien...
...ma within 3 moIn AIS patients with recent...
...traumaGiven the possibility of bleeding co...
...traspinal surgery within 3 moFor patients with...
...ntracranial hemorrhageIVb,d,e altepl...
...emorrhageIVb,d,e alteplase is contraindicated...
...malignancy or GI bleed within 21 dPatien...
...e safety and efficacy of IV3 alteplase for ac...
...MWHIV alteplase should NOT be admini...
...bitors or factor Xa inhibitorsThe use of IVb...
...ant AbciximabAbciximab should NOT be admini...
...ncomitant IV aspirinIV aspirin should NOT...
...endocarditisFor patients with AIS and symptoms co...
...ssectionIV alteplase in AISb,d,e known or suspecte...
...ntra-axial intracranial neoplasmIV a...
...otherwise specified, these eligibility r...
...ment of AIS: IV Administration of Al...
...ed from Jauch et al. Copyright © 2013, Americ...
...Other IV Fibrinolytics and Sonothrombolysis...
...be reasonable to choose tenecteplase (single IV b...
...cteplase administered as a 0.4-mg/kg sin...
...ion of IV defibrinogenating agents or IV...
The use of sonothrombolysis as adju...
....7. Mechanical Thro...
...omitant With IV Alteplase...
...eligible for IV alteplase should receive IV alte...
...atients under consideration for mechanical throm...
3.7.2. 0–6 Hours From Ons...
...ients should receive mechanical thrombectomy with...
...aspiration thrombectomy as first-pass mechanical t...
...nefits are uncertain, the use of mechanica...
...ough its benefits are uncertain, the use...
...the benefits are uncertain, the use of mecha...
...to 24 Hours From Onset...
...tients with AIS within 6–16 hours of l...
...lected patients with AIS within 16–24...
....4. Technique
...e of stent retrievers is indicated in prefe...
...l goal of the thrombectomy procedure should...
...enefit, reperfusion to mTICI grade 2b/3 should...
...hour thrombectomy window evaluation...
...ble to select an anesthetic technique duri...
...f a proximal balloon guide catheter or a large-b...
...tandem occlusions (both extracranial...
...safety and efficacy of IV glycoprotein IIb/I...
...vage technical adjuncts, including in...
...od Pressure Management...
...who undergo mechanical thrombectomy,...
...patients who undergo mechanical thrombec...
...Other Endovascular Therapi...
...mbectomy with stent retrievers is...
...ibrinolysis initiated within 6 hours of s...
....9. Antiplatelet T...
...f aspirin is recommended in patients with A...
...ents presenting with minor noncardioemboli...
...efficacy of the IV glycoprotein IIb/IIIa inhibit...
...T recommended over aspirin for treatment...
...he administration of the IV glycopro...
...s NOT recommended as a substitute for ac...
...Anticoagulants...
...ness of urgent anticoagulation in patients with...
...and usefulness of short-term anticoagulation f...
...he usefulness of argatroban, dabigat...
...nd usefulness of oral factor Xa inhibitors in...
...anticoagulation, with the goal of prevent...
...11. Volume Expansion/Hemodilution,...
...by volume expansion is NOT recommen...
...inistration of high-dose albumin is NOT recommende...
...tion of vasodilatory agents, such as pentoxifyllin...
Devices to mechanically augment cere...
....12. Neuroprotective Agents...
...t present, pharmacological or nonpharmacologica...
...Emergency Carotid Endarterectomy/Carotid...
...sefulness of emergent or urgent car...
...unstable neurological status (eg, stroke-in-...
....14. Othe...
...ranscranial near-infrared laser therapy i...
...al Management of AIS: General Supp...
...1. Stroke Units...
...omprehensive specialized stroke car...
...ndardized stroke care order sets is recommended...
...ead Positioning
The benefit of flat-head positioning ea...
...ecommendations in this section are repeat...
...Supplemental Oxyg...
...and ventilatory assistance are recommen...
...al oxygen should be provided to maint...
...upplemental oxygen is NOT recommended...
...commendation 1 in this section is repeated...
...lood Pressure...
...ypotension and hypovolemia should be corrected to...
...ents with AIS, early treatment of hy...
...patients with BP ≥220/120 mm Hg wh...
...patients with BP...
...: Recommendations in this section are r...
...Temperature...
...of hyperthermia (temperature >38°C) sho...
...ts with AIS, the benefit of treatmen...
...endations in this section are repeat...
.... Glucos...
...emia (blood glucose...
...cates that persistent in-hospital hyper...
4.7. Dysphagia
...screening before the patient begins eating, drink...
...pic evaluation is reasonable for those pati...
...s reasonable for dysphagia screening to be perf...
...well established which instrument to...
...nting oral hygiene protocols to reduce the...
...8. Nutritio...
...diet should be started within 7 days of adm...
...ients with dysphagia, it is reasonable to initial...
...onal supplements are reasonable to...
...in Thrombosis Prophylaxis...
...ile stroke patients without contraindicati...
...of prophylactic-dose subcutaneous heparin...
...prophylactic anticoagulation is used, the benefi...
...emic stroke, elastic compression stockings s...
.... Depression Screen...
...dministration of a structured depression inv...
...diagnosed with poststroke depression should b...
...11. Other...
During hospitalization and inpatient rehabilita...
...d to minimize or eliminate skin friction, to mini...
...nable for patients and families with...
...ine use of prophylactic antibiotics has NOT...
...acement of indwelling bladder cathet...
...Rehabilitation...
...s recommended that early rehabilitation for hosp...
...mmended that stroke survivors receive rehabi...
...ommended that all individuals with stroke be p...
...essment by a clinician with expertise...
...veness of fluoxetine or other selecti...
...e, very early mobilization within 24...
5. In-Hospital Management of AIS: Treatmen...
...1 Brain Swel...
...eneral Recommendations
...ts with large territorial cerebral and cerebe...
...essen the risk of swelling and close m...
...edical Management...
...ic therapy for patients with clinical d...
...erate hyperventilation (Pco2 target, 30...
...barbiturates in the setting of ischemic cerebral...
...se of a lack of evidence of efficacy and the po...
....1.3. Surgical Management-Supratentorial...
...timal trigger for decompressive craniectomy i...
...ents ≤60 years of age who deteriorate neuro...
...nts >60 years of age who deteriorate neurolog...
...rgical Management-Cerebellar Infar...
...lostomy is recommended in the treatment of ob...
...suboccipital craniectomy with dural expansion sh...
...en considering decompressive suboccipital c...
.... Seizures...
...ures after stroke should be treated in a manner...
...c use of antiseizure drugs is NOT recomm...
...ital Institution of Secondary Stroke Prevention...
...1. Brain Imagi...
...vention of recurrent stroke, the use of...
...reasonable in selected patients as part of a...
...s of routine brain MRI to guide tre...
.... Vascular Imaging...
For patients with nondisabling (mRS score...
...or prevention of recurrent stroke, the u...
...aging of the intracranial vasculature to d...
...maging of the intracranial vasculat...
....3.1. Electrocardiographic Monitoring...
...monitoring is recommended to screen fo...
...he effectiveness of prolonged cardiac mon...
...Echocardiograph...
...or prevention of recurrent stroke, the use of...
...y is reasonable in selected patients as...
The effectiveness of routine echocardiogr...
...Glucose...
...AIS, it is reasonable to screen all p...
...ther Tests for Secondary Prevention...
...sefulness of screening for thrombophilic stat...
...creening of patients with recent i...
...testing for antiphospholipid antibodies is NOT...
...screening for hyperhomocysteinemia a...
....6. Antithrombotic Treatmen...
6.6.1. Noncardioembol...
...nts with noncardioembolic AIS, the use of anti...
...arly secondary prevention in patients with noncar...
...ts who have a noncardioembolic AIS...
...ion might be considered in patients wh...
...patients who have a noncardioembolic AIS wh...
...patients with noncardioembolic ische...
....2. Atrial Fibrillati...
...ost patients with an AIS in the setting of atri...
...h a history of ischemic stroke, atrial...
...Arterial Dissection...
...tients with AIS and extracranial carotid...
...patients with AIS and extracranial caroti...
...Hemorrhagic Transformat...
...ients with AIS and HT, initiation or cont...
...arotid Revascularizat...
...n revascularization is indicated f...
...eatment of Hyperlipide...
...eneral Principles...
...S should be managed according to the...
...who are 20 years of age or older and not on lip...
...hanges in lifestyle and effects of LDL-C...
...oice of Lipid-lowering Drugs for Patients wi...
...n patients who are 75 years of age or young...
...s with clinical ASCVD in whom high-intensit...
...nts at increased ASCVD risk with chron...
...with clinical ASCVD, who are judged to be...
...atients with clinical ASCVD who are ju...
...st prices, PCSK9 inhibitors have a low-...
...ents with clinical ASCVD who are on maximally t...
...older than 75 years of age with cli...
...ients older than 75 years of age who are tol...
...nts with clinical ASCVD who are rec...
...aASCVD includes acute coronary syndrome, those w...
Table 7. Risk StatusHaving trouble view...
...Implementation...
...n-patient risk discussion is recommen...
...ents with indication for statin therapy, ide...
In patients with statin-associated side effects th...
...at increased ASCVD risk with severe...
...4. Timing...
...already taking statins at the time o...
...h AIS who qualify for statin treatme...
...5 Special Patient Grou...
...hildbearing age who are treated with...
...bearing age with hypercholesterolemia who...
...th advanced kidney disease that requi...
...th advanced kidney disease who require...
...tution of Antihypertensive Medications...
...g or restarting antihypertensive therap...
....10. Smoking Cessation Interven...
...h AIS should receive in-hospital init...
...okers with an AIS, who receive in-h...
...viders should strongly advise every patie...
...reasonable to advise patients after isc...
...okers with an AIS, in-hospital initiati...
...11. Stroke Education...
Patient education about stroke is rec...