Ischemic stroke medical therapy: Difference between revisions

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Revision as of 03:57, 21 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S [2]

Overview

The medical therapy of ischemic stroke is mainly directed to fibrinolysis of clot by r-tPA with in 3 to 4.5 hours of symptom onset. Acute treatment with antiplatelets may have a role if given within 24-48 hours of stroke onset. Long term management with statins, antiplatelets, anticoagulants, antihypertensive and antidiabetic agents may help prevent the recurrence.^[1] Acute treatment to control blood pressure, blood glucose and fever may help prevent the complications and have a prognostic significance.

Medical Therapy

The reported cases of treatment for COVID-19-associated stroke have followed the same guidelines as patients with no COVID-19 infection. The following recommendations are mainly based on the current guidelines of management for stroke of the AHA 2019.
IV alteplase is always preferred over mechanical thrombectomy when there are no contraindications.^[2]
The usefulness of anticoagulants such as thrombin inhibitors (dabigatran) and factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) is not well established in the acute setting of stroke.^[3]
The use of thrombolysis via ultrasound waves concomitant to IV fibrinolysis is not recommended.^[4]
High-intensity statin therapy should be initiated in patients younger than 75 with clinical ASCVD, to achieving a reduction in LDL-C levels of at least 50%.
In patients older than 75 years of age with clinical ASCVD, it is reasonable to initiate moderate or high-intensity statin therapy after reviewing adverse effects and drug interactions.^[5]^[6]
Risk and beneffits should be discussed before initiation of statin therapy to weight ASCVD risk reduction against the potential for statin-associated side effects.^[5]
Continuation of statin therapy during the acute period of ischemic stroke is reasonable among patients already taking statins.

Alteplase

IV alteplase is recommended for selected patients who can be treated within 3-4.5 hours of ischemic stroke symptom onset or patient last known well or at baseline state.^[7]^[5]^[8]
The dose of IV alteplase is 0.9 mg/kg (maximum dose 90 mg) over 60 min, with 10% of the dose given as a bolus over 1 min.^[5]
IV alteplase should be initiated as soon as possible, having been demonstrated better outcomes the sooner is administered.^[5]
Hyperglycemia should be treated during the first 24 hours after ischemic stroke, to achieve values of 140 to 180 mg/dL.^[5]
IV alteplase may cause bleeding and angioedema.^[5]
Glycoprotein IIb/IIIa inhibitors (tirofiban, apiximab, eptifibatide) should not be coadministered with IV alteplase.^[5]^[9]
IV alteplase may be used in patients under warfarin if the INR is lower than 1.7.^[5]
IV alteplase should not be administered to patients who have received a full dose of low-molecular-weight heparin within the previous 24 hours (including prophylactic doses).^[5]^[10]
Blood pressure should be sustained lower than 180/105 mmHg the first 24 hours after IV alteplase administration. Intensive lowering has been shown to be safe.^[5]^[11]
In case of intracranial bleeding due to alteplase administration, alteplase should be suspended, blood draws should be taken (CBC, coagulation studies), tranexamic acid should be administered (1000 mg IV infused over 10 min), and a subsecuent non-contratested CT scan of the head taken.^[12]
The use of IV alteplase should be used cautiously in patients who undergone a major surgery in the past 2 weeks.^[5]
IV alteplase for ischemic stroke is contraindicated in patients with a severe head trauma or subarachnoid hemorrage in the preceding 3 months.^[5]

Tenecteplase

Tenecteplase may be useful in patients with minor neurological impairment.^[13]
The dose of tenecteplase is a single IV bolus of 0.25-mg/kg (maximum 25 mg).^[14]

Antiplatelet therapy

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.^[15]
The dose of aspirin is usually between 160-300mg daily.^[16]
IV aspirin administration within 90 minutes after the start of IV alteplase is associated with symptomatic intracranial hemorrhage, for which co administration is discouraged but benefits should be assessed in each individual case.^[5]^[17]
Dual antiplatelet therapy with aspirin and clopidogrel (75 mg/d, with a loading dose of 600mg) may be started within 24 hours after symptom onset and continued for 21 days in patients with no cardioembolic ischemic stroke.^[18]
Aspirin should not substitute IV alteplase or mechanical thrombectomy in patients eligible for these therapies.^[5]


Medical treatment	Drug class	Recommendations
Medical treatment	Drug class	Acute	Long-Term
Reperfusion therapy	Tissue plasminogen activator (t-PA)	Recommended within 3-4.5 hours of onset of ischemic stroke in eligible patients by guidelines^[19]^[20]^[21] and systematic reviews^[22]^[23]^[24]	None
Antithrombotic agents	Antiplatelet agents	Oral administration of aspirin (initial dose is 325 mg) is recommended within 24 to 48 hours after stroke onset in most patients^[19] Aspirin is contraindicated in patients with ischemic stroke within 24 hours of t-PA administration^[19] DAPT therapy (aspirin and clopidogrel) is recommended for 90 days in patients with symptomatic intracranial large artery disease	Long term therapy with clopidogrel or aspirin extended release dipyridamole may be used for secondary prevention of non cardioembolic stroke
Antithrombotic agents	Anticoagulants	Parenteral or oral anticoagulation is not recommended within 48 hours of onset of ischemic stroke^[25]	Oral anticoagulants may be used for secondary prevention of ischemic stroke in patients with atrial fibrillation or other cardioembolic disease^[26]
Antilipid therapy	Statins	Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable^[19]	Long term management of ischemic stroke with high intensity statins may be recommended for patients with atherosclerotic disease Patients who cannot tolerate high intensity dose, medium or low intensity statins may prove beneficial
Antihypertensive therapy	Intravenous antihypertensives (Labetolol, nitroprusside)	Used to control high blood pressure in patients with BP>185/110 mmHg before starting t-PA^[19]	Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
Antihypertensive therapy	Oral antihypertensive therapy	Recommended after 24 hours in patient having hypertension	Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
Antihyperglycemic agents	Insulin	May be used to control blood glucose between range of 140-180 mg/dl since hyperglycemia is associated with worst outcome in patients with acute ischemic stroke^[19]	Long term oral antidiabetic may be used for secondary prevention of ischmeic stroke in patients with diabetes mellitus

For AHA/ASA guidelines for Intravenous Fibrinolysis in patients with ischemic stroke, please click here
For AHA/ASA guidelines for General Supportive Care and Treatment of Acute Complications in patients with ischemic stroke, please click here
For AHA/ASA guidelines on anticoagulants usage in patients with ischemic stroke, please click here
For AHA/ASA guidelines on antiplatelets usage in patients with ischemic stroke, please click here
For AHA/ASA guidelines on volume resuscitation usage in patients with ischemic stroke, please click here
For AHA/ASA guidelines on neuroprotective agents in patients with ischemic stroke, please click here
For AHA/ASA guidelines on General Stroke Care in patients with ischemic stroke, please click here

References

↑ Hackam DG, Spence JD (2007). "Combining multiple approaches for the secondary prevention of vascular events after stroke: a quantitative modeling study". Stroke. 38 (6): 1881–5. doi:10.1161/STROKEAHA.106.475525. PMID 17431209.
↑ Saver, Jeffrey L.; Goyal, Mayank; van der Lugt, Aad; Menon, Bijoy K.; Majoie, Charles B. L. M.; Dippel, Diederik W.; Campbell, Bruce C.; Nogueira, Raul G.; Demchuk, Andrew M.; Tomasello, Alejandro; Cardona, Pere; Devlin, Thomas G.; Frei, Donald F.; du Mesnil de Rochemont, Richard; Berkhemer, Olvert A.; Jovin, Tudor G.; Siddiqui, Adnan H.; van Zwam, Wim H.; Davis, Stephen M.; Castaño, Carlos; Sapkota, Biggya L.; Fransen, Puck S.; Molina, Carlos; van Oostenbrugge, Robert J.; Chamorro, Ángel; Lingsma, Hester; Silver, Frank L.; Donnan, Geoffrey A.; Shuaib, Ashfaq; Brown, Scott; Stouch, Bruce; Mitchell, Peter J.; Davalos, Antoni; Roos, Yvo B. W. E. M.; Hill, Michael D. (2016). "Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis". JAMA. 316 (12): 1279. doi:10.1001/jama.2016.13647. ISSN 0098-7484.
↑ Gioia, Laura C.; Kate, Mahesh; Sivakumar, Leka; Hussain, Dulara; Kalashyan, Hayrapet; Buck, Brian; Bussiere, Miguel; Jeerakathil, Thomas; Shuaib, Ashfaq; Emery, Derek; Butcher, Ken (2016). "Early Rivaroxaban Use After Cardioembolic Stroke May Not Result in Hemorrhagic Transformation". Stroke. 47 (7): 1917–1919. doi:10.1161/STROKEAHA.116.013491. ISSN 0039-2499.
↑ Nacu, Aliona; Kvistad, Christopher E.; Naess, Halvor; Øygarden, Halvor; Logallo, Nicola; Assmus, Jörg; Waje-Andreassen, Ulrike; Kurz, Kathinka D.; Neckelmann, Gesche; Thomassen, Lars (2017). "NOR-SASS (Norwegian Sonothrombolysis in Acute Stroke Study)". Stroke. 48 (2): 335–341. doi:10.1161/STROKEAHA.116.014644. ISSN 0039-2499.
↑ ^5.00 ^5.01 ^5.02 ^5.03 ^5.04 ^5.05 ^5.06 ^5.07 ^5.08 ^5.09 ^5.10 ^5.11 ^5.12 ^5.13 ^5.14 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. (2019). "Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 50 (12). doi:10.1161/STR.0000000000000211. ISSN 0039-2499.
↑ Sanossian, Nerses; Saver, Jeffrey L.; Liebeskind, David S.; Kim, Doojin; Razinia, Tannaz; Ovbiagele, Bruce (2006). "Achieving Target Cholesterol Goals After Stroke". Archives of Neurology. 63 (8): 1081. doi:10.1001/archneur.63.8.1081. ISSN 0003-9942.
↑ Lees, Kennedy R.; Emberson, Jonathan; Blackwell, Lisa; Bluhmki, Erich; Davis, Stephen M.; Donnan, Geoffrey A.; Grotta, James C.; Kaste, Markku; von Kummer, Rüdiger; Lansberg, Maarten G.; Lindley, Richard I.; Lyden, Patrick; Murray, Gordon D.; Sandercock, Peter A.G.; Toni, Danilo; Toyoda, Kazunori; Wardlaw, Joanna M.; Whiteley, William N.; Baigent, Colin; Hacke, Werner; Howard, George; Marler, John; Halls, Heather; Holland, Lisa; Mathews, Clare; Smith, Samantha; Wilson, Kate; Koga, Masatoshi; Albers, Gregory; Brott, Thomas; Cohen, Geoffrey; Koga, Masatoshi; Olivot, Jean Marc; Parsons, Mark; Tilley, Barbara; Wahlgren, Nils; del Zoppo, Gregory J (2016). "Effects of Alteplase for Acute Stroke on the Distribution of Functional Outcomes". Stroke. 47 (9): 2373–2379. doi:10.1161/STROKEAHA.116.013644. ISSN 0039-2499.
↑ "The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial". The Lancet. 379 (9834): 2352–2363. 2012. doi:10.1016/S0140-6736(12)60768-5. ISSN 0140-6736.
↑ Adeoye, Opeolu; Sucharew, Heidi; Khoury, Jane; Tomsick, Thomas; Khatri, Pooja; Palesch, Yuko; Schmit, Pamela A.; Pancioli, Arthur M.; Broderick, Joseph P. (2015). "Recombinant Tissue-Type Plasminogen Activator Plus Eptifibatide Versus Recombinant Tissue-Type Plasminogen Activator Alone in Acute Ischemic Stroke". Stroke. 46 (2): 461–464. doi:10.1161/STROKEAHA.114.006743. ISSN 0039-2499.
↑ Powers, William J.; Derdeyn, Colin P.; Biller, José; Coffey, Christopher S.; Hoh, Brian L.; Jauch, Edward C.; Johnston, Karen C.; Johnston, S. Claiborne; Khalessi, Alexander A.; Kidwell, Chelsea S.; Meschia, James F.; Ovbiagele, Bruce; Yavagal, Dileep R. (2015). "2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment". Stroke. 46 (10): 3020–3035. doi:10.1161/STR.0000000000000074. ISSN 0039-2499.
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↑ Huang, Xuya; Cheripelli, Bharath Kumar; Lloyd, Suzanne M; Kalladka, Dheeraj; Moreton, Fiona Catherine; Siddiqui, Aslam; Ford, Ian; Muir, Keith W (2015). "Alteplase versus tenecteplase for thrombolysis after ischaemic stroke (ATTEST): a phase 2, randomised, open-label, blinded endpoint study". The Lancet Neurology. 14 (4): 368–376. doi:10.1016/S1474-4422(15)70017-7. ISSN 1474-4422.
↑ Campbell, Bruce C.V.; Mitchell, Peter J.; Churilov, Leonid; Yassi, Nawaf; Kleinig, Timothy J.; Dowling, Richard J.; Yan, Bernard; Bush, Steven J.; Dewey, Helen M.; Thijs, Vincent; Scroop, Rebecca; Simpson, Marion; Brooks, Mark; Asadi, Hamed; Wu, Teddy Y.; Shah, Darshan G.; Wijeratne, Tissa; Ang, Timothy; Miteff, Ferdinand; Levi, Christopher R.; Rodrigues, Edrich; Zhao, Henry; Salvaris, Patrick; Garcia-Esperon, Carlos; Bailey, Peter; Rice, Henry; de Villiers, Laetitia; Brown, Helen; Redmond, Kendal; Leggett, David; Fink, John N.; Collecutt, Wayne; Wong, Andrew A.; Muller, Claire; Coulthard, Alan; Mitchell, Ken; Clouston, John; Mahady, Kate; Field, Deborah; Ma, Henry; Phan, Thanh G.; Chong, Winston; Chandra, Ronil V.; Slater, Lee-Anne; Krause, Martin; Harrington, Timothy J.; Faulder, Kenneth C.; Steinfort, Brendan S.; Bladin, Christopher F.; Sharma, Gagan; Desmond, Patricia M.; Parsons, Mark W.; Donnan, Geoffrey A.; Davis, Stephen M. (2018). "Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke". New England Journal of Medicine. 378 (17): 1573–1582. doi:10.1056/NEJMoa1716405. ISSN 0028-4793.
↑ Jeong, Han-Gil; Kim, Beom Joon; Yang, Mi Hwa; Han, Moon-Ku; Bae, Hee-Joon; Lee, Seung-Hoon (2016). "Stroke outcomes with use of antithrombotics within 24 hours after recanalization treatment". Neurology. 87 (10): 996–1002. doi:10.1212/WNL.0000000000003083. ISSN 0028-3878.
↑ "The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group". Lancet. 349 (9065): 1569–81. May 1997. PMID 9174558.
↑ Zinkstok, Sanne M; Roos, Yvo B (2012). "Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial". The Lancet. 380 (9843): 731–737. doi:10.1016/S0140-6736(12)60949-0. ISSN 0140-6736.
↑ Johnston, S. Claiborne; Easton, J. Donald; Farrant, Mary; Barsan, William; Conwit, Robin A.; Elm, Jordan J.; Kim, Anthony S.; Lindblad, Anne S.; Palesch, Yuko Y. (2018). "Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA". New England Journal of Medicine. 379 (3): 215–225. doi:10.1056/NEJMoa1800410. ISSN 0028-4793.
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↑ Lansberg MG, O'Donnell MJ, Khatri P, Lang ES, Nguyen-Huynh MN, Schwartz NE; et al. (2012). "Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e601S–36S. doi:10.1378/chest.11-2302. PMC 3278065. PMID 22315273.
↑ "Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke". American Academy of Emergency Medicine. Retrieved 2008-01-25.
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↑ Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E; et al. (2014). "Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials". Lancet. doi:10.1016/S0140-6736(14)60584-5. PMID 25106063.
↑ Paciaroni M, Agnelli G, Micheli S, Caso V (2007). "Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials". Stroke. 38 (2): 423–30. doi:10.1161/01.STR.0000254600.92975.1f. PMID 17204681. ACP JC synopsis
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[SaverGoyal2016-2] Saver, Jeffrey L.; Goyal, Mayank; van der Lugt, Aad; Menon, Bijoy K.; Majoie, Charles B. L. M.; Dippel, Diederik W.; Campbell, Bruce C.; Nogueira, Raul G.; Demchuk, Andrew M.; Tomasello, Alejandro; Cardona, Pere; Devlin, Thomas G.; Frei, Donald F.; du Mesnil de Rochemont, Richard; Berkhemer, Olvert A.; Jovin, Tudor G.; Siddiqui, Adnan H.; van Zwam, Wim H.; Davis, Stephen M.; Castaño, Carlos; Sapkota, Biggya L.; Fransen, Puck S.; Molina, Carlos; van Oostenbrugge, Robert J.; Chamorro, Ángel; Lingsma, Hester; Silver, Frank L.; Donnan, Geoffrey A.; Shuaib, Ashfaq; Brown, Scott; Stouch, Bruce; Mitchell, Peter J.; Davalos, Antoni; Roos, Yvo B. W. E. M.; Hill, Michael D. (2016). "Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis". JAMA. 316 (12): 1279. doi:10.1001/jama.2016.13647. ISSN 0098-7484.

[GioiaKate2016-3] Gioia, Laura C.; Kate, Mahesh; Sivakumar, Leka; Hussain, Dulara; Kalashyan, Hayrapet; Buck, Brian; Bussiere, Miguel; Jeerakathil, Thomas; Shuaib, Ashfaq; Emery, Derek; Butcher, Ken (2016). "Early Rivaroxaban Use After Cardioembolic Stroke May Not Result in Hemorrhagic Transformation". Stroke. 47 (7): 1917–1919. doi:10.1161/STROKEAHA.116.013491. ISSN 0039-2499.

[NacuKvistad2017-4] Nacu, Aliona; Kvistad, Christopher E.; Naess, Halvor; Øygarden, Halvor; Logallo, Nicola; Assmus, Jörg; Waje-Andreassen, Ulrike; Kurz, Kathinka D.; Neckelmann, Gesche; Thomassen, Lars (2017). "NOR-SASS (Norwegian Sonothrombolysis in Acute Stroke Study)". Stroke. 48 (2): 335–341. doi:10.1161/STROKEAHA.116.014644. ISSN 0039-2499.

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[PowersDerdeyn2015-10] Powers, William J.; Derdeyn, Colin P.; Biller, José; Coffey, Christopher S.; Hoh, Brian L.; Jauch, Edward C.; Johnston, Karen C.; Johnston, S. Claiborne; Khalessi, Alexander A.; Kidwell, Chelsea S.; Meschia, James F.; Ovbiagele, Bruce; Yavagal, Dileep R. (2015). "2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment". Stroke. 46 (10): 3020–3035. doi:10.1161/STR.0000000000000074. ISSN 0039-2499.

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[JohnstonEaston2018-18] Johnston, S. Claiborne; Easton, J. Donald; Farrant, Mary; Barsan, William; Conwit, Robin A.; Elm, Jordan J.; Kim, Anthony S.; Lindblad, Anne S.; Palesch, Yuko Y. (2018). "Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA". New England Journal of Medicine. 379 (3): 215–225. doi:10.1056/NEJMoa1800410. ISSN 0028-4793.

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 ==Medical Therapy==
-'''For AHA/ASA guidelines for Intravenous Fibrinolysis in patients with ischemic stroke, please''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Intravenous Fibrinolysis|click here]]<br>
-'''For AHA/ASA guidelines for General Supportive Care and Treatment of Acute Complications in patients with ischemic stroke, please''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#General Supportive Care and Treatment of Acute Complications|click here]]<br>
+*The reported cases of treatment for [[COVID-19]]-associated [[stroke]] have followed the same guidelines as patients with no [[COVID-19]] infection. The following recommendations are mainly based on the current guidelines of management for stroke of the AHA 2019.
-'''For AHA/ASA guidelines on anticoagulants usage in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Anticoagulants|click here]]<br>
+*[[Alteplase|IV alteplase]] is always preferred over mechanical [[thrombectomy]] when there are no contraindications.<ref name="SaverGoyal2016">{{cite journal|last1=Saver|first1=Jeffrey L.|last2=Goyal|first2=Mayank|last3=van der Lugt|first3=Aad|last4=Menon|first4=Bijoy K.|last5=Majoie|first5=Charles B. L. M.|last6=Dippel|first6=Diederik W.|last7=Campbell|first7=Bruce C.|last8=Nogueira|first8=Raul G.|last9=Demchuk|first9=Andrew M.|last10=Tomasello|first10=Alejandro|last11=Cardona|first11=Pere|last12=Devlin|first12=Thomas G.|last13=Frei|first13=Donald F.|last14=du Mesnil de Rochemont|first14=Richard|last15=Berkhemer|first15=Olvert A.|last16=Jovin|first16=Tudor G.|last17=Siddiqui|first17=Adnan H.|last18=van Zwam|first18=Wim H.|last19=Davis|first19=Stephen M.|last20=Castaño|first20=Carlos|last21=Sapkota|first21=Biggya L.|last22=Fransen|first22=Puck S.|last23=Molina|first23=Carlos|last24=van Oostenbrugge|first24=Robert J.|last25=Chamorro|first25=Ángel|last26=Lingsma|first26=Hester|last27=Silver|first27=Frank L.|last28=Donnan|first28=Geoffrey A.|last29=Shuaib|first29=Ashfaq|last30=Brown|first30=Scott|last31=Stouch|first31=Bruce|last32=Mitchell|first32=Peter J.|last33=Davalos|first33=Antoni|last34=Roos|first34=Yvo B. W. E. M.|last35=Hill|first35=Michael D.|title=Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis|journal=JAMA|volume=316|issue=12|year=2016|pages=1279|issn=0098-7484|doi=10.1001/jama.2016.13647}}</ref>
-'''For AHA/ASA guidelines on antiplatelets  usage in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Antiplatelets|click here]]<br>
+*The usefulness of [[anticoagulants]] such as [[thrombin]] inhibitors ([[dabigatran]]) and [[factor Xa]] inhibitors ([[rivaroxaban]], [[apixaban]], [[edoxaban]]) is not well established in the acute setting of [[stroke]].<ref name="GioiaKate2016">{{cite journal|last1=Gioia|first1=Laura C.|last2=Kate|first2=Mahesh|last3=Sivakumar|first3=Leka|last4=Hussain|first4=Dulara|last5=Kalashyan|first5=Hayrapet|last6=Buck|first6=Brian|last7=Bussiere|first7=Miguel|last8=Jeerakathil|first8=Thomas|last9=Shuaib|first9=Ashfaq|last10=Emery|first10=Derek|last11=Butcher|first11=Ken|title=Early Rivaroxaban Use After Cardioembolic Stroke May Not Result in Hemorrhagic Transformation|journal=Stroke|volume=47|issue=7|year=2016|pages=1917–1919|issn=0039-2499|doi=10.1161/STROKEAHA.116.013491}}</ref>
-'''For AHA/ASA guidelines on volume resuscitation  usage in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Volume Expansion, Vasodilators, and Induced Hypertension|click here]]<br>
+*The use of [[thrombolysis]] via ultrasound waves concomitant to [[Fibrinolysis|IV fibrinolysis]] is not recommended.<ref name="NacuKvistad2017">{{cite journal|last1=Nacu|first1=Aliona|last2=Kvistad|first2=Christopher E.|last3=Naess|first3=Halvor|last4=Øygarden|first4=Halvor|last5=Logallo|first5=Nicola|last6=Assmus|first6=Jörg|last7=Waje-Andreassen|first7=Ulrike|last8=Kurz|first8=Kathinka D.|last9=Neckelmann|first9=Gesche|last10=Thomassen|first10=Lars|title=NOR-SASS (Norwegian Sonothrombolysis in Acute Stroke Study)|journal=Stroke|volume=48|issue=2|year=2017|pages=335–341|issn=0039-2499|doi=10.1161/STROKEAHA.116.014644}}</ref>
-'''For AHA/ASA guidelines on neuroprotective agents in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Neuroprotective Agents|click here]]<br>
+*High-intensity [[statin]] therapy should be initiated in patients younger than 75 with clinical [[Coronary heart disease|ASCVD]], to achieving a reduction in [[LDL-C]] levels of at least 50%.
-'''For AHA/ASA guidelines on General Stroke Care in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#General Stroke Care|click here]]
+*In patients older than 75 years of age with clinical [[Coronary heart disease|ASCVD]], it is reasonable to initiate moderate or high-intensity [[statin]] therapy after reviewing  [[adverse effects]] and [[Drug interaction|drug interactions]].<ref name="PowersRabinstein2019">{{cite journal|last1=Powers|first1=William J.|last2=Rabinstein|first2=Alejandro A.|last3=Ackerson|first3=Teri|last4=Adeoye|first4=Opeolu M.|last5=Bambakidis|first5=Nicholas C.|last6=Becker|first6=Kyra|last7=Biller|first7=José|last8=Brown|first8=Michael|last9=Demaerschalk|first9=Bart M.|last10=Hoh|first10=Brian|last11=Jauch|first11=Edward C.|last12=Kidwell|first12=Chelsea S.|last13=Leslie-Mazwi|first13=Thabele M.|last14=Ovbiagele|first14=Bruce|last15=Scott|first15=Phillip A.|last16=Sheth|first16=Kevin N.|last17=Southerland|first17=Andrew M.|last18=Summers|first18=Deborah V.|last19=Tirschwell|first19=David L.|title=Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association|journal=Stroke|volume=50|issue=12|year=2019|issn=0039-2499|doi=10.1161/STR.0000000000000211}}</ref><ref name="SanossianSaver2006">{{cite journal|last1=Sanossian|first1=Nerses|last2=Saver|first2=Jeffrey L.|last3=Liebeskind|first3=David S.|last4=Kim|first4=Doojin|last5=Razinia|first5=Tannaz|last6=Ovbiagele|first6=Bruce|title=Achieving Target Cholesterol Goals After Stroke|journal=Archives of Neurology|volume=63|issue=8|year=2006|pages=1081|issn=0003-9942|doi=10.1001/archneur.63.8.1081}}</ref>
-{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
+*Risk and beneffits should be discussed before initiation of statin therapy to weight [[Coronary heart disease|ASCVD]] risk reduction against the potential for statin-associated side effects.<ref name="PowersRabinstein2019" />
-|+
+*Continuation of statin therapy during the acute period of [[ischemic stroke]] is reasonable among patients already taking [[Statins (patient information)|statins]].
-! rowspan="2" style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Medical treatment}}
-! rowspan="2" style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Drug class}}
+====Alteplase====
-! style="background: #4479BA; width: 350px;" colspan=2 | {{fontcolor|#FFF|Recommendations}}
+*[[Alteplase|IV alteplase]] is recommended for selected patients who can be treated within 3-4.5 hours of [[ischemic stroke]] [[symptom]] [[onset]] or patient last known well or at [[Baseline (medicine)|baseline]] state.<ref name="LeesEmberson2016">{{cite journal|last1=Lees|first1=Kennedy R.|last2=Emberson|first2=Jonathan|last3=Blackwell|first3=Lisa|last4=Bluhmki|first4=Erich|last5=Davis|first5=Stephen M.|last6=Donnan|first6=Geoffrey A.|last7=Grotta|first7=James C.|last8=Kaste|first8=Markku|last9=von Kummer|first9=Rüdiger|last10=Lansberg|first10=Maarten G.|last11=Lindley|first11=Richard I.|last12=Lyden|first12=Patrick|last13=Murray|first13=Gordon D.|last14=Sandercock|first14=Peter A.G.|last15=Toni|first15=Danilo|last16=Toyoda|first16=Kazunori|last17=Wardlaw|first17=Joanna M.|last18=Whiteley|first18=William N.|last19=Baigent|first19=Colin|last20=Hacke|first20=Werner|last21=Howard|first21=George|last22=Marler|first22=John|last23=Halls|first23=Heather|last24=Holland|first24=Lisa|last25=Mathews|first25=Clare|last26=Smith|first26=Samantha|last27=Wilson|first27=Kate|last28=Koga|first28=Masatoshi|last29=Albers|first29=Gregory|last30=Brott|first30=Thomas|last31=Cohen|first31=Geoffrey|last32=Koga|first32=Masatoshi|last33=Olivot|first33=Jean Marc|last34=Parsons|first34=Mark|last35=Tilley|first35=Barbara|last36=Wahlgren|first36=Nils|last37=del Zoppo|first37=Gregory J|title=Effects of Alteplase for Acute Stroke on the Distribution of Functional Outcomes|journal=Stroke|volume=47|issue=9|year=2016|pages=2373–2379|issn=0039-2499|doi=10.1161/STROKEAHA.116.013644}}</ref><ref name="PowersRabinstein2019" /><ref>{{cite journal|title=The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial|journal=The Lancet|volume=379|issue=9834|year=2012|pages=2352–2363|issn=01406736|doi=10.1016/S0140-6736(12)60768-5}}</ref>
+*The [[dose]] of [[Alteplase|IV alteplase]] is 0.9 mg/kg (maximum dose 90 mg) over 60 min, with 10% of the [[dose]] given as a [[bolus]] over 1 min.<ref name="PowersRabinstein2019" />
+*[[Alteplase|IV alteplase]] should be initiated as soon as possible, having been demonstrated better outcomes the sooner is administered.<ref name="PowersRabinstein2019" />
+*[[Hyperglycemia]] should be treated during the first 24 hours after [[ischemic stroke]], to achieve values of 140 to 180 mg/dL.<ref name="PowersRabinstein2019" />
+*[[Alteplase|IV alteplase]] may cause bleeding and [[angioedema]].<ref name="PowersRabinstein2019" />
+*[[Glycoprotein IIb/IIIa inhibitors]] ([[Tirofiban detailed information|tirofiban]], [[apiximab]], [[eptifibatide]]) should not be coadministered with [[Alteplase|IV alteplase]].<ref name="PowersRabinstein2019" /><ref name="AdeoyeSucharew2015">{{cite journal|last1=Adeoye|first1=Opeolu|last2=Sucharew|first2=Heidi|last3=Khoury|first3=Jane|last4=Tomsick|first4=Thomas|last5=Khatri|first5=Pooja|last6=Palesch|first6=Yuko|last7=Schmit|first7=Pamela A.|last8=Pancioli|first8=Arthur M.|last9=Broderick|first9=Joseph P.|title=Recombinant Tissue-Type Plasminogen Activator Plus Eptifibatide Versus Recombinant Tissue-Type Plasminogen Activator Alone in Acute Ischemic Stroke|journal=Stroke|volume=46|issue=2|year=2015|pages=461–464|issn=0039-2499|doi=10.1161/STROKEAHA.114.006743}}</ref>
+*[[Alteplase|IV alteplase]] may be used in patients under warfarin if the [[INR]] is lower than 1.7.<ref name="PowersRabinstein2019" />
+*[[Alteplase|IV alteplase]] should not be administered to patients who have received a full dose of [[low-molecular-weight heparin]] within the previous 24 hours (including [[Prophylaxis|prophylactic]] doses).<ref name="PowersRabinstein2019" /><ref name="PowersDerdeyn2015">{{cite journal|last1=Powers|first1=William J.|last2=Derdeyn|first2=Colin P.|last3=Biller|first3=José|last4=Coffey|first4=Christopher S.|last5=Hoh|first5=Brian L.|last6=Jauch|first6=Edward C.|last7=Johnston|first7=Karen C.|last8=Johnston|first8=S. Claiborne|last9=Khalessi|first9=Alexander A.|last10=Kidwell|first10=Chelsea S.|last11=Meschia|first11=James F.|last12=Ovbiagele|first12=Bruce|last13=Yavagal|first13=Dileep R.|title=2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment|journal=Stroke|volume=46|issue=10|year=2015|pages=3020–3035|issn=0039-2499|doi=10.1161/STR.0000000000000074}}</ref>
+*[[Blood pressure]] should be sustained lower than 180/105 mmHg the first 24 hours after [[Alteplase|IV alteplase]] administration. Intensive lowering has been shown to be safe.<ref name="PowersRabinstein2019" /><ref name="AndersonHuang2019">{{cite journal|last1=Anderson|first1=Craig S|last2=Huang|first2=Yining|last3=Lindley|first3=Richard I|last4=Chen|first4=Xiaoying|last5=Arima|first5=Hisatomi|last6=Chen|first6=Guofang|last7=Li|first7=Qiang|last8=Billot|first8=Laurent|last9=Delcourt|first9=Candice|last10=Bath|first10=Philip M|last11=Broderick|first11=Joseph P|last12=Demchuk|first12=Andrew M|last13=Donnan|first13=Geoffrey A|last14=Durham|first14=Alice C|last15=Lavados|first15=Pablo M|last16=Lee|first16=Tsong-Hai|last17=Levi|first17=Christopher|last18=Martins|first18=Sheila O|last19=Olavarria|first19=Veronica V|last20=Pandian|first20=Jeyaraj D|last21=Parsons|first21=Mark W|last22=Pontes-Neto|first22=Octavio M|last23=Ricci|first23=Stefano|last24=Sato|first24=Shoichiro|last25=Sharma|first25=Vijay K|last26=Silva|first26=Federico|last27=Song|first27=Lili|last28=Thang|first28=Nguyen H|last29=Wardlaw|first29=Joanna M|last30=Wang|first30=Ji-Guang|last31=Wang|first31=Xia|last32=Woodward|first32=Mark|last33=Chalmers|first33=John|last34=Robinson|first34=Thompson G|last35=Anderson|first35=Craig S.|last36=Huang|first36=Yining|last37=Lindley|first37=Richard I.|last38=Chen|first38=Xiaoying|last39=Arima|first39=Hisatomi|last40=Chen|first40=Guofang|last41=Li|first41=Qiang|last42=Billot|first42=Laurent|last43=Delcourt|first43=Candice|last44=Bath|first44=Philip M.|last45=Broderick|first45=Joseph P.|last46=Demchuk|first46=Andrew M.|last47=Donnan|first47=Geoffrey A.|last48=Durham|first48=Alice C.|last49=Lavados|first49=Pablo M.|last50=Lee|first50=Tsong-Hai|last51=Levi|first51=Christopher|last52=Martins|first52=Sheila O.|last53=Olavarria|first53=Veronica V.|last54=Pandian|first54=Jeyaraj D.|last55=Parsons|first55=Mark W.|last56=Pontes-Neto|first56=Octavio M.|last57=Ricci|first57=Stefano|last58=Sato|first58=Shoichiro|last59=Sharma|first59=Vijay K.|last60=Silva|first60=Federico|last61=Song|first61=Lili|last62=Thang|first62=Nguyen H.|last63=Wardlaw|first63=Joanna M.|last64=Wang|first64=Ji-Guang|last65=Wang|first65=Xia|last66=Woodward|first66=Mark|last67=Chalmers|first67=John|last68=Robinson|first68=Thompson G.|last69=Kim|first69=Jong S.|last70=Stapf|first70=Christian|last71=Simes|first71=R. John|last72=Hankey|first72=Graeme J.|last73=Sandercock|first73=Peter|last74=Bousser|first74=Marie-Germaine|last75=Wong|first75=K.S. 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N.|last101=Tay|first101=Nicole|last102=Jenson|first102=Kerry|last103=Richtering|first103=Sarah|last104=Tucker|first104=Sharon|last105=Knight|first105=Elizabeth|last106=Ivanova|first106=Elizaveta|last107=Thembani|first107=Emma|last108=Odgers|first108=Elizabeth|last109=Sanders|first109=Elizabeth|last110=Small|first110=Sabrina|last111=Vaghasiya|first111=Ruchita|last112=Armenis|first112=Manuela|last113=Donnelly|first113=Paul|last114=Baig|first114=Merza 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Truong|last634=Cam|first634=L. Dam Thi|last635=Kim|first635=T. Ngo Thi|last636=Nguyen|first636=B. Pham|last637=Dat|first637=A. Nguyen|last638=Van|first638=C. Nguyen|last639=Duy|first639=T. Mai|last640=Viet|first640=P. Dao|last641=Tien|first641=D. Nguyen|last642=Van|first642=T. Vo|last643=Le Kim|first643=K.|last644=Ngoc|first644=T. Bui|last645=Le Thanh|first645=T. Tran|last646=Hoanh|first646=S. Nguyen|last647=Phuoc|first647=S. Pham|last648=Van|first648=T. Tran|last649=Thi|first649=B. Doan|last650=Thu|first650=H. Nguyen Thi|last651=Duy|first651=M. Nguyen|last652=Van|first652=D. Ngo|title=Intensive blood pressure reduction with intravenous thrombolysis therapy for acute ischaemic stroke (ENCHANTED): an international, randomised, open-label, blinded-endpoint, phase 3 trial|journal=The Lancet|volume=393|issue=10174|year=2019|pages=877–888|issn=01406736|doi=10.1016/S0140-6736(19)30038-8}}</ref>
+*In case of [[Intracranial hemorrhage|intracranial bleeding]] due to [[alteplase]] administration, [[alteplase]] should be suspended, blood draws should be taken ([[Complete blood count|CBC]], [[coagulation studies]]), [[tranexamic acid]] should be administered (1000 mg IV infused over 10 min), and a subsecuent non-contratested [[Computed tomography|CT scan]] of the head taken.<ref name="SloanPrice1995">{{cite journal|last1=Sloan|first1=M. A.|last2=Price|first2=T.R.|last3=Petito|first3=C. K.|last4=Randall|first4=A. M. Y.|last5=Solomon|first5=R. E.|last6=Terrin|first6=M. L.|last7=Gore|first7=J.|last8=Collen|first8=D.|last9=Kleiman|first9=N.|last10=Feit|first10=F.|last11=Babb|first11=J.|last12=Herman|first12=M.|last13=Roberts|first13=W. C.|last14=Sopko|first14=G.|last15=Bovill|first15=E.|last16=Forman|first16=S.|last17=Knatterud|first17=G. L.|title=Clinical features and pathogenesis of intracerebral hemorrhage after rt-PA and heparin therapy for acute myocardial infarction: The Thrombolysis in Myocardial Infarction (TIMI) II Pilot and Randomized Clinical Trial Combined experience|journal=Neurology|volume=45|issue=4|year=1995|pages=649–658|issn=0028-3878|doi=10.1212/WNL.45.4.649}}</ref>
+*The use of [[Alteplase|IV alteplase]] should be used cautiously in patients who undergone a [[major surgery]] in the past 2 weeks.<ref name="PowersRabinstein2019" />
+*[[Alteplase|IV alteplase]] for [[ischemic stroke]] is contraindicated in patients with a severe [[head trauma]] or [[Subarachnoid hemorrhage|subarachnoid hemorrage]] in the preceding 3 months.<ref name="PowersRabinstein2019" />
+====Tenecteplase====
+*[[Tenecteplase]] may be useful in patients with minor [[neurological]] impairment.<ref name="HuangCheripelli2015">{{cite journal|last1=Huang|first1=Xuya|last2=Cheripelli|first2=Bharath Kumar|last3=Lloyd|first3=Suzanne M|last4=Kalladka|first4=Dheeraj|last5=Moreton|first5=Fiona Catherine|last6=Siddiqui|first6=Aslam|last7=Ford|first7=Ian|last8=Muir|first8=Keith W|title=Alteplase versus tenecteplase for thrombolysis after ischaemic stroke (ATTEST): a phase 2, randomised, open-label, blinded endpoint study|journal=The Lancet Neurology|volume=14|issue=4|year=2015|pages=368–376|issn=14744422|doi=10.1016/S1474-4422(15)70017-7}}</ref>
+*The dose of [[tenecteplase]] is a single IV [[bolus]] of 0.25-mg/kg (maximum 25 mg).<ref name="CampbellMitchell2018">{{cite journal|last1=Campbell|first1=Bruce C.V.|last2=Mitchell|first2=Peter J.|last3=Churilov|first3=Leonid|last4=Yassi|first4=Nawaf|last5=Kleinig|first5=Timothy J.|last6=Dowling|first6=Richard J.|last7=Yan|first7=Bernard|last8=Bush|first8=Steven J.|last9=Dewey|first9=Helen M.|last10=Thijs|first10=Vincent|last11=Scroop|first11=Rebecca|last12=Simpson|first12=Marion|last13=Brooks|first13=Mark|last14=Asadi|first14=Hamed|last15=Wu|first15=Teddy Y.|last16=Shah|first16=Darshan G.|last17=Wijeratne|first17=Tissa|last18=Ang|first18=Timothy|last19=Miteff|first19=Ferdinand|last20=Levi|first20=Christopher R.|last21=Rodrigues|first21=Edrich|last22=Zhao|first22=Henry|last23=Salvaris|first23=Patrick|last24=Garcia-Esperon|first24=Carlos|last25=Bailey|first25=Peter|last26=Rice|first26=Henry|last27=de Villiers|first27=Laetitia|last28=Brown|first28=Helen|last29=Redmond|first29=Kendal|last30=Leggett|first30=David|last31=Fink|first31=John N.|last32=Collecutt|first32=Wayne|last33=Wong|first33=Andrew A.|last34=Muller|first34=Claire|last35=Coulthard|first35=Alan|last36=Mitchell|first36=Ken|last37=Clouston|first37=John|last38=Mahady|first38=Kate|last39=Field|first39=Deborah|last40=Ma|first40=Henry|last41=Phan|first41=Thanh G.|last42=Chong|first42=Winston|last43=Chandra|first43=Ronil V.|last44=Slater|first44=Lee-Anne|last45=Krause|first45=Martin|last46=Harrington|first46=Timothy J.|last47=Faulder|first47=Kenneth C.|last48=Steinfort|first48=Brendan S.|last49=Bladin|first49=Christopher F.|last50=Sharma|first50=Gagan|last51=Desmond|first51=Patricia M.|last52=Parsons|first52=Mark W.|last53=Donnan|first53=Geoffrey A.|last54=Davis|first54=Stephen M.|title=Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke|journal=New England Journal of Medicine|volume=378|issue=17|year=2018|pages=1573–1582|issn=0028-4793|doi=10.1056/NEJMoa1716405}}</ref>
+====Antiplatelet therapy====
+*Administration of [[aspirin]] is recommended in patients with AIS within 24 to 48 hours after onset. For those treated with [[Alteplase|IV alteplase]], aspirin administration is generally delayed until 24 hours later.<ref name="JeongKim2016">{{cite journal|last1=Jeong|first1=Han-Gil|last2=Kim|first2=Beom Joon|last3=Yang|first3=Mi Hwa|last4=Han|first4=Moon-Ku|last5=Bae|first5=Hee-Joon|last6=Lee|first6=Seung-Hoon|title=Stroke outcomes with use of antithrombotics within 24 hours after recanalization treatment|journal=Neurology|volume=87|issue=10|year=2016|pages=996–1002|issn=0028-3878|doi=10.1212/WNL.0000000000003083}}</ref>
+*The dose of [[aspirin]] is usually between 160-300mg daily.<ref name="pmid9174558">{{cite journal |vauthors= |title=The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group |journal=Lancet |volume=349 |issue=9065 |pages=1569–81 |date=May 1997 |pmid=9174558 |doi= |url=}}</ref>
+*[[Aspirin|IV aspirin]] administration within 90 minutes after the start of [[Alteplase|IV alteplase]] is associated with symptomatic intracranial hemorrhage, for which co administration is discouraged but benefits should be assessed in each individual case.<ref name="PowersRabinstein2019" /><ref name="ZinkstokRoos2012">{{cite journal|last1=Zinkstok|first1=Sanne M|last2=Roos|first2=Yvo B|title=Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial|journal=The Lancet|volume=380|issue=9843|year=2012|pages=731–737|issn=01406736|doi=10.1016/S0140-6736(12)60949-0}}</ref>
+*[[Dual antiplatelet therapy]] with [[aspirin]] and [[clopidogrel]] (75 mg/d, with a loading dose of 600mg) may be started within 24 hours after [[symptom]] onset and continued for 21 days in patients with no cardioembolic [[ischemic stroke]].<ref name="JohnstonEaston2018">{{cite journal|last1=Johnston|first1=S. Claiborne|last2=Easton|first2=J. Donald|last3=Farrant|first3=Mary|last4=Barsan|first4=William|last5=Conwit|first5=Robin A.|last6=Elm|first6=Jordan J.|last7=Kim|first7=Anthony S.|last8=Lindblad|first8=Anne S.|last9=Palesch|first9=Yuko Y.|title=Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA|journal=New England Journal of Medicine|volume=379|issue=3|year=2018|pages=215–225|issn=0028-4793|doi=10.1056/NEJMoa1800410}}</ref>
+*[[Aspirin]] should not substitute [[Alteplase|IV alteplase]] or mechanical thrombectomy in patients eligible for these therapies.<ref name="PowersRabinstein2019" />
+{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
+|+
+! rowspan="2" style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Medical treatment}}
+! rowspan="2" style="background: #4479BA; width: 150px;" |{{fontcolor|#FFF|Drug class}}
+! colspan="2" style="background: #4479BA; width: 350px;" |{{fontcolor|#FFF|Recommendations}}
 |-
-! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Acute}}
+! style="background: #4479BA; width: 350px;" |{{fontcolor|#FFF|Acute}}
-! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Long-Term}}
+! style="background: #4479BA; width: 350px;" |{{fontcolor|#FFF|Long-Term}}
 |-
 | style="padding: 5px 5px; background: #F5F5F5;" |'''Reperfusion therapy'''
 | style="padding: 5px 5px; background: #F5F5F5;" |[[Tissue plasminogen activator|'''Tissue plasminogen activator''']] '''(t-PA)'''
 | style="padding: 5px 5px; background: #F5F5F5;" |
-* Recommended within 3-4.5 hours of onset of ischemic stroke in eligible patients by guidelines<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205  }} </ref><ref name="pmid    22315273">{{cite journal| author=Lansberg MG, O'Donnell MJ, Khatri P, Lang ES, Nguyen-Huynh MN, Schwartz NE et al.| title=Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e601S-36S | pmid=    22315273 | doi=10.1378/chest.11-2302 | pmc=3278065 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315273  }} </ref><ref>{{cite web|url=http://www.aaem.org/em-resources/position-statements/clinical-practice/thrombolytic-therapy |title=Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke |publisher=American Academy of Emergency Medicine |accessdate=2008-01-25}}</ref> and [[systematic review]]s<ref name="pmid25871671">{{cite journal| author=Prabhakaran S, Ruff I, Bernstein RA| title=Acute stroke intervention: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 14 | pages= 1451-62 | pmid=25871671 | doi=10.1001/jama.2015.3058 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25871671  }} </ref><ref name="pmid25072528">{{cite journal| author=Wardlaw JM, Murray V, Berge E, del Zoppo GJ| title=Thrombolysis for acute ischaemic stroke. | journal=Cochrane Database Syst Rev | year= 2014 | volume= 7 | issue=  | pages= CD000213 | pmid=25072528 | doi=10.1002/14651858.CD000213.pub3 | pmc=4153726 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25072528  }} </ref><ref name="pmid25106063">{{cite journal| author=Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E et al.| title=Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. | journal=Lancet | year= 2014 | volume=  | issue=  | pages=  | pmid=25106063 | doi=10.1016/S0140-6736(14)60584-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25106063  }} </ref>
+* Recommended within 3-4.5 hours of onset of ischemic stroke in eligible patients by guidelines<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205  }} </ref><ref name="pmid 22315273">{{cite journal| author=Lansberg MG, O'Donnell MJ, Khatri P, Lang ES, Nguyen-Huynh MN, Schwartz NE et al.| title=Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e601S-36S | pmid=    22315273 | doi=10.1378/chest.11-2302 | pmc=3278065 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315273  }} </ref><ref>{{cite web|url=http://www.aaem.org/em-resources/position-statements/clinical-practice/thrombolytic-therapy |title=Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke |publisher=American Academy of Emergency Medicine |accessdate=2008-01-25}}</ref> and [[systematic review]]s<ref name="pmid25871671">{{cite journal| author=Prabhakaran S, Ruff I, Bernstein RA| title=Acute stroke intervention: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 14 | pages= 1451-62 | pmid=25871671 | doi=10.1001/jama.2015.3058 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25871671  }} </ref><ref name="pmid25072528">{{cite journal| author=Wardlaw JM, Murray V, Berge E, del Zoppo GJ| title=Thrombolysis for acute ischaemic stroke. | journal=Cochrane Database Syst Rev | year= 2014 | volume= 7 | issue=  | pages= CD000213 | pmid=25072528 | doi=10.1002/14651858.CD000213.pub3 | pmc=4153726 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25072528  }} </ref><ref name="pmid25106063">{{cite journal| author=Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E et al.| title=Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. | journal=Lancet | year= 2014 | volume=  | issue=  | pages=  | pmid=25106063 | doi=10.1016/S0140-6736(14)60584-5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25106063  }} </ref>
 | style="padding: 5px 5px; background: #F5F5F5;" |
 * None
@@ Line 40: / Line 71: @@
 * Long term therapy with [[clopidogrel]] or  aspirin extended release [[dipyridamole]] may be used for secondary prevention of non cardioembolic stroke
 |-
-| style="padding: 5px 5px; background: #F5F5F5;" |[[Anticoagulants|'''Anticoagulants''']]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Anticoagulants]]'''
 | style="padding: 5px 5px; background: #F5F5F5;" |
-*Parenteral or oral anticoagulation is not recommended within 48 hours of onset of ischemic stroke<ref name="pmid17204681"> {{cite journal  |author=Paciaroni M, Agnelli G, Micheli S, Caso V |title=Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials |journal=Stroke |volume=38  |issue=2 |pages=423-30 | year=2007 |pmid=17204681 |doi=10.1161/01.STR.0000254600.92975.1f }} [http://www.acpjc.org/Content/147/1/issue/ACPJC-2007-147-1-017.htm ACP JC synopsis ]</ref>
+*Parenteral or oral anticoagulation is not recommended within 48 hours of onset of ischemic stroke<ref name="pmid17204681"> {{cite journal  |author=Paciaroni M, Agnelli G, Micheli S, Caso V |title=Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials |journal=Stroke |volume=38  |issue=2 |pages=423-30 | year=2007 |pmid=17204681 |doi=10.1161/01.STR.0000254600.92975.1f }} [http://www.acpjc.org/Content/147/1/issue/ACPJC-2007-147-1-017.htm ACP JC synopsis]</ref>
 | style="padding: 5px 5px; background: #F5F5F5;" |
@@ Line 48: / Line 79: @@
 |-
 | style="padding: 5px 5px; background: #F5F5F5;" |'''Antilipid therapy'''
-| style="padding: 5px 5px; background: #F5F5F5;" |[[Statins|'''Statins''']]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Statins]]'''
 | style="padding: 5px 5px; background: #F5F5F5;" |
 *Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205  }} </ref>
@@ Line 57: / Line 88: @@
 | rowspan="2" style="padding: 5px 5px; background: #F5F5F5;" |'''Antihypertensive therapy'''
 | style="padding: 5px 5px; background: #F5F5F5;" |'''Intravenous [[antihypertensives]]'''
 '''([[Labetalol|Labetolol]], [[nitroprusside]])'''
 | style="padding: 5px 5px; background: #F5F5F5;" |
 * Used to control high blood pressure in patients with BP>185/110 mmHg before starting t-PA<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205  }} </ref>
@@ Line 70: / Line 101: @@
 |-
 | style="padding: 5px 5px; background: #F5F5F5;" |'''Antihyperglycemic agents'''
-| style="padding: 5px 5px; background: #F5F5F5;" |[[Insulin|'''Insulin''']]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Insulin]]'''
 | style="padding: 5px 5px; background: #F5F5F5;" |
 * May be used to control blood glucose between range of 140-180 mg/dl since hyperglycemia is associated with worst outcome in patients with acute ischemic stroke<ref name="pmid23370205">{{cite journal| author=Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al.| title=Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. | journal=Stroke | year= 2013 | volume= 44 | issue= 3 | pages= 870-947 | pmid=23370205 | doi=10.1161/STR.0b013e318284056a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23370205  }} </ref>
@@ Line 77: / Line 108: @@
 |-
 |}
+'''For AHA/ASA guidelines for Intravenous Fibrinolysis in patients with ischemic stroke, please''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Intravenous Fibrinolysis|click here]]<br>
+'''For AHA/ASA guidelines for General Supportive Care and Treatment of Acute Complications in patients with ischemic stroke, please''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#General Supportive Care and Treatment of Acute Complications|click here]]<br>
+'''For AHA/ASA guidelines on anticoagulants usage in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Anticoagulants|click here]]<br>
+'''For AHA/ASA guidelines on antiplatelets  usage in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Antiplatelets|click here]]<br>
+'''For AHA/ASA guidelines on volume resuscitation  usage in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Volume Expansion, Vasodilators, and Induced Hypertension|click here]]<br>
+'''For AHA/ASA guidelines on neuroprotective agents in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#Neuroprotective Agents|click here]]<br>
+'''For AHA/ASA guidelines on General Stroke Care in patients with ischemic stroke, please ''' [[AHA/ASA guideline recommendations for of Early management of acute ischemic stroke#General Stroke Care|click here]]
 ==References==