Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Abstract

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...

Association of Acute and Chronic Hyperglycemia With Acute Ischemic Stroke Outcomes Post‐Thrombolysis: Findings From Get With The Guidelines‐Stroke

“…The potential benefit of strict glucose control with aggressive insulin titration in acute stroke is unclear,30 and this hypothesis is currently being tested in a large, randomized, clinical trial 31. To avoid the risk of adverse effects related to hypoglycemia, guidelines recommend to maintain blood glucose in a range of 140 to 180 mg/dL 32. Whereas our retrospective study suggests that better blood glucose regulation measured at admission is associated with better short‐term clinical outcomes, we did not test or measure any interventions that were given in response to these glucose measurements, and thus these findings require prospective, randomized, clinical trials to evaluate the potential benefits and potential risks of any treatment in this patient population.…”

Cardiac Vulnerability to Cerebrogenic Stress as a Possible Cause of Troponin Elevation in Stroke

“…At admission, measurement of serum cardiac troponin I and ECG were routinely performed in all patients following the guidelines since 2007 3. After cardiac investigation, additional cardiac evaluations of patients were performed by cardiologists if the tests were suspected of indicating acute coronary syndrome 4. Among patients who were admitted to the stroke center, patients were excluded if they were diagnosed with troponin‐elevating conditions, including acute coronary syndrome, impaired renal function (estimated glomerular filtration rate <60 mL/min per 1.73 m 2 ), and (3) congestive heart failure (having a history of heart failure or reduced ejection fraction ≤40%) at admission.…”

“…Thus, since 2007, the guidelines for the management of ischemic stroke recommend to perform a 12‐lead electrocardiography and cardiac enzyme test,3, 4 particularly cardiac troponin, which is a highly sensitive and specific biomarker of myocardial damage 5…”

Automatic detection of paroxysmal atrial fibrillation in patients with ischaemic stroke: better than routine diagnostic workup?

“…The detection of paroxysmal AF (pAF) can be challenging due to its short duration, frequently asymptomatic presentation and occurrence in a cluster 2. Although current guidelines recommend electrocardiogram (ECG) monitoring for at least 24 h after a stroke 3, recently published studies report higher detection rates (up to one quarter of patients with ischaemic stroke) with prolonged AF detection times and sequential cardiac monitoring methods 1. A prolongation of the Holter monitoring times might easily be achieved in routine practice and could lead to a higher detection rate of pAF and subsequent prescription of oral anticoagulation, resulting in a reduction of risk of recurrent stroke 4.…”