Summary of Updated Acute Ischemic Stroke guidelines

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

The American Heart Association/American Stroke Association has updated its comprehensive acute ischemic stroke care guidelines in 2013.  

 

The following is a summary of the most important new recommendations:

 

  • Teleradiology networks are recommended for community hospitals that lack access to neurological expertise. (Class I, Level B)

  • Intravenous (IV) thrombolysis is recommended in the setting of early ischemic changes, with the exception of frank hypodensity on computed tomography (CT). (Class I, Level A)

  • A noninvasive intracranial vascular study is strongly recommended if either intra-arterial fibrinolysis or mechanical thrombectomy is being considered, but this study should not delay initiation of tissue plasminogen activator (TPA). (Class I, Level A)

  • The target door-to-needle time for patients who receive intravenous TPA is <60 minutes. (Class I, Level A)

  • IV TPA is recommended in the 3- to 4.5-hour time window — beyond the previously recommended 3-hour window — with additional exclusion criteria (age >80, use of oral anticoagulants, baseline NIH Stroke Scale score >25, imaging evidence of ischemic injury involving more than one third of the middle cerebral artery territory, or a history of both stroke and diabetes mellitus). (Class I, Level B)

  • Use of IV TPA may be considered for patients with mild stroke or those with major surgery in the last 3 months, after weighing the risks and benefits. (Class IIb, Level C)

  • Use of IV TPA is not recommended for patients taking novel anticoagulants unless clotting tests are normal or the patient has not taken medication for >2 days (with normal renal function). (Class III, Level C)

  • When mechanical thrombectomy is considered, stent retrievers are preferred to coil retrievers. (Class I, Level A) The ability of mechanical thrombectomy devices to improve patient outcomes has not yet been established.

  • Rescue intra-arterial thrombolysis or thrombectomy may be reasonable in patients who have failed IV thrombolysis, but additional randomized trial data are needed. (Class IIb, Level B)

  • Permissive hypertension up to a BP of 220/120 mmHg is still recommended for acute ischemic strokes at least for the first 24 hours of hospitalization unless TPA is administered in which case the BP should remain below 185/110 mmHg.

 

acute stroke management