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

Abstract

Emergency medical services (EMS) use by stroke patients by calling 911 has been independently associated with earlier emergency department (ED) arrival (onset-to-door time #3 hours), quicker ED evaluation (more patients with door-to-imaging time #25 minutes), and more eligible patients being treated with IV alteplase. However, only w60% of all stroke patients use EMS and is less likely used by men, blacks, and Hispanics. Although EMS prenotification was associated with increased likelihood of alteplase treatment within 3 hours, EDs were notified by EMS in only 67% of transported patients. There is no clear benefit of bypassing the closest IV alteplase-capable hospital to bring the patient to one that offers a higher level of stroke care, including mechanical thrombectomy. In most cases, noncontrast computed tomography to rule out acute intracranial hemorrhage will provide the necessary information to make decisions regarding acute management. Brain imaging studies should be performed within 20 minutes of arrival in the ED in at least 50% of patients who may be candidates for IV alteplase and/or mechanical thrombectomy. Computed tomography angiography is indicated in patients with suspected intracranial large vessel occlusion before obtaining a serum creatinine concentration in patients without a history of renal impairment and treatment with IV alteplase should not be delayed. IV alteplase treatment should not be delayed while waiting for hematologic or coagulation testing if there is no reason to suspect an abnormal test. The only blood test that must be checked before alteplase is serum glucose to be sure high or low levels are not causing symptoms and because hyperglycemia is associated with worse outcomes. IV alteplase (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 ischemic stroke symptom onset. The benefit is well established for patients with disabling stroke symptoms regardless of age (even >80 years old) and stroke severity. It is generally but not necessarily contraindicated in patients who had major surgery within 14 days. Mechanical thrombectomy with stent retrievers performed via arterial groin punctures should be considered, along with intra-arterial thrombolysis, within 5 to 6 hours of onset of symptoms in patients with causative occlusion of the carotid and intracranial thrombosis. Urgent anticoagulation is not recommended for treatment of patients with acute ischemic stroke. When revascularization is indicated for secondary prevention in patients with minor, nondisabling stroke (mRS score 0-2), it is reasonable to perform carotid endarterectomy or carotid artery stenting between 48 hours and 7 days of the index event rather than delay treatment if there are no contraindications to early revascularization.Conclusion: IV alteplase should be administered within 3 hours of acute ischemic stroke in appropriate patients. Commentary: For those intrepid vascular surgeons who wan...

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