Guidelines for the Early Management of Adults With Ischemic Stroke

New Guidelines for Treatment of Acute Ischemic Stroke

April 19, 2007 — The American Heart Association/American Stroke Association has released new guidelines for the early management of acute ischemic stroke. The guidelines continue to endorse the use of intravenous tissue-type plasminogen activator (tPA) but note that other modalities such as intra-arterial tPA show promise. For the first time, the authors have included recommendations for palliative care.

"Our goal was to focus on the first few hours after stroke onset where we think time is so critical," Harold P. Adams Jr., MD, from the University of Iowa Stroke Center in Iowa City, chair of the guidelines writing committee, told Medscape. "The audience is primarily physicians, but we've also included information for general emergency medical services, and some things for the public as well, focusing on the idea that from the first symptom, time is brain, and everything we can do to expedite the process to hopefully treat the patients and reduce the likelihood of an unfavorable outcome is crucial," he said.

The guidelines were published in the April 12 Stroke ASAP issue and will appear in the May print issue of Stroke.

Dr. Adams has disclosed receiving research grants from Boehringer Ingelheim, Centocor (Johnson & Johnson), Eli Lilly, Merck, NMT Medical, Sanofi, Bristol-Myers Squibb, and GlaxoSmithKline, among other disclosures. Disclosure information for the other coauthors appears in the original article.

Stroke. 2007;38:1655-1711.

Study Highlights

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  The rate of activation of emergency medical services among patients with acute stroke is as low as 29%. As emergency medical services offers the most prompt care, all patients with the acute onset of stroke symptoms should use services such as telephoning 911 (in the United States).

• During initial evaluation, the single most important point in the patient's history is the time of symptom onset. Patients with acute stroke symptoms should receive testing for blood glucose, coagulation times, and complete blood count with platelets, along with 12-lead electrocardiogram and serum cardiac enzymes. However, chest radiography may be withheld if there are no signs of pulmonary or cardiac disease. The evaluation of the patient should be concluded within 60 minutes of arrival in the emergency department.

• CT remains the most common imaging modality for the evaluation of acute stroke, and, besides hemorrhage, there is no CT finding that is specific enough to preclude treatment with recombinant tPA (rtPA). MRI also is acceptable in the evaluation of acute stroke.

• Patients' blood pressure may decline spontaneously in the first 24 hours after stroke. Patients who are candidates for rtPA should have their systolic blood pressure lowered to at least 185 mm Hg and their diastolic blood pressure lowered to at least 110 mm Hg. Consensus opinions state that patients with persistent elevations in systolic blood pressure higher than 220 mm Hg or diastolic blood pressure higher than 120 mm Hg should receive antihypertension therapy.

• Hyperglycemia in the range of 140 to 185 mg/dL in the stroke patient should prompt consideration of insulin therapy.

• Hyperbaric oxygen should not be used in the acute stroke patient except in cases of air embolus.

• rtPA is the treatment of choice for thrombolysis in acute stroke. Treatment with streptokinase is not recommended, and reteplase, urokinase, and other thrombolytic agents should not be used outside of the setting of a clinical trial.

• Intra-arterial thrombolysis may be used for patients with occlusions of the middle cerebral artery who can be treated within 6 hours of symptom onset.

• Urgent anticoagulation generally is not recommended in lieu of intravenous thrombolysis and should be withheld in patients with moderate or severe stroke because of an increased risk for intracranial hemorrhage.

• Aspirin therapy at a dose of 325 mg may be initiated within 24 to 48 hours after stroke onset. Based on current evidence, the authors recommend against the routine use of clopidogrel following stroke.

• During hospitalization, stroke patients should receive a swallowing evaluation as well as prophylaxis against deep venous thrombosis with heparin or low-molecular-weight heparin.

• Pearls for Practice

• The current guidelines recommend that the initial workup of patients with possible stroke include testing for blood glucose, coagulation times, intracranial imaging, and complete blood count, along with 12-lead electrocardiogram and serum cardiac enzymes. However, chest radiography may be withheld if there are no signs of pulmonary or cardiac disease.

• rtPA is the treatment of choice for patients who present within 3 hours of the onset of stroke symptoms.

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