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Guidelines for the Early Management ofAdults with Ischemic Stroke

From the AHA/ASA Stroke Council

Harold P. Adams, Chair; Gregory del Zoppo, Vice-Chair,Mark J. Alberts, Deepak L Bhatt, Lawrence Brass, Anthony

Furlan, Robert L. Grubb, Randy Higashida, Edward C.

Jauch, Chelsea Kidwell, Patrick D. Lyden, Lewis B.

Morgenstern, Adnan I. Qureshi, Robert H. Rosenwasser,Philip A. Scott, Eelco FM Wijdicks

Stroke 2007; 38(5): 1655-1711


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Presentation Compiled by theAHA Stroke Council Professional

Education Committee

Susan C. Fagan, Chair

Deborah Bergman

Dawn Bravata

Seemant Chaturvedi

Kari DunningKathryn Taubert, Staff Scientist

Karen Modesitt, Staff


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Introduction

This slide set was adapted from the AHA/ASAGuidelines for the Early Management of Adults withIschemic Stroke

From the American Heart Association/American

Stroke Association Stroke Council, ClinicalCardiology Council, Cardiovascular Radiology andIntervention Council, and the AtheroscleroticPeripheral Vascular Disease and Quality of CareOutcomes in Research Interdisciplinary WorkingGroups

The American Academy of Neurology affirms thevalue of this guideline as an educational tool forneurologists.

The full-text guidelines are available on the Web site

of the AHA (www.americanheart.org)
http://www.americanheart.org/http://www.americanheart.org/http://www.americanheart.org/


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Introduction Contd

Since the 2003 AHA Stroke Council guidelines,evidence has been published to further refine theapproach to the patient with acute ischemic stroke.

In some cases, where supportive evidence fromclinical trials was not available, the panel made aspecific recommendation on the basispathophysiology and expert practice experience.


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Changes from 2003 Guidelines

Entirely new section on prehospital care

Stroke Centers

More detailed recommendations on generalsupportive care and hospitalization

Multimodal Imaging

Recommendation to RESTART antihypertensives at24 hours after onset.

New recommendations re: thrombolysis eligibilityand delivery

Adams et al. Stroke 2003; 34:1056-1083


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Changes from 2003 Guidelines Contd

Recommendations AGAINST clopidogrel acutely

Recommendations AGAINST using experimental

strategies as part of routine care (hyperbaric O2,Merci device, glycoprotein IIbIIIa antagonists, drug-induced hypertension, combination reperfusionstrategies)

Adams et al. Stroke 2003; 34:1056-1083


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AHA Classes and Levels of Evidence

Class I Agreement the treatment is useful and effective

Class II Conflicting evidence and/or a divergence ofopinion about the usefulness/efficacy of a treatment. Class IIa Weight of evidence is in favor of the

treatment. Class IIb Usefulness/efficacy is less well

established by evidence

Class III Evidence and/or general agreement that thetreatment is not useful/effective and in some cases may be

harmful.

Levels of EvidenceA: Data derived from multiple randomized trials.B: Data derived from a single randomized trial or

nonrandomized studies.C: Consensus opinion of experts.


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Components of Acute Treatment

Prehospital Care

Stroke Center Designation

Emergency Evaluation and DiagnosticsSupportive Care

Thrombolysis (IV and IA)

Antiplatelet agents / anticoagulants

Volume Expansion / Induced Hypertension

Surgical/ Endovascular Interventions

Combination Reperfusion Therapy

Neuroprotection

Hospital Care

Treatment of Acute Complications


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Prehospital Management and Field

Treatment

New: Activation of the 9-1-1 systems by patients orother members of the public is strongly supported

because it speeds treatment of stroke (Class I,Level B)

New: To increase the number of patients who canbe seen and treated within the first few hours after

stroke, educational programs to increase publicawareness of stroke are recommended (Class I,Level B)


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Prehospital Contd

New: To increase the number of patients who aretreated, educational programs for physicians,hospital personnel, and EMS personnel also arerecommended (Class I, Level B)

New : Brief assessment by EMS personnel arerecommended (Class I, Level B)

New :The use of a stroke algorithm is encouraged(Class I, Level B)


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Prehospital Contd

New: The panel recommends that EMS personnelbegin the initial management of stroke in the field(Class I, Level B)

New : The development of stroke protocols to beused by EMS personnel is strongly encouraged.Patients should be transported rapidly forevaluation and treatment to the closest institution

that provides emergency stroke care as describedin the statement (Class I, Level B)

New: Telemedicine can be an effective method to

extend acute stroke care to rural areas. (Class IIb,Level B)


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Designation of Stroke Centers

The creation of PSCs is strongly recommended(Class I, Level B). The organization of suchresources will depend on local variable.

The development of CSC is recommended (Class I,Level C)

Certification of stroke centers by an external body,such as JCAHO, is encouraged (Class I, Level B)

For patients with suspected stroke, EMS shouldbypass hospital that do not have resources to treatstroke and got the closest facility capable oftreating acute stroke (Class I Level B)


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Emergency Diagnosis and Management:Class I recommendations

The goal is to complete an evaluation and decide ontreatment within 60 minutes of the patients arrivalin the ED. Acute stroke teams are encouraged.(Class I, Level B)

The use of a stroke rating scale is recommended(e.g., NIH Stroke Scale) (Class I, Level B)

Patients with clinical evidence of acute cardiac orpulmonary disease may warrant a CXR (Class I,Level B)


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Emergency Diagnosis and Management

Contd

An ECG is recommended (Class I,Level B)

Basic blood tests are recommended

(Class I, Level B)


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New: Most patients with acute stroke do not require

a CXR as part of their initial evaluation (Class III,Level B)

Most patients with stroke do not need a CSF exam(consider if clinical picture suggestive of SAH and

CT head normal) (Class III, Level B)

Emergency Diagnosis and Management:

Class III Recommendations


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Brain and Vascular Imaging : Class Irecommendations

Imaging of the brain is recommended beforeinitiating specific therapy (Class I, Level A)

In most instances, CT will provide the informationto make decisions about emergency management(Class I, Level A)

New: The imaging study should be interpreted by aphysician with expertise in reading brain CT and

MRI(Class I, Level C)


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Brain and Vascular Imaging: Class Irecommendations

Some findings on CT, such as a dense artery sign,are associated with poor prognosis (Class I, Level

A)

New: Multimodal CT and MRI may provideadditional information that will improve diagnosisof ischemic stroke (Class I, Level A)


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Brain and Vascular Imaging: Class IIRecommendations

Other than hemorrhage, no specific CT findingshould preclude use of IV rtPA within 3 hours ofstroke onset (Class IIb, Level A)

Vascular imaging is required before intra-arterial orendovascular interventions (Class IIa, Level B)


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Brain and Vascular Imaging: Class IIIRecommendations

New: Emergency treatment of stroke should not bedelayed in order to obtain multimodal imaging

studies (Class III, Level C)

New: Vascular imaging studies should not delaytreatment of acute stroke patients whose symptomsstarted


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General Supportive Care: Class IRecommendations

Airway support and ventilatory assistance arerecommended for the treatment of acute stroke(Class I, Level C)

Hypoxic patients with stroke should receivesupplemental oxygen (Class I, Level C)

Fever should be treated and antipyretic medicationsshould administered to lower temperature in febrile

patients (Class I, Level C)


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General Supportive Care Contd

Cardiac monitoring to screen for atrial fibrillationand other potentially serious cardiac arrhythmiasshould be performed during the first 24 hours after

onset of ischemic stroke (Class I Level B)

The management of arterial hypertension remainscontroversial. It is generally agreed that a cautiousapproach to the treatment of arterial hypertension

should be recommended (Class I, Level C)


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Patients who have elevated blood pressure and areotherwise eligible for treatment of rtPA may havetheir blood pressure lowered so that their systolicis< 185 mm Hg and their diastolic blood pressure is< 110 mm Hg (Class I, Level B)

New: Until other data become available, consensusexists that the previously described blood pressurerecommendations should be followed in patients

undergoing other acute interventions to recanalizeoccluded vessels, including intra-arterialthrombolysis (Class I, Level C)


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New : Patients with markedly elevated bloodpressure may have their blood pressure lowered. Areasonable goal is ~ 15% during the first 24 hoursafter onset of stroke. Medications should be

withheld unless SPB > 220 or MAP >120 (Class I,Level C)

The cause of arterial hypotension in the setting ofacute stroke should be sought (Class I, Level C)

New: Hypoglycemia should be treated in patientswith acute ischemic stroke (Class I, Level C).Marked elevations in blood glucose should beavoided.


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General Supportive Care: Class IIRecommendations

New: There is no data to guide selection ofmedications for the lowering of blood pressure inthe setting of acute ischemic stroke. Therecommended medications and doses are based on

general consensus (Class IIa, Level C)

New: For patients with preexisting hypertensionevidence indicates antihypertensive therapymedications should be restarted at ~ 24 hours(Class IIa, Level B)

New: Persistent hyperglycemia (>140 mg/dL) duringthe first 24 hours after stroke is associated withpoor outcomes (Class IIa, Level C)


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General Supportive Care: Class IIIRecommendations

Non-hypoxic patients with acute ischemic stroke donot need supplemental oxygen therapy (Class III,Level B

New: Data on hyperbaric oxygen are inconclusive,and some data imply that the intervention may beharmful (Class III, Level B)

Despite the efficacy of hypothermia for improving

neurological outcomes after cardiac arrest, theutility of induced hypothermia for the treatment ofpatients with acute ischemic stroke is notestablished (Class III, Level B)


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Intravenous Thrombolysis: Class I

Recommendations

IV rtPA (0.9 mg.kg, maximum dose 90 mg) isrecommended for selected patients who may be

treated within 3 hours of onset of ischemic stroke(Class I, Level A)

New: Besides bleeding complications, physiciansshould be aware of the potential side effect of

angioedema that may cause partial airwayobstruction (Class I, Level C)


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Intravenous Thrombolysis: Class IIRecommendations

A patient whose BP can be safely lowered withantihypertensive agents may be eligible fortreatment. (Class IIa, Level B)

New: A patient with a seizure at the time of onsetmay be eligible for treatment. (Class IIa, Level C)


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Intravenous Thrombolysis: Class IIIRecommendations

IV streptokinase for treatment of stroke IS NOTrecommended. (Class III, Level A)

New: Use of IV fibrinolytics other than tPA(reteplase, tenecteplase, etc) outside a clinical trialin NOT recommended. (Class III, Level C)


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Intraarterial Thrombolysis: Class IRecommendations

Intraarterial thrombolysis is an option for majorstroke if administered within 6 hours of onset.( Class I, Level B)

Intraarterial thrombolysis should only be attemptedat experienced stroke centers (Class I, Level C)


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Intra-Arterial Thrombolysis : Class IIIII recommendations

New: Intra-arterial thrombolysis is reasonable inpatients who have contraindications to use of IVthrombolysis, such as recent surgery (Class II, LvelC)

The availability of intra-arterial thrombolysis shouldgenerally NOTpreclude the use of IV rtPA in eligiblepatients (Class III, Level C)


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Combination Reperfusion Therapies :Class III recommendation

New: Combinations of interventions to restoreperfusion cannot be recommended outside thesetting of clinical trials (Class III, Level B)


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Anticoagulation: Class IIIRecommendations

Urgent anticoagulation for the prevention of earlyrecurrence, halting worsening or improvingoutcomes, is NOT recommended. (Class III, Level A)

Urgent anticoagulation is NOT recommended formoderate to severe strokes because of anincreased risk of serious intracranial hemorrhage.(Class III, Level A)

Initiation of anticoagulant therapy within 24 h of IVrtPA is NOT recommended. (Class III, Level B)


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AntiplateletTherapy: Class I Recommendation

New Dose Added: Oral aspirin (initial dose of 325mg) within 24 to 48 hours of stroke onset is

recommended for most patients (Class I, Level A)


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Antiplatelet Therapy: Class IIIRecommendations

Aspirin should NOT be considered a substitute forIV rtPA. (Class III, Level A)

Aspirin is NOT recommended within 24 h of IV rtPA.(Class III, Level A)

New: Clopidogrel alone or in combination with

aspirin is NOT recommended. (Class III, Level C)

New: Use of IV GPIIbIIIa receptor antagonistsoutside of clinical trials NOT recommended. (ClassIII, Level B)


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Hemodilution : Class IIIRecommendation

Hemodilution with or without volume expansion isNOT recommended for patients with acuteischemic stroke (Class III, Level A)


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Vasodilators in Acute Ischemic Stroke

Methylxanthine derivatives (e.g., pentoxifylline) arevasodilators that also inhibit platelet aggregation

Several studies have evaluated the use ofpentoxifylline for the reduction of 30-day mortality

Neither pentoxifylline nor pentofylline has beenshown to improve outcomes after stroke


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Vasodilators: Class III Recommendation

Medications such as pentoxifylline are NOT

recommended for patients with acute ischemicstroke (Class III, Level A)


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Induced Hypertension Recommendations

Class I: New: In exceptional cases, vasopressors may be

used to improve cerebral blood flow, but this use

requires close neurological and cardiac monitoring(Class I, Level C)

Class III: New: Drug-induced hypertension is NOT

recommended for most patients with acuteischemic stroke (Class III, Level B)


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No Surgical Recommendations

Safety and effectiveness data about surgicalinterventions for patients with acute ischemicstroke are insufficient to make recommendations


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Endovascular Intervention : Class IIRecommendations

New: Although the MERCI device is a reasonableintervention for extraction of intra-arterial thrombiin carefully selected patients, the utility of thedevice in improving outcomes after stroke is

unclear; additional clinical trials are needed todefine its role in the emergency management ofstroke (Class IIb, Level B)

The usefulness of other endovascular treatments isnot established(Class IIb, Level C)


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Neuroprotection: Class IIIRecommendation

NO intervention with putative neuroprotectiveactions has been established as effective inimproving outcomes after stroke, and therefore

none currently can be recommended (Class III,Level A)


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Hospitalization: Class IRecommendations

The use of stroke units incorporating rehabilitationis recommended (Class I, Level A)

SC anticoagulants for prevention of DVT inimmobilized patients is recommended (Class I,Level A)

New: The use of standardized stroke care ordersets in recommended (Class I, Level B)

Early mobilization to prevent subacute

complications of stroke is recommended (Class I,Level C)


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Hospitalization: Class IRecommendations

New: Assessment of swallowing before startingeating or drinking is recommended (Class I, Level B)

Patients with pneumonia or UTI should receiveantibiotics (Class I, Level B).

Treatment of concomitant medical diseases isrecommended (Class I, Level C)

Early institution of interventions to prevent recurrentstroke is recommended (Class I, Level C)


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Hospitalization: Class IIRecommendations

New: Patients who cannot take food and fluidsorally should receive NG, ND or PEG feedings tomaintain hydration and nutrition while undergoingefforts to restore swallowing (Class IIa, Level B)

ASA can be used for DVT prophylaxis but is lesseffective than anticoagulation (Class IIa, Level A)

Intermittent pneumatic compression devices arerecommended for patients who cannot receiveanticoagulation (Class IIa, Level B)


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Hospitalization: Class IIIRecommendations

New: Nutritional supplements are NOT needed(Class III, Level B)

New: Prophylactic antibiotics are NOTrecommended (Class III, Level B)

If possible, placement of an indwelling bladdercatheter should be avoided because of risk of UTI

(Class III, Level C)


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Treatment of Neurologic Complications :Class I Recommendations

Patients with major infarctions affecting thecerebral hemisphere or cerebellum are at high riskof brain edema and increased ICP. Measures tolessen the risk of edema and close monitoring ofthe patient for worsening during the first days arerecommended (Class I, Level B) New: Transfer ofthe patient to a center with neurosurgical expertiseshould be considered

Patients with acute hydrocephalus secondary toischemic stroke can be treated with a ventriculardrain (Class I, Level B)


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Treatment of Neurologic Complications :Class I Recommendations

Decompressive surgical evacuation of a space-occupying cerebellar infarction is a potentially life-

saving measure, and clinical recovery may be verygood (Class I, Level B)

Recurrent seizures after stroke should be treated aswith other acute neurological conditions (Class I,

Level B)


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Treatment of Neurologic Complications :Class II Recommendations

Aggressive medical measures, includingosmotherapy, are UNPROVEN for management ofmalignant ischemic cerebral edema (Class IIa, Level

C). Hyperventilation is short-lived and medicalmeasures could delay decompressive surgery.

Decompressive surgery for malignant edema in thecerebral hemisphere may be lifesaving but impacton morbidity is unknown. For severely afflicted

patients, advice about the possibility of life withsevere disability should be given to the family(Class IIa, Level B)


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Treatment of Neurologic Complications :Class II Recommendations

New: No specific recommendation is made fortreatment of asymptomatic hemorrhagictransformation (Class IIb, Level C)


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Treatment of Neurologic Complications:Class III Recommendations

Corticosteroids NOT recommended (Class III, LevelA)

Prophylactic anticonvulsants are NOTrecommended (Class III, Level C)


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Summary

These guidelines provide comprehensive andtimely evidence-based recommendations.

There is an intent to fully update the guidelinesevery three years, with updates encouraged whenpivotal studies are published.

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