Background and Purpose-The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. Methods-Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. Results-The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. Guidelines for the Early Management of PatientsThis statement was approved by the American Heart Association Science Advisory and Coordinating Committee on December 12, 2012. A copy of the document is available at http://my.americanheart.org/statements by selecting either the "By Topic" link or the "By Publication Date" link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.The Executive Summary is available as an online-only Data Supplement with this article at http://stroke.ahajournals.org/lookup/suppl/ doi:10.1161/STR.0b013e318284056a/-/DC1.The American Heart Association requests that this document be cited as follows: Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; on behalf of the American Heart Association Stroke Council, Council on Cardio...

In patients with acute ischemic stroke, higher admission glucose levels are associated with significantly lower odds for desirable clinical outcomes and significantly higher odds for symptomatic ICH, regardless of rt-PA treatment. Whether this represents a cause and effect relationship remains to be determined.

Admitting hyperglycemia was common among patients with acute ischemic stroke and was associated with increased short- and long-term mortality and with increased inpatient charges. Inpatient blood glucose management was suboptimal in this hospital. A trial of intensive treatment of hyperglycemia should be considered.

Background and Purpose-Hyperglycemia may worsen brain injury during acute cerebral infarction. We tested the feasibility and tolerability of aggressive hyperglycemia correction with intravenous insulin compared with usual care during acute cerebral infarction. Methods-We conducted a randomized, multicenter, blinded pilot trial for patients with cerebral infarction within 12 hours after onset, a baseline glucose value Ն8.3 mmol/L (Ն150 mg/dL), and a National Institutes of Health Stroke Scale score of 3 to 22. Patients were randomized 2:1 to aggressive treatment with continuous intravenous insulin or subcutaneous insulin QID as needed (usual care). Target glucose levels were Ͻ7.2 mmol/L (Ͻ130 mg/dL) in the aggressive-treatment group and Ͻ11.1 mmol/L (Ͻ200 mg/dL) in the usual-care group. Glucose was monitored every 1 to 2 hours, and the protocol treatments continued for up to 72 hours. Final clinical outcomes were assessed at 3 months. Results-We randomized 46 patients (31 to aggressive treatment and 15 to usual care). All patients in the aggressivetreatment group and 11 (73%) in the usual-care group had diabetes (Pϭ0.008). Glucose levels were significantly lower in the aggressive-treatment group throughout protocol treatment (

IMPORTANCE Hyperglycemia during acute ischemic stroke is common and is associated with worse outcomes. The efficacy of intensive treatment of hyperglycemia in this setting remains unknown. OBJECTIVES To determine the efficacy of intensive treatment of hyperglycemia during acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS The Stroke Hyperglycemia Insulin Network Effort (SHINE) randomized clinical trial included adult patients with hyperglycemia (glucose concentration of >110 mg/dL if had diabetes or Ն150 mg/dL if did not have diabetes) and acute ischemic stroke who were enrolled within 12 hours from stroke onset at 63 US sites between April 2012 and August 2018; follow-up ended in November 2018. The trial included 1151 patients who met eligibility criteria. INTERVENTIONS Patients were randomized to receive continuous intravenous insulin using a computerized decision support tool (target blood glucose concentration of 80-130 mg/dL [4.4-7.2 mmol/L]; intensive treatment group: n = 581) or insulin on a sliding scale that was administered subcutaneously (target blood glucose concentration of 80-179 mg/dL [4.4-9.9 mmol/L]; standard treatment group: n = 570) for up to 72 hours. MAIN OUTCOMES AND MEASURES The primary efficacy outcome was the proportion of patients with a favorable outcome based on the 90-day modified Rankin Scale score (a global stroke disability scale ranging from 0 [no symptoms or completely recovered] to 6 [death]) that was adjusted for baseline stroke severity. RESULTS Among 1151 patients who were randomized (mean age, 66 years [SD, 13.1 years]; 524 [46%] women, 923 [80%] with diabetes), 1118 (97%) completed the trial. Enrollment was stopped for futilitybasedonprespecifiedinterimanalysiscriteria.Duringtreatment,themeanbloodglucoselevel was 118 mg/dL (6.6 mmol/L) in the intensive treatment group and 179 mg/dL (9.9 mmol/L) in the standard treatment group. A favorable outcome occurred in 119 of 581 patients (20.5%) in the intensive treatment group and in 123 of 570 patients (21.6%) in the standard treatment group (adjusted relative risk, 0.97 [95% CI, 0.87 to 1.08], P = .55; unadjusted risk difference, −0.83% [95% CI, −5.72% to 4.06%]). Treatment was stopped early for hypoglycemia or other adverse events in 65 of 581 patients (11.2%) in the intensive treatment group and in 18 of 570 patients (3.2%) in the standard treatment group. Severe hypoglycemia occurred only among patients in the intensive treatment group (15/581 [2.6%]; risk difference, 2.58% [95% CI, 1.29% to 3.87%]). CONCLUSIONS AND RELEVANCE Among patients with acute ischemic stroke and hyperglycemia, treatment with intensive vs standard glucose control for up to 72 hours did not result in a significant difference in favorable functional outcome at 90 days. These findings do not support using intensive glucose control in this setting.

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Background and Purpose-The modified Rankin Scale (mRS) is a popular primary stroke outcome measure, but its usefulness is limited by suboptimal reliability (inter-rater agreement). Methods-We developed and tested the reliability of a simplified mRS questionnaire (smRSq) in 50 patients after stroke seen in outpatient clinics. Randomly chosen paired raters administered the smRSq within 20 minutes of each other and the ratings were blinded until the end of this study. Results-Agreement among the raters was 78%, the statistic was 0.72 (95% CI, 0.58 -0.86), and the weighted w statistic taking into account the extent of disagreement was 0.82 (95% CI, 0.72-0.92). The average time to administer the smRSq was 1.67 minutes. Conclusions-The smRSq appears to have very good reliability that is similar to that of a structured interview mRS and is considerably less time-consuming. (Stroke. 2010;41:1048-1050.)Key Words: clinometrics Ⅲ modified Rankin Scale Ⅲ outcome assessment R eliability (consistency) of measurements is of paramount importance in scientific research. 1 The modified Rankin Scale (mRS) 2 is a popular primary outcome measure in acute stroke trials, but its usefulness is limited by suboptimal reliability (inter-rater agreement). There is considerable variability in the reported reliability of the mRS. 3 A structured interview mRS that takes Ϸ15 minutes to administer was developed to help improve the mRS reliability. 4 In a recent systematic review the overall agreement between mRS raters without a standardized rating approach was 71%, the kappa () statistic was 0.46 (95% CI, 0.41-0.51), and the weighted kappa ( w ) statistic, taking into account the extent of all disagreements, was 0.90 (95% CI, 0.86 -0.94). 3 Using the structured interview mRS, the overall agreement was Ϸ73%, was 0.62 (95% CI, 0.56 -0.69), and w was 0.87 (95% CI, 0.75-1.00). 3,5,6 Inter-rater agreement was significantly improved with the structured interview mRS among raters with varied professional backgrounds, 7 which simulates a multicenter clinical trial. In an effort to simplify, standardize, and increase further the reliability of the mRS, we developed a simplified mRS questionnaire (smRSq) and tested it among raters with varied professional experiences. Materials and MethodsFour stroke faculty members with a total of 63 years experience applying the traditional unstructured mRS jointly created the smRSq (Figure). Using the key issues distinguishing between consecutive mRS categories, we created relatively simple questions that could be answered "yes" or "no" by patients or caregivers with little or no explanation. The key mRS issues were having no residual symptoms (0), being able to resume all prestroke activities (Յ1), being able to live independently (Յ2), being able to walk without assistance (Յ3), and not requiring constant supervision (Յ4).We screened patients for this study consecutively in 4 weekly clinics staffed by the stroke specialists and in 2 weekly resident continuity clinics at the Medical College of Georgia. Eligibility f...

Approximately one quarter of stroke patients correctly interpret their symptoms as representing a stroke. This knowledge is not associated with early presentation to the emergency department. Ambulance transport is independently associated with early arrival at the emergency department. Even when patients know that they are having a stroke, most present late because they perceive their symptoms as "not serious." Widespread public education of stroke-prone individuals may increase the proportion of patients eligible for new acute stroke treatments.