Guidelines for Early Management of Acute Ischemic Stroke: Key Points

Authors:
Powers WJ, Rabinstein AA, Ackerson T, et al., on behalf of the American Heart Association Stroke Council.
Citation:
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 2019;Oct 30:[Epub ahead of print].

The following are key points to remember from the 2019 Update to the American Heart Association/American Stroke Association (AHA/ASA) 2018 Guidelines for the Early Management of Acute Ischemic Stroke:

  1. The updated Guidelines for the Early Management of Patients With Acute Ischemic Stroke were first published in January 2018 and shortly thereafter withdrawn by the AHA/ASA, a decision that was quite controversial. The Guidelines were then republished in April 2018 with seven specific recommendations deleted, as well as the entire section related to in-hospital institution of secondary prevention. The reasons for the deletion of these recommendations were not made clear by the AHA/ASA. The guidelines are now republished, with most of the previously deleted material returned.
  2. Patients with a positive stroke screen and/or a strong suspicion of stroke should be transported rapidly to the closest healthcare facility that can capably administer intravenous (IV) tissue plasminogen activator (tPA). It remains unknown whether it would be beneficial for emergency medical system (EMS) to bypass a closer IV tPA-capable hospital for a thrombectomy-capable hospital. While such an approach may delay IV tPA administration for patients who are and who are not mechanical thrombectomy candidates, this approach would expedite thrombectomy for those who are mechanical thrombectomy candidates.
  3. The benefits of IV tPA are time-dependent, and treatment for eligible patients should be initiated as quickly as possible (even for patients who may also be candidates for mechanical thrombectomy).
  4. IV tPA should be administered to all eligible acute stroke patients within 3 hours of last known normal and to a more selective group of eligible acute stroke patients (based on European Cooperative Acute Stroke Study [ECASS]-III exclusion criteria) within 4.5 hours of last known normal.
  5. In patients with acute ischemic stroke who awaken with symptoms or have unclear time of onset, IV tPA can be beneficial if stat magnetic resonance imaging (MRI) diffusion-weighted imaging (DWI) lesion is smaller than one-third of the middle cerebral artery territory and there is no visible signal change on FLAIR sequences (in these cases, DWI-FLAIR mismatch serves as a surrogate for time <4.5 hours).
  6. For otherwise eligible patients with mild non-disabling stroke symptoms, IV tPA is not recommended.
  7. Prior to initiation of IV tPA in most patients, a noncontrast head computed tomography (CT) and glucose are the only required tests. An international normalized ratio (INR), prothrombin time (PTT), and platelet count do not need to have resulted prior to IV tPA initiation if there is no suspicion for underlying coagulopathy.
  8. For patients who may be candidates for mechanical thrombectomy, an urgent CT angiogram or MR angiogram (to look for large vessel occlusion) is recommended, but this study should not delay treatment with IV tPA if indicated.
  9. Patients ≥18 years should undergo mechanical thrombectomy with a stent retriever if they have minimal prestroke disability, have a causative occlusion of the internal carotid artery or proximal middle cerebral artery, have an National Institutes of Health Stroke Scale (NIHSS) score of ≥6, have a reassuring noncontrast head CT (ASPECT score of ≥6), and if they can be treated within 6 hours of last known normal. No perfusion imaging (CT-P or MR-P) is required in these patients.
  10. In selected acute stroke patients within 6 to 24 hours of last known normal who have evidence of a large vessel occlusion in the anterior circulation and would have been eligible for DAWN or DEFUSE-3, obtaining perfusion imaging (CT-P or MR-P) or an MRI with DWI sequence is recommended to help determine whether the patient is a candidate for extended-window mechanical thrombectomy.
  11. In selected acute stroke patients within 6 to 16 hours of last known normal who have a large vessel occlusion in the anterior circulation and meet other DAWN or DEFUSE-3 eligibility criteria, mechanical thrombectomy is recommended. In selected acute stroke patients within 6 to 24 hours of last known normal who have large vessel occlusion in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy with a stent retriever is reasonable.
  12. As with IV tPA, treatment with mechanical thrombectomy should be initiated as quickly as possible.
  13. Administration of aspirin is recommended in acute stroke patients within 24 to 48 hours after stroke onset. For patients treated with IV tPA, aspirin administration is generally delayed for 24 hours. Urgent anticoagulation (e.g., heparin drip) for most stroke patients is not indicated.
  14. In patients presenting with minor (NIHSS ≤3) non-cardioembolic ischemic stroke who did not receive IV tPA, treatment with dual antiplatelet therapy (aspirin and clopidogrel) started within 24 hours after symptom onset and continued for 21 days is effective in reducing recurrent ischemic stroke for a period of up to 90 days from symptom onset.
  15. The use of stroke units that incorporate rehabilitation is recommended for all acute stroke patients.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Cardiovascular Care Team, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Cardiac Surgery and Arrhythmias, Lipid Metabolism, Interventions and Imaging, Angiography, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Angiography, Aspirin, Brain Ischemia, Critical Care, Heparin, Magnetic Resonance Imaging, Perfusion Imaging, Secondary Prevention, Stents, Stroke, Thrombectomy, Thrombolytic Therapy, Tissue Plasminogen Activator, Vascular Diseases


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