Guidelines Summary
American Heart Association/American Stroke Association
Updated guidelines from the American Heart Association (AHA) and the American Stroke Association (ASA) extend the time limit on mechanical clot removal from 6 hours to up to 24 hours in select patients. [108] The new guidelines recommend thrombectomy in eligible patients 6 to 16 hours after a stroke. [145, 146] They also broaden the eligibility criteria by allowing patients who are ineligible for IV tPA to undergo mechanical thrombectomy within 6 hours.
Patients should be considered for thrombectomy in under 6 hours after stroke onset if they have a large clot in one of the large vessels at the base of the brain and meet the following criteria:
-
Prestroke modified Rankin Scale (mRS) score of 0 to 1;
-
Causative occlusion of the internal carotid artery or middle cerebral artery segment 1 (M1);
-
Age over 18 years;
-
National Institutes of Health Stroke Scale score of 6 or greater; and
-
Alberta Stroke Program Early CT Score of 6 or greater.
The AHA and ASA also issued guidelines for the reduction of stroke risk specifically in women. These gender-specific recommendations include the following: [25, 26]
-
A stroke risk score should be developed specifically for women
-
Women with a history of high blood pressure before pregnancy should be considered for low-dose aspirin and/or calcium supplement treatment to reduce the risk of preeclampsia
-
Blood pressure medication may be considered for pregnant women with moderately high blood pressure (150-159 mmHg/100-109 mmHg), and pregnant women with severe high blood pressure (160/110 mmHg or above) should be treated
-
Women should be screened for high blood pressure before they start using birth control pills because of an increased risk of stroke
-
Women with migraine headaches with aura should be encouraged to quit smoking to reduce the risk of stroke
-
Women over age 75 should be screened for atrial fibrillation
European Stroke Organisation
The European Stroke Organisation published guidelines on mechanical thrombectomy (MT) in acute ischemic stroke. [147] Recommendations include the following:
-
MT plus best medical management (BMM) is recommended for adults with anterior circulation large vessel occlusion-related acute ischemic stroke presenting within 6 hours after symptom onset.
-
MT plus BMM is recommended for adults with anterior circulation large vessel occlusion-related acute ischemic stroke presenting between 6 and 24 hours from time last known well and fulfilling the inclusion criteria for the DEFUSE-3 and DAWN clinical trials.
-
Intravenous (IV) thrombolysis plus MT is recommended for patients with large vessel occlusion-related ischemic stroke. Both treatments should be performed as soon as possible after the patient arrives to the hospital.
-
MT plus BMM (including IV thrombolysis when indicated) is recommended for patients ≥ 80 years with large vessel occlusion-related acute ischemic stroke presenting within 6 hours of symptom onset.
-
MT plus BMM (including IV thrombolysis when indicated) is recommended in the 0–6-hour time window for patients with large vessel occlusion-related anterior circulation stroke without evidence of extensive infarct core.
-
MT plus BMM (including IV thrombolysis when indicated) is recommended in the 6–24-hour time window for patients with large vessel occlusion-related anterior circulation stroke who fulfill the inclusion criteria for the DEFUSE-3 and DAWN clinical trials.
-
Advanced imaging is not necessary for patient selection in adult patients with anterior circulation large vessel occlusion-related acute ischemic stroke presenting from 0–6 hours from time last known well. Advanced imaging is necessary in this group, however, if patients present beyond 6 hours from time last known well.
Evaluating and managing stroke in patients with COVID-19
Because patients with COVID-19 infection have high risk of developing acute stroke, an international panel of stroke experts from 18 countries issued a set of recommendations for managing acute ischemic stroke patients with either suspected or confirmed infection with the virus. [148, 149] Their recommendations include the following:
-
Due to the high rate of mortality in COVID-19 patients who have multiple organ dysfunctions/failure, a Sequential Organ Failure Assessment (SOFA) score may be helpful in devising a treatment plan.
-
It is reasonable to perform chest CT and/or radiography to identify radiologic abnormalities suggestive of COVID-19 infection.
-
It is important to take into account risk factors for contrast-induced nephropathy due to the high rate of renal insufficiency in patients with COVID-19.
-
Tests for assessing coagulation profile such as thromboelastography and serum concentration of D-dimers may be considered as needed.
-
A stringent policy is required to select acute ischemic stroke patients for mechanical thrombectomy.
-
If intubation is needed, the procedure should be performed in a negative-pressure room with teams of experienced clinicians wearing protective gear and using video-guided laryngoscopy. A tracheobronchial specimen may be taken at this time to confirm suspected COVID-19 infection.
-
Parameters from the SIESTA trial [150] should be used if intubation and mechanical ventilation are performed to ascertain that there is no decrease in blood pressure or abnormal blood gases during the procedure.
-
Maximum intensity projection (MIP) image from a computed tomography angiogram (CTA) demonstrates a filling defect or high-grade stenosis at the branching point of the right middle cerebral artery (MCA) trunk (red circle), suspicious for thrombus or embolus. CTA is highly accurate in detecting large- vessel stenosis and occlusions, which account for approximately one third of ischemic strokes.
-
Axial noncontrast computed tomography (NCCT) scan demonstrates diffuse hypodensity in the right lentiform nucleus with mass effect upon the frontal horn of the right lateral ventricle in a 70-year-old woman with a history of left-sided weakness for several hours.
-
Magnetic resonance imaging (MRI) scan in a 70-year-old woman with a history of left-sided weakness for several hours. An axial T2 fluid-attenuated inversion recovery (FLAIR) image (left) demonstrates high signal in the lentiform nucleus with mass effect. The axial diffusion-weighted image (middle) demonstrates high signal in the same area, with corresponding low signal on the apparent diffusion coefficient (ADC) maps, consistent with true restricted diffusion and an acute infarction. Maximum intensity projection from a 3-dimensional (3-D) time-of-flight magnetic resonance angiogram (MRA, right) demonstrates occlusion of the distal middle cerebral artery (MCA) trunk (red circle).
-
Cardioembolic stroke: Axial diffusion-weighted images demonstrate scattered foci of high signal in the subcortical and deep white matter bilaterally in a patient with a known cardiac source for embolization. An area of low signal in the left gangliocapsular region may be secondary to prior hemorrhage or subacute to chronic lacunar infarct. Recurrent strokes are most commonly secondary to cardioembolic phenomenon.
-
Axial noncontrast computed tomography (CT) scan demonstrates a focal area of hypodensity in the left posterior limb of the internal capsule in a 60-year-old man with acute onset of right-sided weakness. The lesion demonstrates high signal on the fluid-attenuated inversion recovery (FLAIR) sequence (middle image) and diffusion-weighted magnetic resonance imaging (MRI) scan (right image), with low signal on the apparent diffusion coefficient (ADC) maps indicating an acute lacunar infarction. Lacunar infarcts are typically no more than 1.5 cm in size and can occur in the deep gray matter structures, corona radiata, brainstem, and cerebellum.
-
Magnetic resonance imaging (MRI) scan was obtained in a 62-year-old man with hypertension and diabetes and a history of transient episodes of right-sided weakness and aphasia. The fluid-attenuated inversion recovery (FLAIR) image (left) demonstrates patchy areas of high signal arranged in a linear fashion in the deep white matter, bilaterally. This configuration is typical for deep border-zone, or watershed, infarction, in this case the anterior and posterior middle cerebral artery (MCA) watershed areas. The left-sided infarcts have corresponding low signal on the apparent diffusion coefficient (ADC) map (right), signifying acuity. An old left posterior parietal infarct is noted as well.
-
A 48-year-old man presented with acute left-sided hemiplegia, facial palsy, and right-sided gaze preference. Angiogram with selective injection of the right internal carotid artery demonstrates occlusion of the M1 segment of the right middle cerebral artery (MCA) and A2 segment of the right anterior cerebral artery (ACA; images courtesy of Concentric Medical).
-
Follow-up imaging after mechanical embolectomy in 48-year-old man with acute left-sided hemiplegia, facial palsy, and right-sided gaze preference demonstrates complete recanalization of the right middle cerebral artery (MCA) and partial recanalization of the right A2 segment (images courtesy of Concentric Medical).
-
Cerebral angiogram performed approximately 4.5 hours after symptom onset in a 31-year-old man demonstrates an occlusion of the distal basilar artery (images courtesy of Concentric Medical).
-
Image on the left demonstrates deployment of a clot retrieval device (older generation device) in a 31-year-old man. Followup angiogram after embolectomy demonstrates recanalization of the distal basilar artery with filling of the superior cerebellar arteries and posterior cerebral arteries. The patient had complete resolution of symptoms following embolectomy (images courtesy of Concentric Medical).
-
Noncontrast computed tomography (CT) scan in a 52-year-old man with a history of worsening right-sided weakness and aphasia demonstrates diffuse hypodensity and sulcal effacement with mass effect involving the left anterior and middle cerebral artery territories consistent with acute infarction. There are scattered curvilinear areas of hyperdensity noted suggestive of developing petechial hemorrhage in this large area of infarction.
-
Magnetic resonance angiogram (MRA) in a 52-year-old man demonstrates occlusion of the left precavernous supraclinoid internal carotid artery (ICA, red circle), occlusion or high-grade stenosis of the distal middle cerebral artery (MCA) trunk and attenuation of multiple M2 branches. The diffusion-weighted image (right) demonstrates high signal confirmed to be true restricted diffusion on the apparent diffusion coefficient (ADC) map consistent with acute infarction.
-
Lateral view of a cerebral angiogram illustrates the branches of the anterior cerebral artery (ACA) and Sylvian triangle. The pericallosal artery has been described to arise distal to the anterior communicating artery or distal to the origin of the callosomarginal branch of the ACA. The segmental anatomy of the ACA has been described as follows: the A1 segment extends from the internal carotid artery (ICA) bifurcation to the anterior communicating artery; A2 extends to the junction of the rostrum and genu of the corpus callosum; A3 extends into the bend of the genu of the corpus callosum; A4 and A5 extend posteriorly above the callosal body and superior portion of the splenium. The Sylvian triangle overlies the opercular branches of the middle cerebral artery (MCA), with the apex representing the Sylvian point.
-
Frontal projection from a right vertebral artery angiogram illustrates the posterior circulation. The vertebral arteries join to form the basilar artery. The posterior inferior cerebellar arteries (PICAs) arise from the distal vertebral arteries. The anterior inferior cerebellar arteries (AICAs) arise from the proximal basilar artery. The superior cerebellar arteries (SCAs) arise distally from the basilar artery prior to its bifurcation into the posterior cerebral arteries (PCAs).
-
Frontal view of a cerebral angiogram with selective injection of the left internal carotid artery (ICA) illustrates the anterior circulation. The anterior cerebral artery (ACA) consists of the A1 segment proximal to the anterior communicating artery, with the A2 segment distal to it. The middle cerebral artery (MCA) can be divided into 4 segments: the M1 (horizontal segment) extends to the anterior basal portion of the insular cortex (the limen insulae) and gives off lateral lenticulostriate branches, the M2 (insular segment), M3 (opercular branches), and M4 (distal cortical branches on the lateral hemispheric convexities).
-
Regions of interest are selected for arterial and venous input (image on left) for dynamic susceptibility-weighted perfusion magnetic resonance imaging (MRI). Signal-time curves (image on right) obtained from these regions of interest demonstrate transient signal drop following the administration of intravenous contrast. The information obtained from the dynamic parenchymal signal changes postcontrast is used to generate maps of different perfusion parameters.
-
Vascular distributions: Middle cerebral artery (MCA) infarction. Noncontrast computed tomography (CT) scanning demonstrates a large acute infarction in the MCA territory involving the lateral surfaces of the left frontal, parietal, and temporal lobes, as well as the left insular and subinsular regions, with mass effect and rightward midline shift. There is sparing of the caudate head and at least part of the lentiform nucleus and internal capsule, which receive blood supply from the lateral lenticulostriate branches of the M1 segment of the MCA. Note the lack of involvement of the medial frontal lobe (anterior cerebral artery [ACA] territory), thalami, and paramedian occipital lobe (posterior cerebral artery [PCA] territory).
-
Vascular distributions: Anterior choroidal artery infarction. The diffusion-weighted image (left) demonstrates high signal with associated signal dropout on the apparent diffusion coefficient (ADC) map involving the posterior limb of the internal capsule. This is the typical distribution of the anterior choroidal artery, the last branch of the internal carotid artery (ICA) before bifurcating into the anterior and middle cerebral arteries. The anterior choroidal artery may also arise from the middle cerebral artery (MCA).
-
Vascular distributions: Anterior cerebral artery (ACA) infarction. Diffusion-weighted image on the left demonstrates high signal in the paramedian frontal and high parietal regions. The opposite diffusion-weighted image in a different patient demonstrates restricted diffusion in a larger ACA infarction involving the left paramedian frontal and posterior parietal regions. There is also infarction of the lateral temporoparietal regions bilaterally (both middle cerebral artery [MCA] distributions), greater on the left indicating multivessel involvement and suggesting emboli.
-
Vascular distributions: Posterior cerebral artery (PCA) infarction. The noncontrast computed tomography (CT) images demonstrate PCA distribution infarction involving the right occipital and inferomedial temporal lobes. The image on the right demonstrates additional involvement of the thalamus, also part of the PCA territory.
-
The supratentorial vascular territories of the major cerebral arteries are demonstrated superimposed on axial (left) and coronal (right) T2-weighted images through the level of the basal ganglia and thalami. The middle cerebral artery (MCA; red) supplies the lateral aspects of the hemispheres, including the lateral frontal, parietal, and anterior temporal lobes; insula; and basal ganglia. The anterior cerebral artery (ACA; blue) supplies the medial frontal and parietal lobes. The posterior cerebral artery (PCA; green) supplies the thalami and occipital and inferior temporal lobes. The anterior choroidal artery (yellow) supplies the posterior limb of the internal capsule and part of the hippocampus extending to the anterior and superior surface of the occipital horn of the lateral ventricle.
Tables
VASCULAR TERRITORY |
Structures Supplied |
Anterior Circulation (Carotid) |
|
Anterior Cerebral Artery |
Cortical branches: medial frontal and parietal lobe Medial lenticulostriate branches: caudate head, globus pallidus, anterior limb of internal capsule |
Middle Cerebral Artery |
Cortical branches: lateral frontal and parietal lobes, lateral and anterior temporal lobe Lateral lenticulostriate branches: globus pallidus and putamen, internal capsule |
Anterior Choroidal Artery |
Optic tracts, medial temporal lobe, ventrolateral thalamus, corona radiata, posterior limb of the internal capsule |
Posterior Circulation (Vertebrobasilar) |
|
Posterior Cerebral Artery |
Cortical branches: occipital lobes, medial and posterior temporal and parietal lobes Perforating branches: brainstem, posterior thalamus and midbrain |
Posterior Inferior Cerebellar Artery |
Inferior vermis; posterior and inferior cerebellar hemispheres |
Anterior Inferior Cerebellar Artery |
Anterolateral cerebellum |
Superior Cerebellar Artery |
Superior vermis; superior cerebellum |
|
Category |
Description |
Score |
1a |
level of consciousness (LOC) |
Alert Drowsy Stuporous Coma |
0 1 2 3 |
1b |
LOC questions (month, age) |
Answers both correctly Answers 1 correctly Incorrect on both |
0 1 2 |
1c |
LOC commands (open and close eyes, grip and release nonparetic hand) |
Obeys both correctly Obeys 1 correctly Incorrect on both |
0 1 2 |
2 |
Best gaze (follow finger) |
Normal Partial gaze palsy Forced deviation |
0 1 2 |
3 |
Best visual (visual fields) |
No visual loss Partial hemianopia Complete hemianopia Bilateral hemianopia |
0 1 2 3 |
4 |
Facial palsy (show teeth, raise brows, squeeze eyes shut) |
Normal Minor Partial Complete |
0 1 2 3 |
5 |
Motor arm left* (raise 90°, hold 10 seconds) (preferably with the palm facing up) |
No drift Drift Cannot resist gravity No effort against gravity No movement |
0 1 2 3 4 |
6 |
Motor arm right* (raise 90°, hold 10 seconds) (preferably with the palm facing up) |
No drift Drift Cannot resist gravity No effort against gravity No movement |
0 1 2 3 4 |
7 |
Motor leg left* (raise 30°, hold 5 seconds) |
No drift Drift Cannot resist gravity No effort against gravity No movement |
0 1 2 3 4 |
8 |
Motor leg right* (raise 30°, hold 5 seconds) |
No drift Drift Cannot resist gravity No effort against gravity No movement |
0 1 2 3 4 |
9 |
Limb ataxia (finger-nose, heel-shin) |
Absent Present in 1 limb Present in 2 limbs |
0 1 2 |
10 |
Sensory (pinprick to face, arm, leg) |
Normal Partial loss Severe loss |
0 1 2 |
11 |
Extinction/neglect (double simultaneous testing) |
No neglect Partial neglect Complete neglect |
0 1 2 |
12 |
Dysarthria (speech clarity to "mama, baseball, huckleberry, tip-top, fifty-fifty") |
Normal articulation Mild to moderate dysarthria Near to unintelligible or worse |
0 1 2 |
13 |
Best language** (name items, describe pictures) |
No aphasia Mild to moderate aphasia Severe aphasia Mute |
0 1 2 3 |
|
Total |
- |
0-42 |
* For limbs with amputation, joint fusion, etc, score 9 and explain ** For intubation or other physical barriers to speech, score 9 and explain. Do not add 9 to the total score. NIH Stroke Scale (PDF) |
|||
What would you like to print?
- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Emergency Response and Transport
- Acute Management of Stroke
- Fibrinolytic Therapy
- Intra-arterial Reperfusion
- Antiplatelet Agents
- Blood Pressure Control
- Mechanical Thrombectomy
- Fever Control
- Cerebral Edema Control
- Seizure Control
- Acute Decompensation
- Anticoagulation and Prophylaxis
- Neuroprotective Agents
- Stroke Prevention
- Specialized Stroke Centers
- Consultations
- Diet
- Show All
- Guidelines
- Medication
- Questions & Answers
- Media Gallery
- Tables
- References
