2018 Guidelines for Acute Ischemic Stroke Provides New Recommendations

by Joseph Esherick, M.D., FAAFP, FHM

The 2018 AHA/ASA guidelines for the early management of acute ischemic stroke provides some important new evidence-based recommendations.  Some important new recommendations described in these guidelines include:

  • The DAWN and DEFUSE 3 trials selected patients for mechanical thrombectomy within an extended time window based on a combination of clinical and imaging-based criteria.  Mechanical thrombectomy can be used for patients with acute ischemic stroke due to an anterior circulation large vessel occlusion.  The time period for mechanical thrombectomy has been extended definitely up to 16 hours, but even up to 24 hours in select patients.
  • For patients who are potential candidates for endovascular therapy, one should obtain early CT angiograms (CTA) of the brain at the same time as the initial neuroimaging.  This CTA can be done prior to serum creatinine in patients with no known kidney disease.  A CTA of the neck to evaluate for carotid artery stenosis can be obtained at the same time for anterior circulation strokes.
  • ROUTINE diagnostic testing is NOT indicated for ALL patients with acute ischemic strokes to include:
    • Cholesterol testing
    • Brain MRI
    • Echocardiogram
  • Consider transesophageal echocardiogram and prolonged cardiac monitoring to evaluate for paroxysmal Afib/flutter in patients with cryptogenic strokes.

Powers WJ et al. 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. Stroke 2018 Jan 24; [e-pub]