Ischemic Stroke Guidelines

Updated: May 27, 2020
  • Author: Edward C Jauch, MD, MS, FAHA, FACEP; Chief Editor: Helmi L Lutsep, MD  more...
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Guidelines

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. [107]  The new guidelines recommend thrombectomy in eligible patients 6 to 16 hours after a stroke. [144, 145] 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: [24, 25]

  • 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. [146] 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. [147, 148] 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 [149] 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.