AHA/ASA guideline recommendations for of Early management of acute ischemic stroke

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Aslam, M.B.B.S[2] Syed Hassan A. Kazmi BSc, MD [3]

2018 AHA/ASA Guidelines for the early Management of Acute Ischemic Stroke

The AHA/ASA published the following guidelines for management of acute ischemic stroke in March, 2018:[1]

Prehospital Stroke Management

Class I
"1. To increase both the number of patients who are treated and the quality of care, educational stroke programs for physicians, hospital personnel, and EMS personnel are recommended. (Level of Evidence: B)"
"2. Activation of the 9-1-1 system by patients or other members of the public is strongly recommended. Dispatchers should make stroke a priority dispatch, and transport times should be minimized. (Level of Evidence: B)"
"3. Prehospital care providers should use prehospital stroke assessment tools, such as the Los Angeles, Prehospital Stroke Screen or Cincinnati Prehospital Stroke Scale . (Level of Evidence: B)"
"4. EMS personnel should begin the initial management of stroke in the field. Development of a stroke protocol to be used by EMS personnel is strongly encouraged. (Level of Evidence: B)"
"5. Patients should be transported rapidly to the closest available certified PSC or CSC or, if no such centers exist, the most appropriate institution that provides emergency stroke care as described in the statement. (Level of Evidence: A)"
"6. EMS personnel should provide prehospital notification to the receiving hospital that a potential stroke patient is en route so that the appropriate hospital resources may be mobilized before patient arrival. (Level of Evidence: B)"

Designation of Stroke Centers and Stroke Care, Quality Improvement Process

Class I
"1. The creation of PSCs is recommended. The organization of such resources will depend on local resources. The stroke system design of regional ASRHs and PSCs that provide emergency care and that are closely associated with a CSC, which provides more extensive care, has considerable appeal. (Level of Evidence: B)"
"2. Certification of stroke centers by an independent external body, such as TJC or state health department, is recommended. Additional medical centers should seek such certification. (Level of Evidence: B)"
"3. Healthcare institutions should organize a multidisciplinary quality improvement committee to review and monitor stroke care quality benchmarks, indicators, evidence-based practices, and outcomes. The formation of a clinical process improvement team and the establishment of a stroke care data bank are helpful for such quality of care assurances. The data repository can be used to identify the gaps or disparities in quality stroke care. Once the gaps have been identified, specific interventions can be initiated to address these gaps or disparities. (Level of Evidence: B)"
"4. For patients with suspected stroke, EMS should bypass hospitals that do not have resources to treat stroke and go to the closest facility most capable of treating acute stroke. (Level of Evidence: B)"
"5. For sites without in-house imaging interpretation expertise, teleradiology systems approved by the Food and Drug Administration (FDA) or equivalent organization are recommended for timely review of brain CT and MRI scans in patients with suspected acute stroke. (Level of Evidence: B)"
"6. When implemented within a telestroke network, teleradiology systems approved by the FDA (or equivalent organization) are useful in supporting rapid imaging interpretation in time for fibrinolysis decision making. (Level of Evidence: B)"
"7. The development of CSCs is recommended. (Level of Evidence: C)"
Class IIa
"1. Implementation of telestroke consultation in conjunction with stroke education and training for healthcare providers can be useful in increasing the use of intravenous rtPA at community hospitals without access to adequate onsite stroke expertise (Level of Evidence: B)"
"2. The creation of ASRHs can be useful. As with PSCs, the organization of such resources will depend on local resources. The stroke system design of regional ASRHs and PSCs that provide emergency care and that are closely associated with a CSC, which provides more extensive care, has considerable appeal (Level of Evidence: C)"

Emergency Triage and Initial Evaluation

Class I
"1. An organized protocol for the emergency evaluation of patients with suspected stroke is recommended. The goal is to complete an evaluation and to begin fibrinolytic treatment within 60 minutes of the patient’s arrival in an ED. Designation of an acute stroke team that includes physicians, nurses, and laboratory/radiology personnel is encouraged. Patients with stroke should have a careful clinical assessment, including neurological examination. (Level of Evidence: B)"
"2. The use of a stroke rating scale, preferably the NIHSS, is recommended. (Level of Evidence: B)"
"3. A limited number of hematologic, coagulation, and biochemistry tests are recommended during the initial emergency evaluation, and only the assessment of blood glucose must precede the initiation of intravenous rtPA. (Level of Evidence: B)"
"4. Baseline electrocardiogram assessment is recommended in patients presenting with acute ischemic stroke but should not delay initiation of intravenous rtPA. (Level of Evidence: B)"
"5. Baseline troponin assessment is recommended in patients presenting with acute ischemic stroke but should not delay initiation of intravenous rtPA. (Level of Evidence: C)"
Class IIb
"1. The usefulness of chest radiographs in the hyperacute stroke setting in the absence of evidence of acute pulmonary, cardiac, or pulmonary vascular disease is unclear. If obtained, they should not unnecessarily delay administration of fibrinolysis. (Level of Evidence: B)"

Parenchymal Brain Imaging

Recommendations for Patients With Acute Cerebral Ischemic Symptoms That Have Not Yet Resolved

Class I
"1. Emergency imaging of the brain is recommended before initiating any specific therapy to treat acute ischemic stroke. In most instances, NECT will provide the necessary information to make decisions about emergency management. (Level of Evidence: A)"
"2. Either NECT or MRI is recommended before intravenous rtPA administration to exclude ICH (absolute contraindication) and to determine whether CT hypodensity or MRI hyperintensity of ischemia is present. (Level of Evidence: A)"
"3. Intravenous fibrinolytic therapy is recommended in the setting of early ischemic changes (other than frank hypodensity) on CT, regardless of their extent.(Level of Evidence: A)"
"4. A noninvasive intracranial vascular study is strongly recommended during the initial imaging evaluation of the acute stroke patient if either intra-arterial fibrinolysis or mechanical thrombectomy is contemplated for management but should not delay intravenous rtPA if indicated (Level of Evidence: B)"
"5. In intravenous fibrinolysis candidates, the brain imaging study should be interpreted within 45 minutes of patient arrival in the ED by a physician with expertise in reading CT and MRI studies of the brain parenchyma (Class I; Level of Evidence C) . (Level of Evidence: C)"
Class IIb
"1. CT perfusion and MRI perfusion and diffusion imaging, including measures of infarct core and penumbra, may be considered for the selection of patients for acute reperfusion therapy beyond the time windows for intravenous fibrinolysis. These techniques provide additional information that may improve diagnosis, mechanism, and severity of ischemic stroke and allow more informed clinical decision making. (Level of Evidence: B)"
Class III
"1. Frank hypodensity on NECT may increase the risk of hemorrhage with fibrinolysis and should be considered in treatment decisions. If frank hypodensity involves more than one third of the MCA territory, intravenous rtPA treatment should be withheld. (Level of Evidence: A)"

Recommendations for Patients With Cerebral Ischemic Symptoms That Have Resolved

Class I
"1. Noninvasive imaging of the cervical vessels should be performed routinely as part of the evaluation of patients with suspected TIAs. (Level of Evidence: A)"
"2. Noninvasive imaging by means of CTA or MRA of the intracranial vasculature is recommended to exclude the presence of proximal intracranial stenosis and/or occlusion and should be obtained when knowledge of intracranial stenoocclusive disease will alter management. Reliable diagnosis of the presence and degree of intracranial stenosis requires the performance of catheter angiography to confirm abnormalities detected with noninvasive testing.(Level of Evidence: A)"
"3. Patients with transient ischemic neurological symptoms should undergo neuroimaging evaluation within 24 hours of symptom onset or as soon as possible in patients with delayed presentations. MRI, including DWI, is the preferred brain diagnostic imaging modality. If MRI is not available, head CT should be performed. (Level of Evidence: B)"

General Supportive Care and Treatment of Acute Complications

Class I
"1. Cardiac monitoring is recommended to screen for atrial fibrillation and other potentially serious cardiac arrhythmias that would necessitate emergency cardiac interventions. Cardiac monitoring should be performed for at least the first 24 hours. (Level of Evidence: B)"
"2. Patients who have elevated blood pressure and are otherwise eligible for treatment with intravenous rtPA should have their blood pressure carefully lowered so that their systolic blood pressure is <185 mm Hg and their diastolic blood pressure is <110 mm Hg before fibrinolytic therapy is initiated. If medications are given to lower blood pressure, the clinician should be sure that the blood pressure is stabilized at the lower level before beginning treatment with intravenous rtPA and maintained below 180/105 mm Hg for at least the first 24 hours after intravenous rtPA treatment. (Level of Evidence: B)"
"3. Airway support and ventilatory assistance are recommended for the treatment of patients with acute stroke who have decreased consciousness or who have bulbar dysfunction that causes compromise of the airway. (Level of Evidence: C)"
"4. Supplemental oxygen should be provided to maintain oxygen saturation >94%. (Level of Evidence: C)"
"5. Sources of hyperthermia (temperature >38°C) should be identified and treated, and antipyretic medications should be administered to lower temperature in hyperthermic patients with stroke. (Level of Evidence: C)"
"6. Until other data become available, consensus exists that the previously described blood pressure recommendations should be followed in patients undergoing other acute interventions to recanalize occluded vessels, including intra-arterial fibrinolysis Patients with transient ischemic neurological symptoms should undergo neuroimaging evaluation within 24 hours of symptom onset or as soon as possible in patients with delayed presentations. MRI, including DWI, is the preferred brain diagnostic imaging modality. If MRI is not available, head CT should be performed. (Level of Evidence: C )"
"7. In patients with markedly elevated blood pressure who do not receive fibrinolysis, a reasonable goal is to lower blood pressure by 15% during the first 24 hours after onset of stroke. The level of blood pressure that would mandate such treatment is not known, but consensus exists that medications should be withheld unless the systolic blood pressure is >220 mm Hg or the diastolic blood pressure is >120 mm Hg. (Level of Evidence: C)"
"8. Hypovolemia should be corrected with intravenous normal saline, and cardiac arrhythmias that might be reducing cardiac output should be corrected. (Level of Evidence: C)"
"9. Hypoglycemia (blood glucose <60 mg/dL) should be treated in patients with acute ischemic stroke. (Level of Evidence: C)"
Class IIa
"1. Evidence from one clinical trial indicates that initiation of antihypertensive therapy within 24 hours of stroke is relatively safe. Restarting antihypertensive medications is reasonable after the first 24 hours for patients who have preexisting hypertension and are neurologically stable unless a specific contraindication to restarting treatment is known. (Level of Evidence: B)"
"2. No data are available to guide selection of medications for the lowering of blood pressure in the setting of acute ischemic stroke.(Level of Evidence: C)"
"3. Evidence indicates that persistent in-hospital hyperglycemia during the first 24 hours after stroke is associated with worse outcomes than normoglycemia, and thus, it is reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL and to closely monitor to prevent hypoglycemia in patients with acute ischemic stroke. (Level of Evidence: C)"
Class IIa
"1. The management of arterial hypertension in patients not undergoing reperfusion strategies remains challenging. Data to guide recommendations for treatment are inconclusive or conflicting. Many patients have spontaneous declines in blood pressure during the first 24 hours after onset of stroke. Until more definitive data are available, the benefit of treating arterial hypertension in the setting of acute ischemic stroke is not well established. Patients who have malignant hypertension or other medical indications for aggressive treatment of blood pressure should be treated accordingly. (Level of Evidence: C)"
Class III
"1. Supplemental oxygen is not recommended in nonhypoxic patients with acute ischemic stroke. (Level of Evidence: B)"

Intravenous Fibrinolysis

Class I
"1. Intravenous alteplase [rtPA] (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke. (Level of Evidence: A)"
"2. In patients eligible for intravenous rtPA, benefit of therapy is time dependent, and treatment should be initiated as quickly as possible. The door-to-needle time (time of bolus administration) should be within 60 minutes from hospital arrival . (Level of Evidence: A)"
"3. Intravenous rtPA (0.9 mg/kg, maximum dose 90mg) is recommended for administration to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke onset. The eligibility criteria for treatment in this time period are similar to those for people treated at earlier time periods within 3 hours, with the following additional exclusion criteria: patients >80 years old, those taking oral anticoagulants regardless of INR, those with a baseline NIHSS score >25, those with imaging evidence of ischemic injury involving more than one third of the MCA territory, or those with a history of both stroke and diabetes mellitus. . (Level of Evidence: B)"
"4. Intravenous rtPA is reasonable in patients whose blood pressure can be lowered safely (to below 185/110 mm Hg) with antihypertensive agents, withthe physician assessing the stability of the blood pressure before starting intravenous rtPA .(Level of Evidence: B)"
"5. In patients undergoing fibrinolytic therapy, physicians should be aware of and prepared to emergently treat potential side effects, including bleeding complications and angioedema that may cause partial airway obstruction. (Level of Evidence: B)"
Class IIa
"1. Intravenous rtPA is reasonable in patients with a seizure at the time of onset of stroke if evidence suggests that residual impairments are secondary to stroke and not a postictal phenomenon. (Level of Evidence: C)"
"2. In otherwise eligible patients who have had a previously demonstrated small number (1–10) of CMBs on MRI, administration of intravenous alteplase is reasonable
"3. Intravenous alteplase for adults presenting with an acute ischemic stroke (AIS) with known sickle cell disease can be beneficial.
"4. Given the extremely low risk of unsuspected abnormal platelet counts or coagulation studies in a population, it is reasonable that urgent intravenous alteplase treatment not be delayed while waiting for hematologic or coagulation testing if there is no reason to suspect an abnormal test.
Class IIb
"1. The effectiveness of sonothrombolysis for treatment of patients with acute stroke is not well established. (Level of Evidence: B)"
"2. The usefulness of intravenous administration of tenecteplase, reteplase, desmoteplase, urokinase, or other fibrinolytic agents and the intravenous administration of ancrod or other defibrinogenating agents is not well established, and they should only be used in the setting of a clinical trial. (Level of Evidence: B)"
"3. The effectiveness of intravenous treatment with rtPA is not well established and requires further study for patients who can be treated in the time period of 3 to 4.5 hours after stroke but have 1 or more of the following exclusion criteria: (1) patients >80 years old, (2) those taking oral anticoagulants, even with INR ≤1.7, (3) those with a baseline NIHSS score >25, or (4) those with a history of both stroke and diabetes mellitus. (Level of Evidence: C)"
"4. Use of intravenous fibrinolysis in patients with conditions of mild stroke deficits, rapidly improving stroke symptoms, major surgery in the preceding 3 months, and recent myocardial infarction may be considered, and potential increased risk should be weighed against the anticipated benefits. (Level of Evidence: C)"
"5.In otherwise eligible patients who have had a previously demonstrated high burden of CMBs (>10) on MRI, treatment with IV alteplase may be associated with an increased risk of intra-cranial hemorrhage, and the benefits of treatment are uncertain. Treatment may be reasonable if there is the potential for substantial benefit
"6.The risk of antithrombotic therapy within the first 24 hours after treatment with IV alteplase (with or without EVT) is uncertain. Use might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV alteplase is known to provide substantial benefit or withholding such treatment is known to cause substantial risk
"7.Tenecteplase administered as a 0.4-mg/kg single intravenous bolus has not been proven to be superior or noninferior to alteplase but might be considered as an alternative to alteplase in patients with minor neurological impairment and no major intracranial occlusion.
Class III (Harm)
"1. The intravenous administration of streptokinase for treatment of stroke is not recommended. (Level of Evidence: A)"
"2. The use of intravenous rtPA in patients taking direct thrombin inhibitors or direct factor Xa inhibitors may be harmful and is not recommended unless

sensitive laboratory tests such as aPTT, INR, platelet count, and ECT, TT, or appropriate direct factor Xa activity assays are normal, or the patient has not

received a dose of these agents for >2 days (assuming normal renal metabolizing function). Similar consideration should be given to patients being considered

for intra-arterial rtPA. (Level of Evidence: C)"

"3. The benefit of IV defibrinogenating agents and of IV fibrinolytic agents other than alteplase and tenecteplase is unproven; therefore, their administration is not recommended outside a clinical trial.
"4. The use of sonothrombolysis as adjuvant therapy with IV thrombolysis is not recommended.

Management after Systemic Intravenous Fibrinolytic Therapy

  1. Admit the patient to intensive care unit or stroke unit for monitoring
  2. If the patient develops severe headache, acute hypertension, nausea, or vomiting or has a worsening neurological examination, discontinue the infusion (if IV alteplase is being administered) and obtain emergency head CT scan
  3. Measure BP and perform neurological assessments every 15 min during and after IV alteplase infusion for 2 h, then every 30 min for 6 h, then hourly until 24 h after IV alteplase treatment
  4. Increase the frequency of BP measurements if SBP is >180 mmHg or if DBP is >105 mmHg; administer antihypertensive medications to maintain BP at or below these levels
  5. Delay placement of nasogastric tubes, indwelling bladder catheters, or intraarterial pressure catheters if the patient can be safely managed without them
  6. Obtain a follow-up CT or MRI scan at 24 h after IV alteplase before starting anticoagulants or antiplatelet agents

Endovascular Interventions

Class I
"1. Patients eligible for intravenous rtPA should receive intravenous rtPA even if intra-arterial treatments are being considered. (Level of Evidence: A)"
"2. Intra-arterial fibrinolysis is beneficial for treatment of carefully selected patients with major ischemic strokes of <6 hours’ duration caused by occlusions of the MCA who are not otherwise candidates for intravenous rtPA. The optimal dose of intra-arterial rtPA is not well established, and rtPA does not have FDA approval for intra-arterial use. (Level of Evidence: B)"
"3. As with intravenous fibrinolytic therapy, reduced time from symptom onset to reperfusion with intraarterial therapies is highly correlated with better clinical outcomes, and all efforts must be undertaken to minimize delays to definitive therapy. (Level of Evidence: B)"
"4.Initial treatment with intra-arterial thrombolysis is beneficial for carefully selected patients with major ischemic strokes of <6 hours’ duration caused by occlusions of the MCA (Level of Evidence B)
"5. When mechanical thrombectomy is pursued, stent retrievers such as Solitaire FR and Trevo are generally preferred to coil retrievers such as Merci. The relative effectiveness of

the Penumbra System versus stent retrievers is not yet characterized. ( (Level of Evidence: A)"

"6.Patients should receive mechanical thrombectomy with a stent retriever if they meet all the following criteria: (1) prestroke mRS score of 0 to 1; (2) causative occlusion of the internal carotid artery or MCA segment 1 (M1); (3) age ≥18 years; (4) NIHSS score of ≥6; (5) ASPECTS of ≥6; and (6) treatment can be initiated (groin puncture) within 6 hours of symptom onset
"7.In selected patients with AIS within 6 to 16 hours of last known normal who have LVO in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended.
"8.The technical goal of the thrombectomy procedure should be reperfusion to a modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 angiographic result to maximize the probability of a good functional clinical outcome.
"9.Reduced time from symptom onset to reperfusion with endovascular therapies is highly associated with better clinical outcomes. To ensure benefit, reperfusion to TICI grade 2b/3 should be achieved as early as possible within the therapeutic window
Class IIa
"1. The Merci, Penumbra System, Solitaire FR, and Trevo thrombectomy devices can be useful in achieving recanalization alone or in combination with pharmacological fibrinolysis in carefully selected patients. Their ability to improve patient outcomes has not yet been established. These devices should continue to be studied in randomized controlled trials to determine the efficacy of such treatments in improving patient outcomes. (Level of Evidence: B)"
"2. Intra-arterial fibrinolysis or mechanical thrombectomy is reasonable in patients who have contraindications to the use of intravenous fibrinolysis. (Level of Evidence: C)"
"3.In selected patients with AIS within 16 to 24 hours of last known normal who have LVO in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable.
"4.The use of a proximal balloon guide catheter or a large-bore distal-access catheter, rather than a cervical guide catheter alone, in conjunction with stent retrievers may be beneficial. Future studies should examine which systems provide the highest recanalization rates with the lowest risk for nontarget embolization.
"5.Select an anesthetic technique during endovascular therapy (EVT) for AIS on the basis of individualized assessment of patient risk factors, technical performance of the procedure, and other clinical characteristics. Further randomized trial data are needed.
"6.In patients who undergo mechanical thrombectomy, it is reasonable to maintain the BP ≤180/105 mmHg during and for 24 hours after the procedure.
Class IIb
"1. Rescue intra-arterial fibrinolysis or mechanical thrombectomy may be reasonable approaches to recanalization in patients with large-artery occlusion who have not responded to intravenous fibrinolysis. Additional randomized trial data are needed. (Level of Evidence: B)"
"2. The usefulness of mechanical thrombectomy devices other than the Merci retriever, the Penumbra System, Solitaire FR, and Trevo is not well established. (Level of Evidence: C )"
"3. The usefulness of emergent intracranial angioplasty and/or stenting is not well established. These procedures should be used in the setting of clinical trials. (Level of Evidence: C)"
"4. The usefulness of emergent angioplasty and/or stenting of the extracranial carotid or vertebral arteries in unselected patients is not well established. Use of these techniques may be

considered in certain circumstances, such as in the treatment of acute ischemic stroke resulting from cervical atherosclerosis or dissection. Additional randomized trial data are needed (Level of Evidence: C)"

"5.Although the benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the MCA segment 2 (M2) or MCA segment 3 (M3) portion of the MCAs
"6.Although the benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries.
"7.Although its benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have prestroke mRS score >1, ASPECTS <6, or NIHSS score <6, and causative occlusion of the internal carotid artery (ICA) or proximal MCA (M1). Additional randomized trial data are needed.
"8.The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances, but stent retrievers remain the first choice.
"9.Use of salvage technical adjuncts including intra-arterial thrombolysis may be reasonable to achieve mTICI 2b/3 angiographic results.
"10.Endovascular therpy (EVT) of tandem occlusions (both extracranial and intracranial occlusions) at the time of thrombectomy may be reasonable
"11.In patients who undergo mechanical thrombectomy with successful reperfusion, it might be reasonable to maintain BP at a level <180/105 mmHg.

Anticoagulants

Class IIb
"1. At present, the usefulness of argatroban or other thrombin inhibitors for treatment of patients with acute ischemic stroke is not well established. These agents should be used in the setting of clinical trials. (Level of Evidence: B)"
"2. The usefulness of urgent anticoagulation in patients with severe stenosis of an internal carotid artery ipsilateral to an ischemic stroke is not well established. (Level of Evidence: B)"
Class III (Harm)
"1. Urgent anticoagulation, with the goal of preventing early recurrent stroke, halting neurological worsening, or improving outcomes after acute ischemic stroke, is not recommended for treatment of patients with acute ischemic stroke. (Level of Evidence: C)"
"2. Urgent anticoagulation for the management of noncerebrovascular conditions is not recommended for patients with moderate-to-severe strokes because of an increased risk of serious intracranial hemorrhagic complications. (Level of Evidence: A)"
"3. Initiation of anticoagulant therapy within 24 hours of treatment with intravenous rtPA is not recommended. (Level of Evidence: B)"

Antiplatelets

Class I
"1. Administration of aspirin is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with IV alteplase, aspirin administration is generally delayed until 24 hours later but might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV alteplase is known to provide substantial benefit or withholding such treatment is known to cause substantial risk.. (Level of Evidence: A)"
Class IIb
"1. The usefulness of clopidogrel for the treatment of acute ischemic stroke is not well established. Further research testing the usefulness of the emergency administration of clopidogrel

in the treatment of patients with acute stroke is required (Level of Evidence: C)"

"2. The efficacy of intravenous tirofiban and eptifibatide is not well established, and these agents should be used only in the setting of clinical trials. (Level of Evidence: C)"
Class III (Harm)
"1. Aspirin is not recommended as a substitute for other acute interventions for treatment of stroke, including intravenous rtPA. (Level of Evidence: B)"
"2. The administration of other intravenous antiplatelet agents that inhibit the glycoprotein IIb/IIIa receptor is not recommended. Further research testing the usefulness of emergency administration

of these medications as a treatment option in patients with acute ischemic stroke is required. (Level of Evidence: B)"

"3. The administration of aspirin (or other antiplatelet agents) as an adjunctive therapy within 24 hours of intravenous fibrinolysis is not recommended. (Level of Evidence: C)"

Volume Expansion, Vasodilators, and Induced Hypertension

Class I
"1. In exceptional cases with systemic hypotension producing neurological sequelae, a physician may prescribe vasopressors to improve cerebral blood flow. If drug-induced hypertension is used, close neurological and cardiac monitoring is recommended. (Level of Evidence: C)"
Class IIb
"1. The administration of high-dose albumin is not well established as a treatment for most patients with acute ischemic stroke until further definitive evidence regarding efficacy becomes available. (Level of Evidence: B)"
"2. At present, use of devices to augment cerebral blood flow for the treatment of patients with acute ischemic stroke is not well established. These devices should be used in the setting of clinical trials. (Level of Evidence: B)"
"3. The usefulness of drug-induced hypertension in patients with acute ischemic stroke is not well established. Induced hypertension should be performed in the setting of clinical trials . (Level of Evidence: B)"
Class III (Harm)
"1. Hemodilution by volume expansion is not recommended for treatment of patients with acute ischemic stroke (Level of Evidence: A)"
"2. The administration of vasodilatory agents, such as pentoxifylline, is not recommended for treatment of patients with acute ischemic stroke. (Level of Evidence: A)"
Class III (Harm)
"1. Hemodilution by volume expansion is not recommended for treatment of patients with acute ischemic stroke (Level of Evidence: A)"
"2. The administration of vasodilatory agents, such as pentoxifylline, is not recommended for treatment of patients with acute ischemic stroke. (Level of Evidence: A)"
"3. The administration of vasodilatory agents, such as pentoxifylline, is not recommended for treatment of patients with acute ischemic stroke. (Level of Evidence: A)"

Neuroprotective Agents

Class IIa
"1. Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable. (Level of Evidence: B)"
Class IIb
"1. The utility of induced hypothermia for the treatment of patients with ischemic stroke is not well established, and further trials are recommended. (Level of Evidence: B)"
"2. At present, transcranial near-infrared laser therapy is not well established for the treatment of acute ischemic stroke, and further trials are recommended. (Level of Evidence: B)"
Class III (Harm)
"1. At present, no pharmacological agents with putative neuroprotective actions have demonstrated efficacy in improving outcomes after ischemic stroke, and therefore, other neuroprotective agents are not recommended. (Level of Evidence: A)"
"2. Data on the utility of hyperbaric oxygen are inconclusive, and some data imply that the intervention may be harmful. Thus, with the exception of stroke secondary to air embolization, this intervention is not recommended for treatment of patients with acute ischemic stroke . (Level of Evidence: B)"

Surgical Interventions

Class IIb
"1. The usefulness of emergent or urgent CEA when clinical indicators or brain imaging suggests a small infarct core with large territory at risk (eg, penumbra), compromised by inadequate flow from a critical carotid stenosis or occlusion, or in the case of acute neurological deficit after CEA, in which acute thrombosis of the surgical site is suspected, is not well established (. (Level of Evidence: B)"
"2. In patients with unstable neurological status (either stroke-in-evolution or crescendo TIA), the efficacy of emergent or urgent CEA is not well established. (Level of Evidence: B)"
"3.Patients eligible for IV alteplase should receive IV alteplase even if EVTs are being considered.

General Stroke Care

Class I
"1. The use of comprehensive specialized stroke care (stroke units) that incorporates rehabilitation is recommended. (Level of Evidence: A)"
"2. Patients with suspected pneumonia or UTIs should be treated with appropriate antibiotics. (Level of Evidence: A)"
"3. Airway support and ventilatory assistance are recommended for the treatment of patients with acute stroke who have decreased consciousness or who have bulbar dysfunction that causes compromise of the airway. (Level of Evidence C)
"4. Supplemental oxygen should be provided to maintain oxygen saturation >94%. (Level of Evidence C)
"5. In patients with AIS, early treatment of hypertension is indicated when required by comorbid conditions (eg, concomitant acute coronary event, acute heart failure, aortic dissection, postthrombolysis sICH, or preeclampsia/eclampsia). Lowering BP initially by 15% is probably safe. (Level of Evidence C)
"6. Subcutaneous administration of anticoagulants is recommended for treatment of immobilized patients. (Level of Evidence: A)"
"7. The use of standardized stroke care order sets is recommended to improve general management. (Level of Evidence: B)"
"8. Assessment of swallowing before the patient begins eating, drinking, or receiving oral medications is recommended. (Level of Evidence: B)"
"9. Patients who cannot take solid food and liquids orally should receive NG, nasoduodenal, or PEG tube feedings to maintain hydration and nutrition while undergoing efforts to restore swallowing. (Level of Evidence: B)"
"10. Early mobilization of less severely affected patients and measures to prevent subacute complications of stroke are recommended. (Level of Evidence: C)"
"11. Treatment of concomitant medical diseases is recommended. (Level of Evidence: C)"
12. Early institution of interventions to prevent recurrent stroke is recommended. (Level of Evidence: C)"
Class IIa
"1. The use of aspirin is reasonable for treatment of patients who cannot receive anticoagulants for DVT prophylaxis (. (Level of Evidence: A)"
"2. In selecting between NG and PEG tube routes of feeding in patients who cannot take solid food or liquids orally, it is reasonable to prefer NG tube feeding until 2 to 3 weeks after stroke onset. (Level of Evidence: B)"
"3. The use of intermittent external compression devices is reasonable for treatment of patients who cannot receive anticoagulants. (Level of Evidence: B)"
Class III (Harm)
"1. Routine use of nutritional supplements has not been shown to be beneficial. (Level of Evidence: B)"
"2. Routine use of prophylactic antibiotics has not been shown to be beneficial. (Level of Evidence: B)"
"3. Routine placement of indwelling bladder catheters is not recommended because of the associated risk of catheter-associated UTIs. (Level of Evidence: C)"

Treatment of Acute Neurological Complications

Class I
"1. Patients with major infarctions are at high risk for complicating brain edema and increased ICP. Measures to lessen the risk of edema and close monitoring of the patient for signs of neurological worsening during the first days after stroke are recommended. Early transfer of patients at risk for malignant brain edema to an institution with neurosurgical expertise should be considered. (Level of Evidence: A)"
"2. Decompressive surgical evacuation of a space-occupying cerebellar infarction is effective in preventing and treating herniation and brain stem compression. (Level of Evidence: B)"
"3. Decompressive surgery for malignant edema of the cerebral hemisphere is effective and potentially lifesaving. Advanced patient age and patient/family valuations of achievable outcome states may affect decisions regarding surgery. (Level of Evidence: B)"
"4. Recurrent seizures after stroke should be treated in a manner similar to other acute neurological conditions, and antiepileptic agents should be selected by specific patient characteristics. (Level of Evidence: B)"
"5. Placement of a ventricular drain is useful in patients with acute hydrocephalus secondary to ischemic stroke. (Level of Evidence: C)"
Class IIb
"1. Although aggressive medical measures have been recommended for treatment of deteriorating patients with malignant brain edema after large cerebral infarction, the usefulness of these measures is not well established. (Level of Evidence: C)"
Class III (Harm)
"1. Because of lack of evidence of efficacy and the potential to increase the risk of infectious complications, corticosteroids (in conventional or large doses) are not recommended for treatment of cerebral edema and increased ICP complicating ischemic stroke. (Level of Evidence: A)"
"2. Prophylactic use of anticonvulsants is not recommended. (Level of Evidence: C)"

References

  1. Powers, William J.; Rabinstein, Alejandro A.; Ackerson, Teri; Adeoye, Opeolu M.; Bambakidis, Nicholas C.; Becker, Kyra; Biller, José; Brown, Michael; Demaerschalk, Bart M.; Hoh, Brian; Jauch, Edward C.; Kidwell, Chelsea S.; Leslie-Mazwi, Thabele M.; Ovbiagele, Bruce; Scott, Phillip A.; Sheth, Kevin N.; Southerland, Andrew M.; Summers, Deborah V.; Tirschwell, David L. (2018). "2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 49 (3). doi:10.1161/STR.0000000000000158. ISSN 0039-2499.



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