Early Management of Patients With Acute Ischemic Stroke
Key Points
Key Points
Treatment
...reatment...
...al Stroke Management and Systems of Care...
...rehospital Systems...
...alth leaders, along with medical professionals a...
Such educational programs should be designed to sp...
...on of the 9-1-1 system by patients or other...
...Assessment and Management...
...troke assessment tool by first aid providers, inc...
...ould provide prehospital notification to the r...
1.3. EMS Systems
Regional systems of stroke care sh...
...in coordination with local, regional...
...atients with a positive stroke screen or...
...n several IV alteplase-capable hospital options ex...
...tive prehospital procedures to iden...
...al Stroke Capabilities...
...ication of stroke centers by an independ...
...pital Stroke Teams...
...ganized protocol for the emergency...
...of an acute stroke team that includes phys...
...omponent quality improvement initi...
...s recommended that stroke systems of...
...ablishing and monitoring target tim...
...Telemedicine...
...es without in-house imaging interpretatio...
...ented within a telestroke network, t...
...of telemedicine/telestroke resources an...
...oke/teleradiology evaluations of AIS pat...
...ation of IV alteplase guided by telestroke consu...
...troke networks may be reasonable for triaging...
...ing alteplase decision-making suppo...
...Organization and Integration of Co...
...hospitals caring for stroke patients within a...
...nt services within a hospital that may be...
...l thrombectomy requires the patient to be at a...
...t may be useful for primary stroke center...
...y be useful for government agencie...
1.8. Establishment of Data Repos...
...cipation in a stroke data repository is reco...
...e System Care Quality Improvement P...
...care institutions should organize a multidisci...
...tcome measures should include adjustments for bas...
...ous quality improvement processes, i...
.... Emergency Evaluation and Treatm...
2.1. Stroke Scale...
...use of a stroke severity rating scale, prefe...
...le 1. National Institutes of Health Stroke Scale (...
.... Head and Neck Imagin...
2.2.1. Initial Imagi...
...ents with suspected acute stroke should rec...
...e established so that brain imaging s...
...ntrast CT (NCCT) is effective to exclud...
...nce (MR) imaging (MRI) is effective to exclude...
...P or MR angiography (MRA) with diffusion-...
.... IV Alteplase Eligibi...
Administration of IV alteplase in eli...
...atients eligible for IV alteplase,...
...s with AIS who awake with stroke symptoms or have...
...Mechanical Thrombectomy EligibilityāVess...
For patients who otherwise meet criteria...
...h suspected LVO who have not had n...
In patients with suspected intracranial L...
...s who are potential candidates for mechanical...
...asonable to incorporate collateral flow status in...
...nical Thrombectomy EligibilityāMultim...
...atients with AIS within 6ā24 hours of las...
...en evaluating patients with AIS within 6 h...
...r Diagnostic Tests...
...essment of blood glucose must precede the in...
...ne electrocardiographic assessment...
...seline troponin assessment is recommended in patie...
...fulness of chest radiographs in the...
...l Supportive Care and Emergency Tr...
...Airway, Breathing, and Oxygenati...
...ort and ventilatory assistance are...
...oxygen should be provided to maintain oxyge...
...ntal oxygen is NOT recommended in non-hypoxic pati...
...xygen (HBO) is NOT recommended for p...
...2. Blood Pressure...
...and hypovolemia should be corrected to m...
Patients who have elevated BP and are othe...
...nts for whom mechanical thrombectomy is planned a...
...fulness of drug-induced hypertension in...
...ptions to Treat Arterial Hypertension in...
...Temperature...
...of hyperthermia (temperature >38Ā°C) shou...
...nts with AIS, the benefit of treatment with ind...
...Blood Glucos...
...mia (blood glucose
...indicates that persistent in-hospital hyperglycem...
...IV Alteplase...
...General Principles...
...ible for IV alteplase, benefit of therapy is tim...
...patients undergoing fibrinolytic therapy, p...
...e potential risks should be discussed duri...
...ans should be aware that hypoglycemia and hype...
...time from onset of symptoms to treatment...
...5.2. Time Windows...
....9 mg/kg, maximum dose 90 mg over 60 minutes with...
IV alteplase (0.9 mg/kg, maximum dose 90 mg over...
....9 mg/kg, maximum dose 90 mg over 60...
.... Mild Stroke...
...rwise eligible patients with mild but disabling st...
For otherwise eligible patients with m...
...otherwise eligible patients with mi...
...erwise eligible patients with mild non-...
...r Specific Circumstances...
...r adults presenting with an AIS with known...
...ith a hyperdense MCA sign, IV alteplase c...
...5. Bleeding Risk...
...remely low risk of unsuspected abnormal platel...
...gible patients who have previously ha...
...e eligible patients who have previously had a hi...
...efficacy of the IV glycoprotein IIb/III...
...imab should NOT be administered co...
...hould NOT be administered within 90 minutes af...
...lase should NOT be administered to patients who...
3.5.6. Post-alteplase Tre...
...uld be maintained at
...thrombotic therapy (other than IV aspirin) with...
...nagement of Symptomatic Intracranial Ble...
...4. Management of Orolingual Angioedema...
...able 5. Eligibility Recommendation...
Indications
...aIVb alteplase (0.9 mg/kg, maximum do...
...AgeFor otherwise medically eligible pati...
...Severe strokeFor severe stroke, IVb alteplase i...
...3 hāMild disabling strokeFor otherwise...
...alteplase (0.9 mg/kg, maximum dose 90 mg o...
...geIV alteplase treatment in the 3- to 4.5-h...
...tment should be initiated as quickly as pos...
...alteplase is recommended in patients with...
...IVb alteplase is recommended in otherwise elig...
...administration is recommended in the setting...
...tiplatelet therapy...
...se is recommended for patients taking antipla...
...V alteplase is recommended for patient...
...e renal diseaseIn patients with end-stage ren...
...ditional recommendations for treatment withĀ IVĀ ...
...o 4.5 hāAgeFor patients >80 y of age presentin...
...Diabetes mellitus and prior strokeIn AIS...
...Severe strokeThe benefit of IV altepla...
...d disabling strokeFor otherwise eligible...
...d unknown time of onsetIV alteplase (0.9 mg/kg,...
...reexisting disabi...
...sting disability does not seem to indep...
...reexisting dementia may benefit fr...
...improvementIVb alteplase treatment is reas...
...onsetIVb,d alteplase is reasonable in pati...
...lucoseTreatment with IV alteplase in patients with...
...agulopathy...
...d alteplase may be reasonable in patients who h...
...ety and efficacy of IV alteplase for acute str...
...punctureIV alteplase may be considered for...
...al punctureThe safety and efficacy of administeri...
...t major traumaIn AIS patients with recent ma...
...ecent major surgeryUse of IV alteplase in ca...
...d genitourinary bleedingReported literature detai...
Menstruat...
...is probably indicated in women who...
...history of recent or active vaginal bleeding c...
Because the potential benefits of IV alteplase pro...
...racranial cervical dissectionsIV a...
...rterial dissectionIV alteplase usefuln...
...ruptured intracranial aneurysm...
For patients presenting with AIS who are known to...
...s and risk of IV alteplase in patients wi...
...anial vascular malformations...
...ts presenting with AIS who are known to h...
...he increased risk of ICH in this populat...
CMBs
...eligible patients who have previou...
...herwise eligible patients who have previous...
...itant tirofiban, eptifibatideThe effi...
...l intracranial neoplasmsIV alteplase treatment...
...ents presenting with concurrent AIS and acute MI,...
Recent M...
...r patients presenting with AIS and a histo...
...patients presenting with AIS and a history of...
...atients presenting with AIS and a history of...
...pericarditis...
...ith major AIS likely to produce seve...
...r patients presenting with moderate...
...ial or ventricular thrombus...
...or patients with major AIS likely to produce se...
...ts presenting with moderate AIS li...
...her cardiac dise...
...ith major AIS likely to produce severe disabili...
...nts presenting with major AIS likely to produc...
...cedural strokeIV alteplase is reaso...
Systemic malignancyThe safety and efficacy of...
...regnanc...
...eplase administration may be consider...
...y and efficacy of IVb,d alteplase i...
...gical conditionsUse of IV alteplase in patients...
...l diseaseIV alteplase for adults present...
Hyperdense MCA signIn patients with a hy...
...Treating clinicians should be aware that i...
...imicsThe risk of symptomatic intracranial h...
...ntraindication...
...to 3-h windowāMild nondisabling strok...
...h windowāMild nondisabling strokeFor otherwi...
...s insufficient evidence to identify a th...
...should NOT be administered to a patient whose...
...ic stroke within 3 moUse of IV alteplase in pat...
...uma within 3 moIn AIS patients with r...
...ead traumaGiven the possibility of b...
Intracranial/intraspinal surgery within...
...of intracranial hemorrhageIVb,d,e altepl...
...ubarachnoid hemorrhageIVb,d,e alte...
...gnancy or GI bleed within 21 dPati...
...The safety and efficacy of IV3 alteplase for acu...
...lase should NOT be administered to patie...
...bin inhibitors or factor Xa inhibit...
...t AbciximabAbciximab should NOT be administ...
...mitantĀ IVĀ aspirinIV aspirin should NOT be a...
...docarditisFor patients with AIS and symptoms cons...
...h dissectionIV alteplase in AISb,d,e known or...
...ntracranial neoplasmIV alteplase treatment for pa...
...otherwise specified, these eligibility recommenda...
...ment of AIS: IV Administration of Alteplase...
Reprinted from Jauch et al. Copyright Ā© 2013,...
.... Other IV Fibrinolytics and Sono...
...ay be reasonable to choose tenecteplase...
...dministered as a 0.4-mg/kg single IV b...
...e administration of IV defibrinogenati...
...thrombolysis as adjuvant therapy wi...
...hanical Thrombectomy...
...7.1. Concomitant With IV Alteplase
...ligible for IV alteplase should receive...
...ts under consideration for mechanica...
...7.2. 0ā6 Hours Fro...
...should receive mechanical thrombec...
...piration thrombectomy as first-pass mechanical...
...efits are uncertain, the use of mechanical...
...lthough its benefits are uncertain, the use...
...ough the benefits are uncertain, the use of mec...
...6 to 24 Hours From Ons...
...d patients with AIS within 6ā16 hours of last...
...ted patients with AIS within 16ā24 hours of...
3.7.4. Techni...
...nt retrievers is indicated in preference to t...
...goal of the thrombectomy procedur...
...t, reperfusion to mTICI grade 2b/3 shoul...
...- to 24-hour thrombectomy window evaluation and...
...asonable to select an anesthetic technique...
...proximal balloon guide catheter or a lar...
...of tandem occlusions (both extracranial and...
...afety and efficacy of IV glycoprotein IIb/IIIa...
...f salvage technical adjuncts, including intra-a...
...Blood Pressure Management
...who undergo mechanical thrombectomy, it is re...
...ho undergo mechanical thrombectomy w...
...Other Endovascular Therapies...
...al thrombectomy with stent retrievers is re...
...erial fibrinolysis initiated within 6 hour...
...ntiplatelet Treatme...
...ion of aspirin is recommended in patien...
...nts presenting with minor noncardioe...
...e efficacy of the IV glycoprotein IIb/III...
...icagrelor is NOT recommended over as...
...nistration of the IV glycoprotein I...
...in is NOT recommended as a substitute for acu...
3.10. Anticoagu...
...of urgent anticoagulation in patie...
...nd usefulness of short-term anticoagulation fo...
...present, the usefulness of argatroban, dabigatran,...
...safety and usefulness of oral factor Xa inhibit...
...agulation, with the goal of preventing e...
...pansion/Hemodilution, Vasodilators, and H...
...y volume expansion is NOT recommended for treatm...
...stration of high-dose albumin is NOT recommended...
The administration of vasodilatory agent...
...nically augment cerebral blood flow for the tr...
.... Neuroprotective A...
...t present, pharmacological or nonpharmac...
...rgency Carotid Endarterectomy/Carotid A...
...e usefulness of emergent or urgent ca...
...ts with unstable neurological status (eg, s...
....14. Other...
Transcranial near-infrared laser therapy is...
...ital Management of AIS: General Suppor...
4.1. Stroke U...
...of comprehensive specialized stroke care (strok...
...standardized stroke care order sets is recomm...
...Head Positioning
...f flat-head positioning early after hosp...
...te: Recommendations in this section a...
...plemental Oxygen...
...ort and ventilatory assistance are recommende...
...emental oxygen should be provided...
...ental oxygen is NOT recommended in nonhypox...
...ote: Recommendation 1 in this section is r...
...Blood Pressure...
...hypovolemia should be corrected to maintain...
...ients with AIS, early treatment of hyperte...
In patients with BP ā„220/120 mm Hg who...
...patients with BP...
...tions in this section are repeated...
4.5. Tempera...
...perthermia (temperature >38Ā°C) should be identif...
...s with AIS, the benefit of treatment with induce...
...ote: Recommendations in this section are repe...
....6. Glucose
...mia (blood glucose...
...dence indicates that persistent in-h...
...Dysphagia...
...creening before the patient begins eatin...
...pic evaluation is reasonable for those...
...able for dysphagia screening to be perfor...
...well established which instrument to choose for ev...
...g oral hygiene protocols to reduce the risk...
...8. Nutrition...
...ould be started within 7 days of admission...
...patients with dysphagia, it is reasonable to...
...lements are reasonable to consider for patient...
...Vein Thrombosis Prophylax...
...e stroke patients without contrain...
...of prophylactic-dose subcutaneous he...
...n prophylactic anticoagulation is used, the benefi...
In ischemic stroke, elastic compress...
...0. Depression Screening...
...f a structured depression inventory is recom...
...ents diagnosed with poststroke depression sh...
4.11. Oth...
During hospitalization and inpatient rehabil...
...mmended to minimize or eliminate skin friction,...
...easonable for patients and families with str...
...use of prophylactic antibiotics has NOT be...
...ne placement of indwelling bladder cathet...
...12. Rehabilitat...
...s recommended that early rehabilitat...
It is recommended that stroke survivors...
...recommended that all individuals with stroke b...
...sessment by a clinician with expertise in reha...
...ss of fluoxetine or other selective serotoni...
...gh-dose, very early mobilization within...
...Management of AIS: Treatment of Acute Complica...
...1 Brain Swell...
....1.1. General Recommend...
...ts with large territorial cerebral...
Measures to lessen the risk of swelling and cl...
....2. Medical Managem...
Use of osmotic therapy for patients with clinical...
...erate hyperventilation (Pco2 target, 30ā34 mm...
...a or barbiturates in the setting of ischemic cere...
...of a lack of evidence of efficacy an...
...Management-Supratentorial Infarction...
...ptimal trigger for decompressive cra...
...ients ā¤60 years of age who deteriorate n...
...0 years of age who deteriorate neur...
...rgical Management-Cerebellar Infarction
...omy is recommended in the treatment of o...
Decompressive suboccipital craniec...
...hen considering decompressive suboccipital crani...
...2. Seizure...
...rent seizures after stroke should be...
...use of antiseizure drugs is NOT recomme...
...n-Hospital Institution of Secondar...
...Brain Imagin...
...of recurrent stroke, the use of MRI is...
...rain MRI is reasonable in selected pati...
The effectiveness of routine brain...
...Vascular Imaging...
...nts with nondisabling (mRS score 0ā2) AIS in the...
...n of recurrent stroke, the use of int...
...maging of the intracranial vasculature to...
...ing of the intracranial vasculature to...
6.3.1. Electrocardiographic...
...ardiac monitoring is recommended to screen...
...ess of prolonged cardiac monitoring duri...
...3.2. Echocardiogra...
...ntion of recurrent stroke, the use of echocardio...
...ocardiography is reasonable in selected patie...
...effectiveness of routine echocardiography to guide...
...4. Gluco...
...fter AIS, it is reasonable to screen all...
...ests for Secondary Prevention...
...lness of screening for thrombophilic stat...
...ng of patients with recent ischemi...
...outine testing for antiphospholipid ant...
...ine screening for hyperhomocysteinemia am...
...thrombotic Treatment...
....6.1. Noncardioembolic Strok...
...or patients with noncardioembolic AIS, the...
...early secondary prevention in patients w...
...o have a noncardioembolic AIS while taking aspiri...
...coagulation might be considered in patient...
...o have a noncardioembolic AIS while taking antipla...
...n patients with noncardioembolic ischemic stroke,...
...6.2. Atrial Fibrill...
...most patients with an AIS in the setting of atri...
...ents with a history of ischemic stroke, atri...
...3. Arterial Dissecti...
...tients with AIS and extracranial carotid or ver...
...r patients with AIS and extracranial carot...
...4. Hemorrhagic Transformation...
...nts with AIS and HT, initiation or contin...
...tid Revascularization...
...ularization is indicated for secondary prevention...
...ment of Hyperlipidemia...
...General Principles...
...th AIS should be managed according to the 201...
...dults who are 20 years of age or older...
...changes in lifestyle and effects of LDL-Cā...
...oice of Lipid-lowering Drugs for Patients with Cl...
...who are 75 years of age or younger...
...ients with clinical ASCVD in whom high-intensity...
...ts at increased ASCVD risk with chronic...
...atients with clinical ASCVD, who are judged to be...
...atients with clinical ASCVD who are judged...
...list prices, PCSK9 inhibitors have a low-cost v...
...clinical ASCVD who are on maximally tolera...
In patients older than 75 years of a...
...patients older than 75 years of age who...
...s with clinical ASCVD who are receiving maximally...
...aASCVD includes acute coronary syndrome, those...
...StatusHaving trouble viewing table? Expand...
...8.3 Implementation...
...ient risk discussion is recommended...
...patients with indication for statin therapy,...
...with statin-associated side effects that...
...n patients at increased ASCVD risk with...
....8.4. Timing...
...ong patients already taking statins at th...
...ts with AIS who qualify for statin treatm...
...cial Patient Groups...
...en of childbearing age who are treated with...
...ldbearing age with hypercholesterolemi...
In adults with advanced kidney disea...
...advanced kidney disease who require dialysis trea...
...of Antihypertensive Medications...
...or restarting antihypertensive therapy during...
6.10. Smoking Cessation Interventio...
...AIS should receive in-hospital ini...
...or smokers with an AIS, who receive in-hos...
...re providers should strongly advis...
...le to advise patients after ischem...
...rs with an AIS, in-hospital initiation of...
...Stroke Education...
...n about stroke is recommended. Patients s...