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 Anwar, M.B.B.S[2]

2015 AHA/ASA Guidelines for the Early Management of Acute Ischemic Stroke

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)"

|bgcolor="LemonChiffon"|"3. Noninvasive screening for unruptured intracranial aneurysms in patients with ADPKD and ≥1 relatives with ADPKD and SAH or intracranial aneurysm may be considered(Level of Evidence: C)" |- |bgcolor="LemonChiffon"|"4. Noninvasive screening for unruptured intracranial aneurysms in patients with ≥2 first-degree relatives with SAH or intracranial aneurysms might be reasonable (Level of Evidence: C)" |- |bgcolor="LemonChiffon"|"5. Noninvasive screening for unruptured intracranial aneurysms in patients with cervical fibromuscular dysplasia may be considered(Level of Evidence: C)" |- |bgcolor="LemonChiffon"|"6.Pharmacogenetic dosing of vitamin K antagonists may be considered when therapy is initiated(Level of Evidence: C)" |}